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Guideline Summary
Guideline Title
Alcohol use and pregnancy consensus clinical guidelines.
Bibliographic Source(s)
Carson G, Cox LV, Crane J, Croteau P, Graves L, Kluka S, Koren G, Martel MJ, Midmer D, Nulman I, Poole N, Senikas V, Wood R. Alcohol use and pregnancy consensus clinical guidelines. J Obstet Gynaecol Can. 2010 Aug;32(8 Suppl 3):S1-32. [126 references]
Guideline Status

This is the current release of the guideline.

Scope

Disease/Condition(s)

Pregnancy

Guideline Category
Counseling
Evaluation
Management
Risk Assessment
Screening
Treatment
Clinical Specialty
Family Practice
Internal Medicine
Obstetrics and Gynecology
Preventive Medicine
Intended Users
Advanced Practice Nurses
Health Care Providers
Nurses
Physician Assistants
Physicians
Substance Use Disorders Treatment Providers
Guideline Objective(s)

To establish national standards of care for the screening and recording of alcohol use and counselling on alcohol use of women of child-bearing age and pregnant women based on the most up-to-date evidence

Target Population

Women of child-bearing age and pregnant women

Interventions and Practices Considered
  1. Maternal alcohol screening and periodic screening of women of child-bearing age, including:
    • Single question method
    • Motivational interviewing
    • Supportive dialogue
    • Structured questionnaires
    • Laboratory-based screening tools
  2. Documentation of alcohol use
  3. Awareness/assessment of risk factors
  4. Brief interventions/time-limited motivational counselling strategies
  5. Harm reduction/treatment strategies
Major Outcomes Considered
  • Rates of fetal alcohol spectrum disorder (FASD) disabilities and secondary disabilities
  • Rates of alcohol consumption

Methodology

Methods Used to Collect/Select the Evidence
Searches of Electronic Databases
Searches of Unpublished Data
Description of Methods Used to Collect/Select the Evidence

Published literature was retrieved through searches of PubMed, CINAHL, and the Cochrane Library in May 2009 using appropriate controlled vocabulary (e.g., pregnancy complications, alcohol drinking, prenatal care) and key words (e.g., pregnancy, alcohol consumption, risk reduction). Results were restricted to literature published in the last five years with the following research designs: systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no language restrictions. Searches were updated on a regular basis and incorporated in the guideline to May 2010. Grey (unpublished) literature was identified through searching the websites of health technology assessment (HTA) and HTA-related agencies, national and international medical specialty societies, clinical practice guideline collections, and clinical trial registries. Each article was screened for relevance and the full text acquired if determined to be relevant.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Quality of Evidence Assessment*

I: Evidence obtained from at least one properly randomized controlled trial

II-1: Evidence from well-designed controlled trials without randomization

II-2: Evidence from well-designed cohort (prospective or retrospective) or case-control studies, preferably from more than one centre or research group

II-3: Evidence from comparisons between times or places with or without the intervention. Dramatic results in uncontrolled experiments (such as the results of treatment with penicillin in the 1940s) could also be included in this category

III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees

*Adapted from the Evaluation of Evidence criteria described in the Canadian Task Force on Preventive Health Care.

Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review
Description of the Methods Used to Analyze the Evidence

The evidence obtained was reviewed and evaluated by the members of the Expert Workgroup established by the Society of Obstetricians and Gynaecologists of Canada.

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

The quality of evidence was evaluated and recommendations were made according to guidelines developed by the Canadian Task Force on Preventive Health Care.

Rating Scheme for the Strength of the Recommendations

Classification of Recommendations†

A. There is good evidence to recommend the clinical preventive action.

B. There is fair evidence to recommend the clinical preventive action.

C. The existing evidence is conflicting and does not allow to make a recommendation for or against use of the clinical preventive action; however, other factors may influence decision-making.

D. There is fair evidence to recommend against the clinical preventive action.

E. There is good evidence to recommend against the clinical preventive action.

L. There is insufficient evidence (in quantity or quality) to make a recommendation; however, other factors may influence decision-making.

