Alcohol Abuse in Pregnancy

Alcohol in the form of beverages is a licit drug for consumption. It is found throughout the world, and has been
consumed for centuries by both men and women on different occasions. Even so, alcohol is known to cause
dependency among people that have a tendency to become alcoholic, and/or the ones who are exposed to bouts
of depression and stress, frequent use, as well as personal motivations leading to alcohol consumption.
The consumption of alcohol during pregnancy is the most common cause of births of mentally delayed
children among mothers who are drinkers, and the principal cause of fetus malformation in the Western
Hemisphere. The excessive consumption of alcohol by women during pregnancy constitutes one of the most
frequent problems found during pregnancy, and can lead to Fetal Alcohol Syndrome (FAS) endangering the
neural-psychiatric well-being of the progeny of alcoholic women.
Even though the effects of alcoholic consumption during pregnancy have been known for centuries, it has only
come to be recognized in medical circles during the last 40 years after the French paediatrician, Lemoine
published his 1968 paper entitled, Physical Anomalies Encountered in Children of Alcoholic Women. An
important factor in the study of alcohol consumption during pregnancy is considering what exactly constitutes
the limiting factors of consumption that would compromise fetal development.

Alcohol and Pregnancy Science

Alcohol, like the chemical element mercury, is a confirmed teratogen (a substance that interferes with normal
prenatal development). Alcohol can cause central nervous system (brain and spinal cord) malformations with
associated neurobehavioral dysfunction. By comparison, lead is a neurotoxin but not a teratogen in that it
produces neurobehavioral dysfunction in the absence of brain and spinal cord malformations.
Science definitively recognizes that when a pregnant woman consumes alcohol, the alcohol crosses the
placenta into the blood supply of the developing embryo or fetus. An embryo or fetus has neither the developed
organ systems nor enzymes able to metabolize alcohol.
The first paper in the medical literature describing a constellation of birth defects linked to prenatal alcohol
exposure was published in France in 1968 by Dr. Paul Lemoine.

The first paper in U.S. medical literature appeared in 1973 authored by Drs David Smith and Ken Lyons
Jones. As of 2012, nearly 4,000 papers have been published confirming the toxicity of alcohol to the embryo or
fetus, the underlying mechanisms of alcohol-induced damage to the embryo or fetus, and the physical and
functional birth defects related to prenatal alcohol exposure.
No published study has suggested that alcohol is not a teratogen or demonstrated that prenatal alcohol use has
any potential benefit to human development.
The basic and biomedical research demonstrates that alcohol damages the developing brain through multiple
actions at different cellular sites interfering with normal development by disrupting cell migration, cell
functions, and causing cell death.
Alcohol can cause damage to multiple regions of the brain, specifically to the corpus collosum (connects brain
hemispheres), cerebellum (consciousness and voluntary processes), basal ganglia (movement and cognition),
hippocampus (emotional behaviour and memory), hypothalamus (sensory input), among other neural regions.
Ethanol is the principal psychoactive constituent in alcoholic beverages. In utero it has been found to:

Interfere with normal proliferation of nerve cells;

Increase the formation of free radicalscell damaging molecular fragments;

Alter cells ability to regulate cell growth, division and survival;

Impair the development and function of astocytes, cells that guide the migration of nerve cells to their
proper places;

Interfere with the normal adhesion of cells to one another;

Alter the formation of axons, nerve cell extensions that conduct impulses away from the cell body;

Alter the pathways of biochemical or electrical signals within cells;

Alter the expression of genes, including genes that regulate cell development.

Human development occurs in an orderly process of biochemical and structural transition during which new
constituents are being formed and spatially arranged throughout gestation. At any time in the span of
development these ongoing processes can be subtly or severely disturbed or abruptly halted resulting in
abnormal development or fetal death.

Therefore, at any time alcohol is present it has the potential to harm development. For example, the hallmark
facial dysmorphology associated with Fetal Alcohol Syndrome will only occur if alcohol is present during the
specific window of development.
Of all the substances of abuse, including marijuana, cocaine and heroin, alcohol produces by far the most
serious neurobehavioral effects on the embryo or fetus.

