Acne vulgaris ( acne ) can occur in pregnancy possibly due to the hormonal changes influencing sebum production. [ 23 ] [ 24 ]  There are limited antiacne medications that are safe in pregnancy. External applications of  azelaic acid ,  glycolic acid , or  benzoyl peroxide  (alone or combined with  clindamycin  or erythromycin) are the safest options to treat mild to moderate acne. [ 24 ] [ 25 ] [ 26 ]   Erythromycin  is the antibiotic of choice for severe acne, barring the use of its estolate salt which risks maternal hepatotoxicity. [ 27 ]  Topical  nicotinamide  and topical zinc are safe, however, there are no FDA  pregnancy category  ratings. [ 27 ] [ 28 ]  Topical  salicylic acid  and topical  dapsone  are classified as FDA  pregnancy category  C. [ 23 ] [ 28 ]  Acne medications to avoid during pregnancy include oral  isotretinoin  and topical  tazarotene  as there have been reports of birth defects. [ 23 ] [ 29 ] [ 30 ]  As safety data is lacking, the use of topical retinoids, such as  adapalene  and  tretinoin , is not recommended. [ 25 ] [ 31 ]   Antiandrogenic  drugs, including  spironolactone  and  cyproterone acetate , should be avoided. [ 23 ] [ 30 ]  If planning to conceive while using contraindicated medications, a washout and waiting period before conception is advised. [ 24 ]  A herbal product,  vitex agnus-castus  should not be used during gestation due to undesirable hormonal effects. [ 32 ]


Safety data supports the use of blue and red  light therapy  as non-drug treatments to consider. [ 23 ] [ 24 ]  Personal hygiene and a healthy lifestyle also help, however dietary restriction and abrasive agents found in facial cleaning products are not beneficial. [ 25 ]  As there are limited options to safely treat acne in pregnancy, shared decision-making between the health care provider and client is recommended. [ 23 ] [ 25 ]


Anticoagulants  are medications that prevent the blood from forming clots and are also known as blood thinners. [ 33 ]  These medications are commonly used for both prevention and treatment in people who are at risk for or have experienced a heart attack, stroke, or  venous thromboembolism . [ 33 ]  Pregnancy increases the  risk of clot formation  in women due to elevated levels of certain clotting factors and compounds in the body, and the risk increases even more immediately after birth and remains elevated up to 3 months after delivery. [ 34 ] [ 35 ]  Anticoagulants must be prescribed with caution as these medications can have negative health consequences for the developing baby and need to consider dosing and medication management options. [ 36 ]


Warfarin  (brand name Coumadin) is a commonly prescribed blood thinner both in the inpatient and outpatient hospital settings. In pregnant women, warfarin is contraindicated and should be avoided as it crosses the placental barrier. Additionally, warfarin is listed as Pregnancy Category D, which means it has a risk of harming the fetus. [ 37 ]  However, it has been shown that daily warfarin doses up to 5 mg may be beneficial for pregnant women who are at higher risk of  thromboembolism . [ 38 ]


A common low molecular weight heparin drug is called  enoxaparin  (brand name Lovenox). Enoxaparin is listed as Pregnancy Category B, meaning animal studies have failed to show harmful effects to the fetus and therefore are safe to use in pregnant women. [ 37 ] [ 39 ]  However, pregnant women taking LMWH may not experience the full anticoagulant effect due to the nature of the medication compared to other anticoagulants (i.e. warfarin) and may be less favorable for users as it is an injectable medication. [ 40 ]


Unfractionated  heparin  is another type of anticoagulant that has been widely used. UFH is classified as Pregnancy Category C, which means animal studies have shown potential for adverse effects to the fetus; however, there needs to be more studies done to confirm the presence of a risk to the fetus. UFH can be used in pregnant women as long as the benefits outweigh the risk. [ 37 ]


Direct oral anticoagulants  are newer types of anticoagulants that are available as oral medications and are widely used in non-pregnant populations. As many studies looking at DOACs exclude pregnant women, there is not enough evidence to demonstrate the safety and efficacy of DOACs in pregnant women. [ 40 ]  Currently, rivaroxaban (Xarelto), dabigatran (Pradaxa), and edoxaban (Savaysa) are DOACs listed under Pregnancy Category C, and apixaban (Eliquis) is listed under Pregnancy Category B. [ 41 ]


SSRI use in pregnancy has been associated with a variety of risks with varying degrees of proof of causation. As depression is independently associated with negative pregnancy outcomes, determining the extent to which observed associations between antidepressant use and specific adverse outcomes reflect a causative relationship has been difficult in some cases. [ 42 ]  In other cases, the attribution of adverse outcomes to antidepressant exposure seems fairly clear.


