THE PERINATAL CONSEQUENCES OF SMOKING AND ALCOHOL-USE

The use of alcohol and tobacco products by pregnant women represents a major perinatal health problem. Although these two substances are use d to a much greater extent than illicit drugs (cocaine, opiates, marij uana, amphetamines, etc.), they receive much less attention. Approxima tely 20% of pregnant women smoke cigarettes or consume alcohol during their pregnancy. Although it is true that these ''drugs'' are legal, i t is important not to confuse legality with safety. If the goal of the clinician caring for pregnant women is to minimize perinatal complica tions and to protect the developing fetus and the mother, then any dru g exposure should be judged primarily by its potential to adversely af fect the pregnancy. A complete understanding of the dangers associated with smoking and alcohol use is critical in addressing the modifiable risks of a given patient population. Smoking is associated with spont aneous abortion, placental previa, abruptio placentae, premature ruptu re of the membranes, preterm birth, and abnormalities of fetal growth (low birth weight and small for gestational age infants). The perinata l mortality rate among smokers is 150% of that seen in nonsmokers. It has been suggested that smoking is responsible for 15% of all preterm births and 20% to 30% of all infants of low birth weight. These associ ated complications have a dramatic impact on overall perinatal morbidi ty and mortality. Programs aimed at smoking cessation have proven to b e relatively successful and have been shown to result in an improvemen t in overall perinatal outcome. Maternal alcohol use is associated wit h spontaneous abortion, morphologic and behavioral teratogenesis, abno rmalities of fetal growth, and abruptio placentae. The fetal alcohol s yndrome, first described approximately 20 to 25 years ago, is the lead ing known cause of mental retardation in the western world. The fetal alcohol syndrome comprises prenatal and/or postnatal growth retardatio n, craniofacial abnormalities, and central nervous system involvement (e.g, mental retardation). The incidence of fetal alcohol syndrome is approximately 1.9 per 1000 births, whereas the incidence of alcohol-re lated birth defects, a partial expression of fetal alcohol syndrome, i s 3.1 per 1000. Among heavy drinkers the incidence of fetal alcohol sy ndrome is 43 per 1000, and in ''alcoholics'' the incidence is in the 3 5% to 40% range. The economic impact of health problems related to fet al alcohol syndrome has been estimated at approximately $75 million pe r year. Fetal growth is compromised by maternal alcohol consumption. T here is an increase in the incidence of infants who are small for gest ational age, infants of low birth weight, and an overall 150 to 250 gm decrement in mean birth weight across gestational ages. These observa tions underscore the importance of identifying women of reproductive a ge whose alcohol use puts them at risk for perinatal complications. Re commendations for tools to assist in the identification of this popula tion are outlined.