Characteristics and behaviours in children with FAS:

Abnormal facial features, such as a smooth ridge between the nose and upper lip (this ridge is called the
philtrum)

Small head size

Shorter-than-average height

Low body weight

Poor coordination

Hyperactive behaviour

Difficulty with attention

Poor memory

Difficulty in school (especially with math)

Learning disabilities

Speech and language delays

Intellectual disability or low IQ

Poor reasoning and judgment skills

Sleep and sucking problems as a baby

Vision or hearing problems

Problems with the heart, kidney, or bones

Clinical Therapy
Antepartum care of the alcohol-abusing woman involves medical, socioeconomic, and legal considerations.
The use of a team approach allows for the comprehensive management necessary to provide safe labor and
delivery for the woman and her fetus.
Appropriate treatment of alcohol withdrawal (AW) can relieve the patients discomfort, prevent the
development of more serious symptoms, and forestall cumulative effects that might worsen future withdrawals.
Hospital admission provides the safest setting for the treatment, although many patients with mild to moderate
symptoms can be treated successfully on an outpatient basis. Severe AW requires pharmacological
intervention. Although a wide variety of medications have been used for this purpose, clinicians disagree on
the optimum medications and prescribing schedules. The treatment of specific withdrawal complications such
as delirium tremens and seizures presents special.

Supportive Care for Alcohol Abuse

The purpose of supportive care is to treat such disorders and to remedy nutritional deficiencies. Patients with
AW should be subject to a physical examination, with particular emphasis on detecting conditions such as
irregular heartbeat (i.e., arrhythmia), inadequate heart function (i.e., congestive heart failure), liver disease

(e.g., alcoholic hepatitis), pancreatic disease (i.e., alcoholic pancreatitis), infectious diseases (e.g.,
tuberculosis), bleeding within the digestive system, and nervous system impairment. Vital signs (e.g., heartbeat
and blood pressure) should be stabilized and disturbances of water and nutritional balances corrected. The
presence of water in the blood problems and requires further research.

Treatment Settings for Alcohol Detoxification

Patients with Alcohol abuse can be treated safely and effectively either within a hospital or clinic (i.e., inpatient
treatment) or on an ambulatory basis (i.e., outpatient treatment). Although studies have compared the
effectiveness of outpatient versus inpatient detoxification, no specific criteria have been rigorously tested.
Cold turkey withdrawal is not advisable during pregnancy because of risk to the fetus. Maintenance and
support therapy are best individualized to the womans history and condition.
Detoxification units once were very popular but have been replaced largely by institutional rehabilitation
settings where withdrawal can be medically supervised and therapeutic counselling begun. Opiate antagonists
such as naloxone (Narcan) are sometimes used to augment therapy, and they have demonstrated some
effectiveness, although recent evidence-based scientific review found the research insufficient to draw the
conclusion that the pharmaceuticals should be part of management. Disulfiram (Antabuse) is a deterrent drug
that, when combined with alcohol, results in profound nausea and vomiting. It must be ingested by the
alcoholic and may be of greatest value in deterring impulsive drinking. During pregnancy, it is unclear how
much alcohol intake, or what threshold, will result in abnormalities and features of fetal alcohol syndrome
(FAS). The fetus seems to be the most vulnerable to alcohol during the first few weeks of pregnancy, usually
before the woman suspects she is pregnant. Regular moderate (more than two mixed drinks, two glasses of
wine, or two beers a day) to heavy alcohol consumption during any stage in pregnancy has been associated
with central nervous system abnormalities, behavioural abnormalities, and features of fetal alcohol syndrome.

Nursing Care Management

Nurses and other healthcare providers should make it a practice to screen all pregnant women for substance
abuse because illicit drug users seldom use only one drug. Several screening tools are available. The nurse
should be alert for clues in the history or womans appearance that suggest substance abuse then the nurse can