SSRI use in pregnancy is associated with an increased risk of spontaneous abortion of about 1.7-fold, [ 43 ] [ 44 ]  and is associated with preterm birth and low birth weight. [ 45 ]


A systematic review of the risk of major birth defects in antidepressant-exposed pregnancies found a small increase (3% to 24%) in the risk of major malformations and a risk of cardiovascular birth defects that did not differ from non-exposed pregnancies. [ 46 ]  A study of fluoxetine-exposed pregnancies found a 12% increase in the risk of major malformations that did not reach statistical significance. [ 47 ]  Other studies have found an increased risk of cardiovascular birth defects among depressed mothers not undergoing SSRI treatment, suggesting the possibility of ascertainment bias, e.g. that worried mothers may pursue more aggressive testing of their infants. [ 48 ]  Another study found no increase in cardiovascular birth defects and a 27% increased risk of major malformations in SSRI exposed pregnancies. [ 44 ]  The FDA advises for the risk of birth defects with the use of paroxetine [ 49 ]  and the MAOI should be avoided.


A 2013 systematic review and meta-analysis found that antidepressant use during pregnancy was statistically significantly associated with some pregnancy outcomes, such as gestational age and preterm birth, but not with other outcomes. The same review cautioned that because differences between the exposed and unexposed groups were small, it was doubtful whether they were clinically significant. [ 50 ]


A  neonate  (infant less than 28 days old) may experience a  withdrawal syndrome  from abrupt discontinuation of the antidepressant at birth. Antidepressants can be present in varying amounts in breast milk, but their effects on infants are currently unknown. [ 51 ]


Diarrhea is not a common symptom of pregnancy; however, it can occur as a result of reduced gastric acidity and slowed intestinal motility. [ 53 ]  Bismuth subsalicylate (Pepto-Bismol), loperamide (Imodium), and atropine/diphenoxylate (Lomotil) are antidiarrheal agents that can be used to treat diarrhea. However, not all of them are safe to use during pregnancy. One of the components of bismuth subsalicylate is salicylate, which is a component that crosses the placenta. Due to this, there is an increased risk for intrauterine growth retardation, fetal hemorrhage, and maternal hemorrhage within organogenesis and in the second/third trimester. [ 12 ]  Loperamide has limited data on the impact it has on pregnancy, but there is an association with cardiovascular malformation in the first trimester. [ 14 ] [ 12 ]  Atropine/diphenoxylate currently has insufficient evidence of teratogenicity in humans, but trials with animals showed evidence of teratogenic effects. [ 14 ]


Antihistamines  may be prescribed in early pregnancy for the treatment of nausea and vomiting along with symptoms of asthma and allergies. [ 54 ]   First generation antihistamines  include  diphenhydramine  (Benadryl),  chlorpheniramine  (Diabetic Tussin),  hydroxyzine  (Atarax), and  doxepin  (Sinequan). [ 55 ]  Second generation antihistamines include  loratadine  (Claritin),  cetrizine  (Zyrtec), and  fexofenadine  (Allegra). [ 12 ]  First generation antihistamines have the ability to cross the  blood-brain barrier  which can result in sedative and  anticholinergic  effects while effectively treating allergic reactions and nausea and vomiting related to pregnancy. On the other hand, second generation antihistamines do not cross the blood-brain barrier, thus eliminating sedating effects. Currently, there is a lack of association between prenatal antihistamine exposure and birth defects. [ 54 ]


Antihistamines during pregnancy have not been linked to birth defects; however, further research is necessary for some antihistamine medications to determine safety during pregnancy. [ 56 ]  It is suggested that women speak to their healthcare professionals before taking any over-the-counter or prescription medication while pregnant to ensure that there are no adverse health outcomes. [ 1 ]


