Fetal alcohol-spectrum disorders: identifying at-risk mothers

Figures & data

Table 1 Maternal or pregnancy characteristics commonly associated with having a child with fetal alcohol-spectrum disorder

Risk factor	References
Demographics and lifestyle factors
Age (higher)	^Citation37, ^Citation50, ^Citation158^–^Citation162, ^Citation181
SES, educational attainment (lower)	^Citation50, ^Citation59, ^Citation73, ^Citation131, ^Citation159, ^Citation161, ^Citation163^–^Citation165
Marital status (unmarried)	^Citation50, ^Citation131, ^Citation162, ^Citation166
Employment status (unemployed)	^Citation50, ^Citation164, ^Citation166
Body size/BMI (smaller size, lower BMI)	^Citation131, ^Citation159, ^Citation164
Nutritional status (suboptimal)	^Citation47, ^Citation131
Religion/spirituality (less)	^Citation59, ^Citation163
Contraception (less effective)	^Citation59
Mental health/psychological factors
Mental health problems/mental illness	^Citation37, ^Citation50, ^Citation59
Depression	^Citation37, ^Citation59, ^Citation73
Stress	^Citation163
Cognitive impairment	^Citation59
Trauma or injuries	^Citation37, ^Citation162
Sexual abuse	^Citation37, ^Citation59, ^Citation162
Alcohol-consumption patterns/factors
Binge	^Citation37, ^Citation50, ^Citation131, ^Citation158, ^Citation159, ^Citation162
Greater consumption prior to pregnancy	^Citation159, ^Citation160, ^Citation162
Greater quantity/frequency of consumption	^Citation37, ^Citation50, ^Citation73, ^Citation131, ^Citation158^–^Citation160, ^Citation162, ^Citation164, ^Citation167
Family history of alcohol problems	^Citation158, ^Citation163
Alcohol-related medical/life problems	^Citation37
Other drug use
Tobacco use/smoking	^Citation50, ^Citation159, ^Citation160, ^Citation162, ^Citation164
Illegal drug use	^Citation50, ^Citation59, ^Citation73
Pregnancy
Parity (higher)	^Citation50, ^Citation131, ^Citation158^–^Citation160, ^Citation162
Gravidity (higher)	^Citation37, ^Citation131, ^Citation158, ^Citation159, ^Citation162
Prenatal care (late)	^Citation73, ^Citation160, ^Citation161, ^Citation166, ^Citation168
Prenatal care (less)	^Citation37, ^Citation50, ^Citation160, ^Citation161, ^Citation168
Already having an affected child	^Citation50
Paternal
Perceived support (lower)	^Citation59
Alcohol consumption (higher)	^Citation84, ^Citation162, ^Citation165, ^Citation169, ^Citation170
Father’s age (higher)	^Citation161

Abbreviations: SES, socioeconomic status; BMI, body mass index.

Table 2 Biomarkers

Marker	Matrix, type of consumption detected, and detection time	References
Indirect
MCV	• Detects chronic and heavy consumption	^Citation89
	• Insufficiently sensitive or specific for moderate-to-low consumption
GGT		^Citation90
CDT		^Citation91, ^Citation92
Direct
EtOH	• Breath, blood, and urine	^Citation190, ^Citation191
	○ recent consumption (hours)
FAEEs	• Blood	^Citation94, ^Citation97, ^Citation171^–^Citation173
	○ recent consumption (1–2 days)
	• Plasma
	○ recent consumption (~2 hours)
	• Maternal hair
	○ heavy chronic consumption (months)
	• Newborn hair
	○ heavy consumption over the last 16 weeks of pregnancy (months)
	• Meconium
	○ heavy consumption from ~20th week (months)
EtG (EtS)	• Urine	^Citation107, ^Citation174, ^Citation175
	○ recent consumption (75–80 hours)
	• Blood
	○ recent consumption (18 hours)
	• Plasma
	○ recent consumption (8 hours)
	• Maternal hair
	○ heavy chronic consumption
	• Meconium
	○ heavy consumption from ~20th week
PEth	• Blood	^Citation118, ^Citation176
	○ low-to-moderate consumption (4–6 weeks)
	• DBSs
	○ prenatal exposure; possibly low-to-moderate consumption (2–3 weeks)

Note: Heavy consumption = three or more drinks/occasion.

Abbreviations: MCV, mean corpuscular volume (of erythrocytes); GGT, γ-glutamyltransferase; CDT, carbohydrate-deficient transferrin; EtOH, ethanol; FAEEs, fatty acid ethyl esters; EtG, ethyl glucuronide; EtS, ethyl sulfate; PEth, phosphatidylethanol; DBSs, dried blood spots.

Table 3 Brief alcohol-screening tools for use with women of childbearing age and in pregnancy

Screening tool	Sensitivity/specificity for risky drinking at indicated cut point#	Comments	References
T-ACE (T-ACER3)	≥1*: 76%–92%/38%–85%	• Developed for pregnant women	^Citation134^–^Citation139, ^Citation177^–^Citation180, ^Citation182
	≥2*: 69%–95%/40%–89%	• Validated in pregnant women
	≥3*: 38%–79%/81%–97%	• Sensitive among minority populations
		• Better than medical records
		• Focused on heavy drinking
		• Increasing cut point in T-ACER3 improved specificity while maintaining high sensitivity, thereby improving PPV
TWEAK	≥1*: 87%–92%/67%–72%	• Developed for pregnant women	^Citation136, ^Citation137, ^Citation182^–^Citation185
	≥2*: 79%–100%/36%–83%	• Validated in pregnant women
		• Less sensitive among minority populations
		• Focused on heavy drinking
AUDIT-C	≥3*: 67%–95%/85%	• Developed for pregnant women, but may be unreliable in some obstetric settings	^Citation185, ^Citation186^–^Citation188
		• Effective among a variety of populations
		• Focus on very heavy alcohol exposure
CAGE	≥1*: 59%–68%/82%	• Not developed for or recommended for pregnant women	^Citation136^–^Citation138, ^Citation180, ^Citation182, ^Citation189
	≥2*: 38%–49%/92%–93%	• Less effective in women than men
		• Less sensitive in non-Caucasian women than Caucasian and
		minority or disadvantaged compared to T-ACE or TWEAK
		• Designed to identify lifetime drinking and heavy exposure

Notes:

* These values indicate the score at which someone is identified as a risky drinker.

# Data presented as sensitivity (probability that a risky drinker is identified as a risky drinker by the screen – ie, screens positive) and specificity (probability that a nonrisky drinker is negative on the screen).

Abbreviations: T-ACE, tolerance, annoyed, cut down, eye-opener; T-ACER3, T-ACE with cut point increased to 3 points; TWEAK, tolerance, worry, eye-opener, amnesia, “kut” down; AUDIT-C, alcohol use disorders identification test – consumption; CAGE, cut down, annoy, guilty, eye-opener; PPV, positive predictive value.

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