progress to questions about alcohol consumption and finally to questions focusing on past illicit drug use. The
nurse who is matter-of-fact and non-judgemental is more likely to elicit honest responses. Formalized alcohol
questionnaires can be used to screen targeted at risk groups. The T-ACE questionnaire has been validated and
appears to be accurate in detecting women who drink more than 1 oz. absolute alcohol per day (approximately
25 g or 2.5 units). Screening is most sensitive for women interviewed during the first 15 weeks of pregnancy.
T-ACE is an acronym from the following:
T TOLERANCE: How many drinks does it take to make you feel high?
A ANNOYED: Have people ANNOYED you by criticizing your drinking?
C CUT DOWN: Have you felt you ought to CUT DOWN on your drinking?
E EYE OPENER: Have you ever had a drink first thing in the morning?
The scoring of the test is straight forward. If answer to the Tolerance question is more than 2, a score of 2 is
given, and a score of 1 is assigned to a positive answer in all others. A total score of more than 2 is considered
positive for problem drinking and this correctly identifies over 70% of heavy drinkers during pregnancy.
An alternative is the Leeds Dependency Questionnaire (LDQ) which is a 10-item, self- completion
questionnaire designed to measure dependence on a variety of substances. It has been shown to be understood
by users of alcohol and opiates. The questionnaire has advantages as it is sensitive to change over time through
the range from mild to severe dependence. The test-retest reliability was found to be 0.95
Biochemical markers blood gamma-glutamyl transferase, alcohol concentration and the thiocyyanate and mean
corpuscular volume can be used as surrogates of excessive alcohol consumption, but they are not accurate and
can only be used as pointers to potential at risk women.
Nursing assessment of the woman who is known to abuse alcohol focuses on her general health status, with
specific attention to nutritional status, susceptibility to infections, and evaluation of all body systems. The
nurse must also assess the womans understanding of the substance abuse on herself and her pregnancy. Some
women are reluctant to discuss their alcohol abuse while others are quite open about it. Once the nurse
establishes a relationship of trust, the nurse can gain information to use in planning the womans ongoing care.

Nursing Diagnoses
Alcohol, a central nervous system depressant, is used socially in our society for many reasons: to enhance the
flavour of food, to encourage relaxation and conviviality, for celebrations, and as a sacred ritual in some
religious ceremonies. Therapeutically, it is the major ingredient in many OTC/prescription medications. It can
be harmless, enjoyable, and sometimes beneficial when used responsibly and in moderation.
It is rapidly absorbed from the stomach and small intestine into the bloodstream. On the other hand, alcohol
withdrawal refers to symptoms that may occur when a person who has been drinking too much alcohol every
day suddenly stops drinking alcohol.
Alcohol withdrawal symptoms usually occur within 8 hours after the last drink, but can occur days later.
Symptoms usually peak by 24 72 hours, but may persist for weeks. Common symptoms include: anxiety or
nervousness, depression, fatigue, irritability, jumpiness or shakiness, mood swings, nightmares and not
thinking clearly.

Nursing Care Plans

Diagnostic Studies

Blood alcohol/drug levels: Alcohol level may/may not be severely elevated, depending on amount
consumed, time between consumption and testing, and the degree of tolerance, which varies widely. In the
absence of elevated alcohol tolerance, blood levels in excess of 100 mg/dL are associated with ataxia; at
200 mg/dL the patient is drowsy and confused; respiratory depression occurs with blood levels of 400
mg/dL and death is possible. In addition to alcohol, numerous controlled substances may be identified in a
poly-drug screen, e.g., amphetamine, cocaine, morphine, Percodan, Quaalude.

CBC: Decreased Hb/Hct may reflect such problems as iron-deficiency anaemia or acute/chronic GI
bleeding. WBC count may be increased with infection or decreased if immunosuppressed.

Glucose/Ketones: Hyperglycaemia/hypoglycemia may be present, related to pancreatitis, malnutrition,

or depletion of liver glycogen stores. Ketoacidosis may be present with/without metabolic acidosis.

Electrolytes: Hypokalaemia and hypomagnesaemia are common.

Liver function tests: LDH, AST, ALT, and amylase may be elevated, reflecting liver or pancreatic
damage.

Nutritional tests: Albumin is low and total protein may be decreased. Vitamin deficiencies are usually
present, reflecting malnutrition/malabsorption.

Other screening studies (e.g., hepatitis, HIV, TB): Depend on general condition, individual risk
factors, and care setting.

Urinalysis: Infection may be identified; ketones may be present, related to breakdown of fatty acids in
malnutrition (pseudodiabetic condition).

Chest x-ray: May reveal right lower lobe pneumonia (malnutrition, depressed immune system,
aspiration) or chronic lung disorders associated with tobacco use.

ECG: Dysrhythmias, cardiomyopathies, and/or ischemia may be present because of direct effect of
alcohol on the cardiac muscle and/or conduction system, as well as effects of electrolyte imbalance.

Addiction Severity Index (ASI): An assessment tool that produces a problem severity profile of the
patient, including chemical, medical, psychological, legal, family/social, and employment/support aspects,
indicating areas of treatment needs.

Nursing priorities
1.

Maintain physiological stability during acute withdrawal phase.

2.

Promote patient safety.