Hypertensive issues are the most common cardiovascular disorders during pregnancy, occurring within 5 to 10% of all pregnant females. [ 57 ]   Anti-hypertensives  are blood pressure medications used to treat high blood pressure in pregnant women. [ 38 ]  This class of medication is commonly used to treat problems such as heart failure, heart attack, and kidney failure. [ 38 ]  Caution must be exercised with the use of various hypertensive agents for the treatment of blood pressure. [ 57 ]  While the drug classes of Angiotensin Converting Enzyme inhibitors (ACEi), Angiotensin Receptor Blockers (ARB), and angiotensin receptor neprilysin inhibitors (ARNI) have been shown to be potent anti-hypertensive agents, their use is advised against during pregnancy. [ 57 ]  ACEi and ARB have known fetotoxicities when used during the second or third trimester or both. [ 58 ]  Signs and symptoms of ACEi and ARB use during pregnancy include kidney damage or failure,  oligohydramnios , anuria, joint contractures, and hypoplasia of the skull. [ 58 ]  Common, alternative agents for high blood pressure in pregnant women include  anti-adrenergic  and  beta-blocking  medications, such as methyldopa or metoprolol, respectively. [ 58 ]


Decongestants are often used in conjunction with cold medications or to combat pregnancy rhinitis in pregnant women. Common decongestants include  pseudoephedrine  and  phenylephrine . [ 14 ]  Pseudoephedrine is an  alpha-adrenergic receptor agonist  that enacts a  vasoconstrictive  effect to reduce airflow resistance in the nasal cavity and allow easier breathing by relieving a stuffy or congested nose. When taken in early trimesters, there has been limited evidence to associate pseudoephedrine with birth defects. However, studies often found it difficult to isolate pseudoephedrine's involvement, due to the variety of combination products that contain pseudoephedrine in conjunction with other medications. [ 11 ]  Since pseudoephedrine activates alpha adrenergic receptors, it has the ability to elevate blood pressure and cause vasoconstriction within the uterine arteries. This can negatively affect blood flow to the fetus. [ 14 ]  Due to the lack of studies, decongestants in combination drugs or isolated forms are suggested to be used sparingly during pregnancy. Saline nasal sprays, among other non-pharmacological treatments, are considered to be safe alternatives for decongestants. [ 12 ]


Dietary supplements  such as folic acid and iron are important for a healthy pregnancy. [ 5 ]  Some dietary supplements can cause side effects and harm to the mother or unborn child. [ 5 ]  Pregnant women should discuss all dietary supplements with their health care professional to determine the appropriate dosage and which supplements are safe during pregnancy. [ 5 ]


Caution should be taken before consuming dietary supplements while pregnant as dietary supplements are considered "foods" rather than medications and are not regulated for safety and efficacy by the FDA. [ 59 ] [ 60 ]


Many countries such as the USA, Canada, Chile, and Costa Rica have fortified foods with  folic acid  and have seen a reduced incidence of  neural tube defect (NTD) . [ 61 ]


The  Center for Disease Control and Prevention (CDC)  recommends that all women of child-barring age receive 400 μg of folic acid supplement (even if they are not planning on getting pregnant). Women who have already had an NTD-affected pregnancy and are planning to become pregnant again should receive 4000 μg each day for a month before and for the first three months of pregnancy. [ 62 ]  The recommendation came from a study conducted by the British  Medical Research Council (MRC)  Vitamin Study Group from July 1983 to April 1991 involving 33 centers (17 of which in the UK and the remaining 16 in 6 different countries) that compared pregnancy outcomes of folic acid and other vitamins interventions with placebo. That study found a risk reduction of 71% of NTD-affected pregnancies in groups receiving folic acid when compared to groups receiving placebo. In the study, there were four intervention groups, Group A received 4 mg of folic acid; Group B received a multivitamin that contained folic acid; Group C placebo and Group D received a multivitamin without folic acid. In the groups that received folic acid, 6 out of 593 (1%) infants and fetuses had NTD reoccurrence compared to the groups that received no folic acid, which had 21 infants and fetuses with NTD out of 602 (3.5%). [ 63 ]  There were no significant benefit found in the vitamin intervention groups. [ 61 ]


