INFORMATION FOR CANDIDATE:

A 35 years old pregnant lady, Shauna Miles,

comes to your GP clinic for her first antenatal
checkup. She is 10 weeks pregnant. She drinks
heavily and is a smoker for the past 10 years.
YOUR TASK IS TO:
Take a further history
Discuss identified issues with her
Answer patients and examiners questions

HOPC: A 35 years old pregnant lady, Shauna Miles, comes to your GP clinic for her first
antenatal checkup. She is 10 weeks pregnant. The pregnancy was not planned but she
does not mind to have a baby.
She drinks heavily (4-8 standard drinks daily, vodka shots and wine) and is a smoker (20
cig./day) for the past 10 years. She usually drinks with her partner.
No other illicit drugs.
She has never got into trouble with her drinking at work, socially or with the police
(driving).
CAGE questions negative (feeling need to cut down, feeling annoyed about criticism of
her drinking, guilty about drinking, need for morning eye opener).
O+G Hx.: menarche age 14, regular periods, 28 days, 3-4 days, P0G1, no PIDs or STDs,
contraception with condoms, never been on pill, steady partner for 12 years, regular pap
smears (normal).
PHx. + FHx.: unremarkable
SHx: married, part time book keeper, no obvious problems, no medication, NKA.
DIAGNOSIS: ALCOHOL AND NICOTINE ABUSE IN PREGNANCY
EFFECTS OF ALCOHOL ON PREGNANCY AND BABY:
Alcohol has multiple potential effects on the pregnancy and the fetus:
Spontaneous miscarriage
Intra-uterine growth restriction (IUGR)
Fetal alcohol syndrome:
a) fetal growth restriction
b) facial, skeletal and cardiovascular defects
c) neurologic dysfunction (intellectual disability, mental retardation, learning,
emotional and behavioral problems)
d) low birth weight
e) neonatal death due to failure to thrive.
Premature birth
EFFECTS OF SMOKING ON PREGNANCY AND BABY:
Smoking is one of the worst, correctable risk factors for adverse pregnancy outcomes.
Nicotine, tar and carbon monoxide in cigarettes can cause hypoxia and vasoconstriction
with increased thickness of the villous membrane, acutely decreasing the intervillous
perfusion and leading to decreased gas exchange within the placenta, leading to a number
of possible problems which can be compounded by carboxyhaemoglobin formation:
increasing risk of spontaneous miscarriage (twice normal)
intra-uterine growth restriction (IUGR)
placenta previa
abruptio placentae
premature rupture of the membranes (PROM) or preterm PROM (PPROM)
preterm birth
chorioamnionitis

stillbirth
perinatal morbidity and mortality.
Neonates whose mothers smoke are also more likely to have anencephaly,
congenital heart defects, orofacial clefts, sudden infant death syndrome (SIDS),
deficiencies in physical growth and intelligence, and behavioral problems. They
are more prone to respiratory problems like pneumonia and asthma (later) and ear
infections.
Smoking cessation or limitation reduces risks.

MANAGEMENT:
There is no doubt that cessation of alcohol and smoking improves the outcome of the
pregnancy! The main stay intervention is psychosocial management. Understanding this
and admitting it is the problem and the resulting concerns about the possible damage to
the baby are strong motivators!
Help manuals or videos can be powerful allies.
The ideal way is to stop both or to establish clear and realistic goals.
Withdrawals can occur and the GP can support the patient or sometimes the referral to a
specialist service is necessary.
Ideally the family or partners should be involved because if the partner continuous to
smoke the prospect is not good. Other factors to be considered are coping skills and
coexisting emotional and psychological/psychiatric problems. Help can be provided with
counseling, AA or other support groups.
Stress has to be addresses with healthy living, like exercising, meditation, and other
relaxation techniques.
Nicotine patches are controversial because of possible toxic effects on fetus!