3.

Provide appropriate referral and follow-up.

4.

Encourage/support SO involvement in Intervention (confrontation) process.

5.

Provide information about condition/prognosis and treatment needs.

Discharge goals
1.

Homeostasis achieved.

2.

Complications prevented/resolved.

3.

Sobriety being maintained on a day-to-day basis.

4.

Ongoing participation in rehabilitation program/attending group therapy, e.g., Alcoholics Anonymous.

5.

Condition, prognosis, and therapeutic regimen understood.

6.

Plan in place to meet needs after discharge.

1. Anxiety/Fear
Nursing Diagnosis

Anxiety/Fear

May be related to

Cessation of alcohol intake/physiological withdrawal

Situational crisis (hospitalization)

Threat to self-concept, perceived threat of death

Possibly evidenced by

Feelings of inadequacy, shame, self-disgust, and remorse

Increased helplessness/hopelessness with loss of control of own life

Increased tension, apprehension

Fear of unspecified consequences; identifies object of fear

Desired Outcomes

Verbalize reduction of fear and anxiety to an acceptable and manageable level.

Express sense of regaining some control of situation/life.

Demonstrate problem-solving skills and use resources effectively.

Nursing Intervention

Rationale

Determine cause of anxiety, involving patient in the

Person in acute phase of withdrawal may be unable to

process. Explain that alcohol withdrawal increases

identify and accept what is happening. Anxiety may be

anxiety and uneasiness. Reassess level of anxiety

physiologically or environmentally caused. Continued

on an ongoing basis.

alcohol toxicity will be manifested by increased anxiety

and agitation as effects of medication wear off.

Develop a trusting relationship through frequent

Provides patient with a sense of humanness, helping to

contact being honest and non-judgmental. Project

decrease paranoia and distrust. Patient will be able to

an accepting attitude about alcoholism.

detect biased or condescending attitude of caregivers.

Maintain a calm environment, minimizing noise.

Reduces stress.

Inform patient about what you plan to do and why.

Enhances sense of trust, and explanation may increase

Include patient in planning process and provide

cooperation and reduce anxiety. Provides sense of control

choices when possible.

over self in circumstance where loss of control is a

significant factor. Note: Feelings of self-worth are
intensified when one is treated as a worthwhile person.

Reorient frequently.

Patient may experience periods of confusion, resulting in

increased anxiety.

Orient the patient to reality.

He may also experience hallucinations and may try to

harm himself and others.

Monitor patient for signs of depression.

To prevent suicidal attempts.

Administer medications as indicated:

Benzodiazepines: chlordiazepoxide (Librium),

Antianxiety agents are given during acute withdrawal to

diazepam (Valium);

help patient relax, be less hyperactive, and feel more in

control.

Barbiturates: phenobarbital, or possibly

These drugs suppress alcohol withdrawal but need to be

secobarbital (Seconal), pentobarbital (Nembutal).

used with caution because they are respiratory depressants

and REM sleep cycle inhibitors.

Arrange Intervention (confrontation) in

Process wherein SO and family members, supported by

controlled setting

staff, provide information about how patients drinking

and behaviour have affected each one of them, helps
patient acknowledge that drinking is a problem and has
resulted in current situational crisis.

Provide consultation for referral to detoxification

Patient is more likely to contract for treatment while still

and

hurting and experiencing fear and anxiety from last

crisis center for ongoing treatment program as soon

drinking episode. Motivation decreases as well-being

as medically stable (oriented to reality).

increases and person again feels able to control the

problem. Direct contact with available treatment

resources provides realistic picture of help. Decreases
time for patient to think about it, change mind or
restructure and strengthen denial systems.
2. Sensory-Perceptual Alterations
Nursing Diagnosis

Sensory-Perceptual Alterations

May be related to

Chemical alteration: Exogenous (e.g., alcohol consumption/sudden cessation) and endogenous (e.g.,
electrolyte imbalance, elevated ammonia and BUN)

Sleep deprivation

Psychological stress (anxiety/fear)

Possibly evidenced by

Disorientation to time, place, person, or situation

Changes in usual response to stimuli; exaggerated emotional responses, change in behaviour

Bizarre thinking

Listlessness, irritability, apprehension, activity associated with visual/auditory hallucinations

Fear/anxiety

Desired Outcomes

Regain/maintain usual level of consciousness.

Report absence of/reduced hallucinations.

Identify external factors that affect sensory-perceptual abilities.