Iron deficiency  is common in pregnancy, with the highest occurrence rate during the third trimester as iron demand increases to support the placenta, fetal development and the iron stores for the first six months after birth. Low iron levels can cause fatigue, reduced work capacity, cardiovascular stress, lower resistance to infection and iron deficiency anemia. Iron deficiency anemia in pregnancy can lead to an increased risk of premature delivery, low birth weight and increased risk of perinatal mortality. [ 64 ]


The  Recommended Dietary Allowance (RDA)  suggests 27 mg of iron a day which would account for normal iron losses, iron used by the fetus and related tissues during gestation and increased maternal hemoglobin mass changes. [ 64 ]  WHO recommends taking supplements of 30–60 mg of elemental iron a day throughout pregnancy for all pregnant individuals. Iron demand depends on individual specific factors and risk of deficiency; for specific dose recommendations, individuals should discuss with their doctors. [ 65 ]


Dietary sources of iron include meat, poultry, fish, eggs, legumes, vegetables, fruits, grains, nuts and iron-fortified grain products. Eating at least one source of vitamin C with each meal is also recommended, as it can help increase iron absorption. Examples of vitamin C sources include broccoli, cantaloupe, citrus fruits and their juices, kiwis, mangos, potatoes, strawberries, sweet peppers, tomatoes, and tomato sauce. On the contrary, caffeine, calcium supplements and antacids should be separated from meals and iron supplements by 1–2 hours as they can decrease iron absorption. [ 64 ]


According to the  World Health Organization ,  substance abuse  refers to the damaging or risky consumption of  psychoactive substances , which includes alcohol and illegal drugs. [ 66 ] [ 67 ]  When pregnant women use psychotropic substances, whether they are prescribed or not, it can have adverse effects on the developing fetus. [ 66 ]  These effects may include causing  birth defects , delayed development, and  intrauterine growth restriction . [ 66 ]  Additionally, it raises the likelihood of various  pregnancy complications , including spontaneous  miscarriage ,  preterm birth , and puts the mother at an increased risk of medical issues such as  postpartum bleeding  and  placental abruption . [ 66 ]


Alcohol should not be consumed while pregnant. Even a small amount of alcohol is not known to be safe for the unborn baby. [ 68 ]  Alcohol passes easily from the mother's bloodstream through the placenta and into the bloodstream of the fetus. Since the fetus is smaller and does not have a fully developed liver, the concentration of alcohol in its bloodstream lasts longer, increasing the chances of detrimental side effects. [ 69 ]  The severity of effects alcohol may have on a developing fetus depends upon the amount and frequency of alcohol consumed as well as the stage of pregnancy. Rates of alcohol consumption can generally be categorized in one of three ways: heavy drinking (more than 48-60 grams of ethanol/day), moderately high drinking (24-48 grams of ethanol/day), and binge drinking (4-5 drinks/90 grams of ethanol at a time). [ 70 ]


Heavy drinking and binge drinking are closely associated with a higher risk of  fetal alcohol spectrum disorders  (FASDs). The most severe form of FASD is  fetal alcohol syndrome  (FAS). This used to be the only diagnosis for fetal disorders due to alcohol consumption, but the term was broadened to a "spectrum" due to the variety of abnormalities observed in newborns. This was most likely because of the different amounts of alcohol ingested during pregnancy indicating that there is not a clear, specific dose that determines if a fetus will be affected by alcohol or not. FAS is characterized by slower physical growth, distinct facial abnormalities including smooth philtrum, thin vermilion, and short palpebral fissures,  neurological deficits , or smaller head circumference. Other problems associated with FASD include delayed or uncoordinated  motor skills ,  hearing  or  vision problems ,  learning disabilities ,  behavior problems , and inappropriate  social skills  compared to  same-age peers . Those affected are more likely to have trouble in school, legal problems, participate in high-risk behaviors, and develop  substance use disorders  themselves.