†Adapted from the Classification of Recommendations criteria described in the Canadian Task Force on Preventive Health Care.

Cost Analysis
  • Lifetime direct tangible costs per individual related to health care, education, and social services in Canada for fetal alcohol spectrum disorder have been estimated to be $1.4 million.
  • Brief interventions are cost effective, and they can be implemented in various clinical settings by the practitioner or an assistant.
Method of Guideline Validation
Internal Peer Review
Description of Method of Guideline Validation

This Clinical Practice Guideline has been reviewed and approved by the Executive and Council of the Society of Obstetricians and Gynaecologists of Canada.

Recommendations

Major Recommendations

The grades of recommendations (A-E and L) and quality of evidence (I, II-1, II-2, II-3, and III) are defined at the end of the "Major Recommendations" field.

Why Alcohol Use Is a Problem and Why Guidelines Are Required

Summary Statements

  1. There is evidence that alcohol consumption in pregnancy can cause fetal harm. (II-2) There is insufficient evidence regarding fetal safety or harm at low levels of alcohol consumption in pregnancy. (III)
  2. There is insufficient evidence to define any threshold for low-level drinking in pregnancy. (III)
  3. Abstinence is the prudent choice for a woman who is or might become pregnant. (III)

Recognition, Screening, and Documentation

Recommendations

  1. Universal screening for alcohol consumption should be done periodically for all pregnant women and women of child-bearing age. Ideally, at-risk drinking could be identified before pregnancy, allowing for change. (II-2B)
  2. Health care providers should create a safe environment for women to report alcohol consumption. (III-A)
  3. The public should be informed that alcohol screening and support for women at risk is part of routine women's health care. (III-A)

Selected Factors Associated with Alcohol Use Among Pregnant Women and Women of Child-bearing Age

Recommendation

  1. Health care providers should be aware of the risk factors associated with alcohol use in women of reproductive age. (III-B)

Counselling and Communication With Women About Alcohol Use

Summary Statement

  1. Intensive cultural-, gender-, and family-appropriate interventions need to be available and accessible for women with problematic drinking and/or alcohol dependence. (II-2)

Recommendations

  1. Brief interventions are effective and should be provided by health care providers for women with at-risk drinking (see Table 12 in the original guideline document for assessment, advice, assistance, and recommended approaches to alcohol interventions with women of child-bearing years). (II-2B)
  2. If a woman continues to use alcohol during pregnancy, harm reduction/treatment strategies should be encouraged. (II-2B)
  3. Pregnant women should be given priority access to withdrawal management and treatment. (III-A)
  4. Health care providers should advise women that low-level consumption of alcohol in early pregnancy is not an indication for termination of pregnancy. (II-2A)

Pregnancy Scenarios

Clinical Tips

  • A woman may be afraid to tell her practitioner the full extent of her alcohol use. She may be testing the health care practitioner to see if she will be judged.
  • The use of other substances is common and needs to be a consideration in women who consume alcohol.

Definitions:

Quality of Evidence Assessment*

I: Evidence obtained from at least one properly randomized controlled trial

II-1: Evidence from well-designed controlled trials without randomization

II-2: Evidence from well-designed cohort (prospective or retrospective) or case-control studies, preferably from more than one centre or research group

II-3: Evidence from comparisons between times or places with or without the intervention. Dramatic results in uncontrolled experiments (such as the results of treatment with penicillin in the 1940s) could also be included in this category

III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees

Classification of Recommendations†

A. There is good evidence to recommend the clinical preventive action.

B. There is fair evidence to recommend the clinical preventive action.

C. The existing evidence is conflicting and does not allow to make a recommendation for or against use of the clinical preventive action; however, other factors may influence decision-making.

D. There is fair evidence to recommend against the clinical preventive action.

E. There is good evidence to recommend against the clinical preventive action.

L. There is insufficient evidence (in quantity or quality) to make a recommendation; however, other factors may influence decision-making.

*Adapted from the Evaluation of Evidence criteria described in the Canadian Task Force on Preventive Health Care.