Nursing Intervention

Rationale

Assess level of consciousness;

Speech may be garbled, confused, or slurred. Response to commands may

ability to speak, response to

reveal inability to concentrate, impaired judgment, or muscle coordination

stimuli and commands.

deficits.

Observe behavioural responses

Hyperactivity related to CNS disturbances may escalate rapidly.

such as hyperactivity,

Sleeplessness is common due to loss of sedative effect gained from alcohol

disorientation, confusion,

usually consumed before bedtime. Sleep deprivation may aggravate

sleeplessness, irritability.

disorientation and confusion. Progression of symptoms may indicate

impending hallucinations (stage II) or DTs (stage III).

Provide calm environment,

To reduce the incidence of delusions and hallucinations.

minimizing noise and shadows.

Avoid restraining the patient

To protect patient and others.

unless necessary.
Note onset of hallucinations.

Auditory hallucinations are reported to be more frightening and threatening

Document as auditory, visual,

to patient. Visual hallucinations occur more at night and often include insects,

and tactile.

animals, or faces of friends and enemies. Patients are frequently observed

picking the air. Yelling may occur if patient is calling for help from
perceived threat (usually seen in stage III AWS).

Provide quiet environment. Speak in calm,

Reduces external stimuli during hyperactive stage. Patient may

quiet voice. Regulate lighting as indicated.

become more delirious when surroundings cannot be seen, but

Turn off radio and TV during sleep.

some respond better to quiet, darkened room.

Provide care by same personnel whenever

Promotes recognition of caregivers and a sense of consistency,

possible.

which may reduce fear.

Monitor patient for signs of depression.

To avoid harming himself and attempts of suicide.

Encourage SO to stay with patient

May have a calming effect, and may provide a reorienting

whenever possible.

influence.

Reorient frequently to person, place, time,

May reduce confusion, prevent and limit misinterpretation of

and surrounding environment as indicated.

external stimuli.

Avoid bedside discussion about patient or

Patient may hear and misinterpret conversation, which can

topics unrelated to the patient that do not

aggravate hallucinations.

include the patient.

Provide environmental safety (place bed in

Patient may have distorted sense of reality or be fearful or suicidal,

low position, leave doors in full open or

requiring protection from self.

closed position, observe frequently, place

call light or bell within reach, remove
articles that can harm patient).
Provide seclusion, restraints as necessary.

Patients with excessive psychomotor activity, severe

hallucinations, violent behaviour, and suicidal gestures may
respond better to seclusion. Restraints are usually ineffective and
add to patients agitation, but occasionally may be required to
prevent self-harm.

Orient the patient to reality.

He may experience hallucinations and may try to harm himself and

others.

Monitor laboratory studies: electrolytes,

Changes in organ function may precipitate or potentiate sensory-

magnesium levels, liver function studies,

perceptual deficits. Electrolyte imbalance is common. Liver

ammonia, BUN, glucose, ABGs.

function is often impaired in the chronic alcoholic, and ammonia

intoxication can occur if the liver is unable to convert ammonia to
urea. Ketoacidosis is sometimes present without glycosuria;
however, hyperglycaemia or hypoglycemia may occur, suggesting
pancreatitis or impaired gluconeogenesis in the liver. Hypoxemia
and hypercarbia are common manifestations in chronic alcoholics
who are also heavy smokers.

Administer medications as indicated:

Reduces hyperactivity, promoting relaxation and sleep. Drugs that

Antianxiety agents as indicated

have little effect on dreaming may be desired to allow dream

recovery (REM rebound) to occur, which has previously been
suppressed by alcohol use.

3. Risk for Injury

Nursing Diagnosis

Risk for Injury

Risk factors may include

Cessation of alcohol intake with varied autonomic nervous system responses to the systems suddenly
altered state

Involuntary clonic/tonic muscle activity (seizures)

Equilibrium/balancing difficulties, reduced muscle and hand/eye coordination

Desired Outcomes

Demonstrate absence of untoward effects of withdrawal.

Nursing Intervention

Rationale

Experience no physical injury.