Alcohol consumption is a risk factor for  miscarriage . [ 71 ]


Babies exposed to alcohol, benzodiazepines, barbiturates, and some antidepressants (SSRIs) during pregnancy may experience  neonatal withdrawal . [ 72 ]


The onset of clinical presentation typically appears within 48 to 72 hours of birth but may take up to 8 days. [ 73 ] [ 74 ]


Drinking of alcohol by parents is linked to  sudden infant death syndrome  (SIDS). [ 75 ]  One study found a positive correlation between the two during New Years celebrations and weekends. [ 76 ]  Another found that  alcohol use disorder  was linked to a more than doubling of risk. [ 77 ]


Caffeine  is a widespread drug consumed by adults due to its behavioral and stimulating effects. According to the  American College of Obstetricians and Gynecologists , an acceptable intake of caffeine for pregnant women is less than or equal to 200 mg per day. [ 78 ]  Consumption of caffeine is not associated with adverse reproductive and developmental effects. [ 79 ]  The half-life of caffeine is longer in pregnancy by 8 to 16 more hours, which means that caffeine stays in the person longer, increases fetal exposure to caffeine, and is eliminated slower in the body. [ 78 ]  Other comprehensive reviews reported that caffeine intake of more than 300 mg per day have been associated with spontaneous abortions and low birth weight, but further research is needed to establish this causal relationship. [ 78 ]


Cannabis use during pregnancy should be avoided. [ 80 ]  There is no known safe dose of cannabis while pregnant and use of cannabis may lead to birth defects, pre-term birth, or low birth weight. [ 80 ]   Tetrahydrocannabinol (THC) , an active ingredient in cannabis, can both cross the placenta and accumulates in high concentrations in breast milk. [ 81 ]  Cannabis consumption in pregnancy might be associated with restrictions in growth of the fetus, miscarriage, and cognitive deficits. [ 81 ]  Infants exposed to prenatal cannabis may show signs of increased tremors and altered sleep patterns. [ 82 ]  Cannabis is the most frequently used illicit drug amongst pregnant women. [ 83 ]  There are significant limitations to the current research available. One limitation is because most studies done are dated in the 1980s. [ 84 ]  Additionally, many studies done on cannabis that evaluate its safety often fail to account for confounding factors, a variable that could also be having an effect on an outcome that is not the test variable. For example, tobacco use and sociodemographic differences are often not adjusted for accordingly in many studies. [ 85 ]


Use of  cocaine  in pregnant women is dangerous and can lead to cardiovascular complications like  hypertension ,  myocardial infarction  and  ischemia ,  kidney failure , liver rupture,  cerebral ischemia ,  cerebral infarction , and maternal death. [ 86 ]   Cardiac  muscles become more sensitive to cocaine in pregnancy, in the presence of increasing  progesterone  concentrations. [ 86 ]  Cocaine use leads to increased risk for  perinatal  outcomes: preterm delivery, low birth weight (less than 2500 grams) or reduced birth rate, small size and earlier gestational age at delivery. [ 87 ]


Prenatal cocaine exposure  (PCE) is associated with  premature birth ,  birth defects ,  attention deficit hyperactivity disorder  (ADHD), and other conditions. [ 88 ]


Use of methamphetamine is dangerous for pregnant women and to the fetus. [ 89 ]   Methamphetamines  are a class of drugs that provide stimulant-like effects, including euphoria and alertness. The drug crosses the  placenta  and affects the fetus during the  gestational  stage of pregnancy. [ 89 ]  Methamphetamine use in pregnancy may lead to babies born with an earlier gestational age at delivery (pre-term), lower birth weight, and smaller head circumference. [ 89 ]  Methamphetamine use during pregnancy also negatively impacts brain development and behavioral functioning and increases the risk of the baby having ADHD and lower mental processing speed. [ 89 ]


Opioids such as  heroin ,  fentanyl ,  oxycodone  and  methadone  should not be taken while pregnant. Opioid use during pregnancy may cause adverse outcomes for the women and unborn child. [ 11 ]  Women who use opioids during pregnancy in a non-medical fashion are at a higher risk for premature birth, lower birth weight, still birth, specific birth defects, and withdrawal ( neonatal abstinence syndrome ). [ 11 ]


