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Alcohol Use Disorders
21
LauraOrsolini, RosaVolgare, GiuliaFrancesconi,
GiovanniMartinotti, andUmbertoVolpe
21.1 Introduction
Alcohol consumption among women of childbearing age is increasing globally
(WHO 2018). The COVID-19 pandemic has indeed worsened alcohol consumption
worldwide (Rehm etal. 2020). About 10% of women declared to regularly drink
alcohol during pregnancy, with some variability across worldwide countries (WHO
2018). Certain groups, such as women with substance use disorders (SUD), low
socioeconomic status or coming from marginalized communities/cultural minorities, seemed to be more at risk to develop AUD during the perinatal period (Popova
etal. 2017; Dozet etal. 2023).
In general, as stated by the guidelines proposed by the Australian Government
Department of Health (2018), clinicians should always advise all women who are
pregnant or planning a pregnancy that not drinking is the safest option as maternal
alcohol consumption may adversely affect the developing fetus (NHMRC 2009).
Although no conclusive evidence shows that low levels of prenatal alcohol exposure
cause fetal harm, periodic binge drinking or regular heavy drinking (i.e., drinking
on average 70 grams alcohol weekly) during pregnancy can lead to serious adverse
outcomes (Woodruff and Roberts 2019). In fact, alcohol intake during pregnancy is
associated with an increased risk of miscarriage, preterm birth, stillbirth and sudden
infant death syndrome (SIDS) as well as it may determine the onset of a range of
lifelong behavioural, intellectual and physical disabilities (i.e., ‘fetal alcohol spectrum disorders’ [FASDs]) (CDC 2024). To date, literature supports that there is no
L. Orsolini (*) · R. Volgare · G. Francesconi · U. Volpe
Unit of Clinical Psychiatry, Department of Experimental and Clinical Medicine (DIMSC),
Polytechnic University of Marche, Ancona, Italy
e-mail: l.orsolini@staff.univpm.it
G. Martinotti
University “G.D’Annunzio” di Chieti-Pescara, Chieti, Italy
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2025
F. Uguz, L. Orsolini (eds.), Perinatal Psychopharmacology,
https://doi.org/10.1007/978-3-031-99720-4_21
447
448
L. Orsolini et al.
safe time for alcohol use during pregnancy nor there is no known safe amount of
alcohol use during pregnancy (CDC 2024).
However, despite some strong evidence that alcohol intake could determine often
unpredictable and serious irreversible detrimental consequences on maternal and
fetal outcomes both throughout the pregnancy and postpartum periods, few research
information and well-designed clinical studies provided clear owchart and treatment management strategies to support the use of specic pharmacological interventions for AUD during pregnancy and breastfeeding. Similarly, few studies
addressed how to manage alcohol detoxication programs among pregnant and
breastfeeding women, as well as the use of benzodiazepines (BZDs) in pregnant
women is still controversial in many studies. Coherently, many policies have been
developed addressing alcohol use in pregnancy (Drabble etal. 2014). Among these
policies there are supportive initiatives which include measures giving pregnant
women priority access to alcohol treatment or mandating point-of-sale signage
warning of the risks of drinking during pregnancy; and punitive initiatives which
include measures requiring mandatory reporting of patients who abuse alcohol during pregnancy to Child Protective Services or allowing civil commitment of alcohol-abusing pregnant women to involuntary treatment or protective custody of the
state (Roberts etal. 2017).
The present chapter will provide an overview about the epidemiology of AUDs
in pregnancy and breastfeeding, the associated risks about the development of major
and minor malformations and perinatal complications, with a particular focus on the
foetal alcohol spectrum disorder (FASD) and foetal alcohol syndrome (FAS), and,
nally, will provide some clinical guidelines for the management (pharmacological
and not-pharmacological) of AUD both in pregnancy and postpartum period
(Table21.1).