Identify stage of AWS (alcohol withdrawal syndrome);

Prompt recognition and intervention may halt

i.e., stage I is associated with signs and symptoms of

progression of symptoms and enhance recovery

hyperactivity (tremors, sleeplessness, nausea

or improve prognosis. In addition, recurrence or

and vomiting, diaphoresis, tachycardia, hypertension).

progression of symptoms indicates need for changes

Stage II is manifested by increased hyperactivity plus

in drug therapy and more intense treatment to prevent

hallucinations and seizure activity. Stage III symptoms

death.

include DTs and extreme autonomic hyperactivity with

profound confusion, anxiety, insomnia, fever.
Monitor and document seizure activity. Maintain patent

Grand mal seizures are most common and may be

airway. Provide environmental safety (padded side rails,

related to decreased magnesium levels,

bed in low position).

hypoglycemia, elevated blood alcohol, or history of

head trauma and preexisting seizure disorder. Note: In
absence of history and other pathology causing

seizures, they usually stop spontaneously, requiring

only symptomatic treatment. Note: Antiepileptic
drugs are not indicated for alcohol withdrawal
seizures.
Check deep-tendon reflexes. Assess gait, if possible.

Reflexes may be depressed, absent, or hyperactive.

Peripheral neuropathies are common, especially in
malnourished patient. Ataxia (gait disturbance) is
associated with Wernickes syndrome (thiamine
deficiency) and cerebellar degeneration.

Assist with ambulation and self-care activities as

Prevents falls with resultant injury.

needed.
Provide for environmental safety when indicated.

May be required when equilibrium, hand and eye

coordination problems exist.

Administer medications as indicated:

Benzodiazepines (BZDs): chlordiazepoxide (Librium),

BZDs are commonly used to control neuronal

diazepam (Valium), clonazepam (Klonopin), oxazepam

hyperactivity because of their minimal respiratory and

(Serax), clorazepate (Tranxene);

cardiac depression and anticonvulsant properties.

Studies have also shown that these drugs can prevent
progression to more severe states of withdrawal. IV
and PO administration is preferred route because IM
absorption is unpredictable. Muscle-relaxant qualities
are particularly helpful to patient in controlling the
shakes, trembling, and ataxic quality of movements.
Patient may initially require large doses to achieve
desired effect, and then drugs may be tapered and
discontinued, usually within 96 hr. Note: These agents
are used cautiously in patients with known hepatic
disease because they are metabolized by the liver,

although Serax has a shorter half-life.

Haloperidol (Haldol);

May be used in conjunction with BZDs for patients

experiencing hallucinations.

Thiamine;

Thiamine deficiency (common in alcohol abuse) may

lead to neuritis, Werneckes syndrome, and
Korsakoffs psychosis.

Magnesium Sulfate.

Reduces tremors and seizure activity by decreasing

neuromuscular excitability.

Key Facts on Alcohol and Pregnancy

There is no safe amount or type of alcohol to consume during pregnancy. Any amount of alcohol,
even if its just one glass of wine, passes from the mother to the baby. It makes no difference if the
alcohol is wine, beer, or liquor or distilled spirits (vodka, rum, tequila, etc.)

A developing baby cant process alcohol. Developing babies lack the ability to process alcohol with
their liver, which is not fully formed. They absorb all of the alcohol and have the same blood alcohol
concentration as the mother.

Alcohol causes more harm than heroin or cocaine during pregnancy. The Institute of Medicine
says, Of all the substances of abuse (including cocaine, heroin, and marijuana), alcohol produces by
far the most serious neurobehavioral effects in the fetus. No type of alcohol or illicit drugs consumed
during pregnancy is completely without risk.

Alcohol used during pregnancy can result in FASD. An estimated 40,000 newborns each year are
believed to have an FASD, Fetal Alcohol Spectrum Disorders, with damage ranging from major to
subtle.

1 in 100 newborns in the U.S. might have FASD, nearly the same rate as Autism. FASD is more
prevalent than Down Syndrome, Cerebral Palsy, SIDS, Cystic Fibrosis, and Spina Bifida combined.
Alcohol use during pregnancy is the leading preventable cause of birth defects, developmental
disabilities, and learning disabilities.

Bibliography

Davidson. M.R., London, M., Ladewig, P.W., (2012). Maternal-newborn nursing and womens
healthcare. 9th Ed. USA: Pearson Prentice Hall.
James, D. K., Steer, P. J., Weiner, C.P. & Gonik, B., (1999). High Risk Pregnancy Management
Options. 2nd Ed. London, United Kingdom: Harcourt Brace and Company
Varney, H., Kriebs, J., Gegor, C., (2004) Varneys Midwifery. 4th Ed. USA: Jones and Bartlett
Publishers.
.