†Adapted from the Classification of Recommendations criteria described in the Canadian Task Force on Preventive Health Care.

Clinical Algorithm(s)

The original guideline contains a clinical algorithm decision tree for levels of examination and screening.

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations" field).

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits
  • Maternal alcohol screening and recording by health care providers could lead to a reduction of primary fetal alcohol spectrum disorder (FASD) disabilities as well as a reduction of secondary disabilities often related to FASD in the absence of diagnosis and appropriate interventions.
  • The younger the age at which the affected child is identified, the lower the frequency of secondary disabilities.
Potential Harms
  • Disadvantages of toxicology tests include the high costs associated with laboratory analysis and the possibility that the trust between the care provider and the woman will be jeopardized.
  • Pregnant women and new mothers report experiencing discrimination and lack of support from health care providers and others in a position to assist them with alcohol problems. In addition, women fear losing custody of their children if their alcohol use is made known to child welfare authorities. (Substance use in pregnancy is almost unique as a health problem that can result in the loss of child custody.) For women, these fears of prejudicial treatment and removal of children create serious barriers to open discussion of their alcohol use, to providing consent to laboratory testing, and to seeking support or treatment.

Qualifying Statements

Qualifying Statements

This document reflects emerging clinical and scientific advances on the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed. Local institutions can dictate amendments to these opinions. They should be well documented if modified at the local level.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools
Chart Documentation/Checklists/Forms
Clinical Algorithm
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
Carson G, Cox LV, Crane J, Croteau P, Graves L, Kluka S, Koren G, Martel MJ, Midmer D, Nulman I, Poole N, Senikas V, Wood R. Alcohol use and pregnancy consensus clinical guidelines. J Obstet Gynaecol Can. 2010 Aug;32(8 Suppl 3):S1-32. [126 references]
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2010 Aug 1
Guideline Developer(s)
Society of Obstetricians and Gynaecologists of Canada - Medical Specialty Society
Source(s) of Funding

The Society of Obstetricians and Gynaecologists of Canada

Guideline Committee

Society of Obstetricians and Gynaecologists of Canada Expert Workgroup

Composition of Group That Authored the Guideline

Principal Authors: George Carson, MD, FRCSC, Regina SK; Lori Vitale Cox, PhD, Elsipogtog NB; Joan Crane, MD, FRCSC, St. John's NL; Pascal Croteau, MD, CCFP, Shawville QC; Lisa Graves, MD, CCFP, Montreal QC; Sandra Kluka, RN, PhD, Winnipeg MB; Gideon Koren, MD, FRCPC, FACMT, Toronto ON; Marie-Jocelyne Martel, MD, FRCSC, Saskatoon SK; Deana Midmer, RN, EdD, Toronto ON; Irena Nulman, MD, FRCPC, Toronto ON; Nancy Poole, MA, Victoria BC; Vyta Senikas, MD, FRCSC, MBA, Ottawa ON; Rebecca Wood, RM, Winnipeg MB

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Endorser(s)
Association of Obstetricians and Gynecologists of Quebec - Medical Specialty Society
Canadian Association of Midwives - Professional Association
Canadian Association of Perinatal and Women's Health Nurses (CAPWHN) - Professional Association
College of Family Physicians of Canada - Professional Association
Federation of Medical Women of Canada - Professional Association
Motherisk - For Profit Organization
Society of Rural Physicians of Canada - Professional Association
Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available in Portable Document Format (PDF) from the Society of Obstetricians and Gynaecologists of Canada Web site External Web Site Policy.

Print copies: Available from the Society of Obstetricians and Gynaecologists of Canada, La société des obstétriciens et gynécologues du Canada (SOGC) 780 promenade Echo Drive Ottawa, ON K1S 5R7 (Canada); Phone: 1-800-561-2416.

Availability of Companion Documents

The T-ACE and TWEAK question tools are available in the original guideline document External Web Site Policy.

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on December 9, 2010. The information was verified by the guideline developer on January 11, 2011.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

Disclaimer

NGC Disclaimer

The National Guideline Clearinghouseâ„¢ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

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