21.2 Epidemiology
According to the National Survey on Drug Use and Health (NSDUH 2022), around
8.5% of pregnant women in the United States consumed at least one alcoholic drink
in the previous 30days, 5.3% drank ve or more drinks (aka ‘binge drinking’) during one episode in the previous 30days and 1.7% had ve or more drinks on the
same occasion ve or more times (aka ‘heavy drinking’) in the last 30 days.
However, overall pregnant women have been reported to on average consume less
alcohol, compared to non-pregnant women (8.5% vs 55.1% drank at least once in
the last 30 days; 5.3% vs 27.0% reported binge drinking; 1.7% vs 5.7% reported
heavy drinking) (NSDUH 2022). In fact, some studies also documented that around
85% of women who regularly intake alcohol, when they become pregnant, usually
decide to discontinue alcohol consumption, mainly due to the fear of causing detrimental fetal consequences (Alvik etal. 2006). However, the epidemiological trend
seemed to document a progressive increase of pregnancy alcohol use and binge
drinking rates in recent years. In fact, between 2018 and 2020, about one in seven
pregnant women reported drinking alcohol in the past 30days, with 40% of them
21 Alcohol Use Disorders
449
Table 21.1
Clinicians should advise women who intend to plan a pregnancy to discontinue alcohol
consumption, as there is a good quality evidence that drinking excessive amounts of alcohol
during pregnancy may damage foetal development
Clinicians and researchers do not still know the minimum or threshold level at which alcohol
begins to pose a signicant threat to pregnancy, hence, it is preferred not using alcohol at all
Clinicians should know that alcohol is a teratogen agent, therefore, it should be avoided during
pregnancy, especially during the rst trimester
The likelihood of developing foetal malformations increases with increased volume and
frequency of alcohol consumption during the rst trimester, hence, it is preferred not having
binge or heavy drinking during this period
During antenatal visits, it is important to collect a complete medical history (paying particular
attention to indicators of possible AUD such as hepatitis, experiences of sexual and/or physical
abuse, presence of psychiatric comorbidities, recognizing that some pregnant women may
hesitate to disclose substance use due to fear of repercussions, involvement with social
services, losing custody of children or judgmental treatment
A screening assessment for alcohol consumption, specically designed for pregnant and/or
nursing women, may help clinicians to adopt preventive tools, provide advice to stop alcohol
consumption, and therapeutic strategies for the management of AUD
Laboratory testing can aid in measuring prenatal alcohol exposure
After identifying pregnant and/or nursing women at risk of AUD, clinicians should suggest
involving a drug and/or alcohol specialist in counselling and care
AUD during pregnancy may contribute to an increased risk of congenital malformations or
later intellectual disability
AUD during pregnancy may contribute to the onset of FASD
The optimal management approach for pregnant women with AUD involves a combination of
pharmacological treatment, specialist consultation, and psychosocial interventions
Pregnant women should be given priority access to withdrawal management and treatment
Research on the safety of alcohol pharmacotherapies during pregnancy is limited. In the
United States, the Food and Drug Administration (FDA) has approved only three medications
for the treatment of AUD: Naltrexone, disulram, and acamprosate
Psychosocial interventions appear to reduce the frequency of alcohol use especially with
interventions that combine parenting skills with a substance use component. Peer support
groups seem to be very helpful too
Special attention should be paid to the postnatal period where the risk of relapse is very high
Expert recommendations based on scientic evidence and clinical experience
engaging in binge drinking (Gosdin etal. 2022). In particular, pregnant women who
experienced frequent mental distress (i.e., 14 or more days of poor mental health in
the past 30days) and those women who did not have a usual healthcare provider
were more likely to report alcohol intake (Gosdin etal. 2022).
21.3 Risk ofCongenital Major Malformations
andPerinatal Complications
The French paediatrician Paul Lemoine rstly identied alcohol as a teratogenic
agent in 1967, by describing 127 cases of a similar pattern of abnormalities in those
children exposed to a ‘chronic alcoholism’ of their mothers (Lemoine etal. 1968;