Opioids can cross the placenta and the blood brain barrier to the fetus. [ 90 ]  Opioid use is the main cause of neonatal abstinence syndrome, which is where the baby experiences withdrawals from the opioid they were exposed to during the pregnancy. Typical symptoms may include tremors, convulsions, twitching, excessive crying, poor feeding or sucking, slow weight gain, breathing problems, fever, diarrhea, and vomiting. [ 91 ]  There is no consensus on the effects on cognitive abilities. [ 92 ]  Further research is required to determine the long-term effects of  in utero  exposure to opioid medications on children. [ 11 ]


Smoking during pregnancy is dangerous to the unborn baby and may cause pre-term birth, birth defects such as cleft lip or cleft palate, or miscarriage. [ 93 ] [ 80 ]  Tobacco is the most commonly used substance among pregnant women, at 25%. [ 87 ] [ 94 ]   Nicotine  crosses the placenta and accumulates within fetal tissues. Children born to women who smoked heavily were more susceptible to behavioral problems such as  ADHD , poor  impulse control , and  aggressive behaviors . [ 87 ]  Tobacco contains  carbon monoxide , which has the potential to prevent the fetus from receiving sufficient oxygen. Other health concerns tobacco poses are premature birth, low birth weight, and an increased risk of  sudden infant death syndrome  (SIDS) of up to three times compared to infants not exposed to tobacco. [ 93 ]  Smoking and pregnancy, combined, cause twice the risk of  premature rupture of membranes ,  placental abruption  and  placenta previa . In addition to the fetus, women in general who smoke heavily are less likely to become pregnant. [ 95 ]


Until 2014, the U.S.  Code of Federal Regulations  required that certain drugs and biological products be labelled specifically with respect to their effects on pregnant populations, including a definition of a "pregnancy category". These rules were enforced by the FDA, and medications that have been studied for their effects in pregnancy fell under the following Pregnancy Categories: A, B, C, D, or X depending on how they have been studied and what kind of results were found from the studies. [ 96 ] [ 97 ] [ 98 ]  In 2014, however, the FDA has developed a "Pregnancy and Lactation Labeling Rule (PLLR)" which requires product labels to include specific information related to the safety and effectiveness of medications to pregnant and lactating women. This ruling has removed the requirement of stating pregnancy categories in prescription drug labels. [ 99 ]


Australia's categorization system takes into account  birth defects , the effects around birth or when the mother gives birth, and problems that will arise later in the child's life due to the drug taken. The system places them into a category based on the severity of the consequences that the drug can have on the infant when it crosses the placenta. [ 100 ]


Early postnatal hospital discharge  generally refers to the  postpartum  hospital discharge of the mother and newborn within 48 hours. [ 1 ]  The duration of what is considered "early discharge" varies between countries from 12 to 72 hours due to the differences in average duration of hospital stay. [ 2 ]  The  World Health Organization  recommends healthy mothers and newborns following an uncomplicated  vaginal delivery  at a health facility to stay and receive care at the facility for at least 24 hours after delivery. [ 3 ]  This recommendation is based on findings which suggest that the first 24 hours after giving birth poses the greatest risks for both the mother and  newborn . [ 4 ]


The length of postnatal hospital stay has changed internationally since the 19th century when giving birth at hospitals were first introduced. [ 5 ]  Following  World War II , the length of postnatal hospital discharge has been declining, leading to global increases in early postnatal hospital discharge. [ 5 ] [ 6 ] [ 7 ]


Conclusions regarding the effects of early postnatal hospital discharge on mothers and newborns remain unclear. [ 8 ]  This is due to inconsistency of the definition of early postnatal hospital discharge, methodologies and clinical interventions between research studies. [ 8 ]  Research findings have suggested adverse effects for mothers regarding  breastfeeding  and  depression , whereas others have suggested no differences and even positive effects. [ 2 ] [ 9 ] [ 10 ] [ 11 ] [ 12 ] [ 13 ] [ 14 ]  Similarly, mixed conclusions have been found on the influence of early postnatal hospital discharge on the  morbidity  of newborns. [ 13 ] [ 15 ] [ 16 ] [ 17 ] [ 18 ]


During the 19th century, most women across the world gave birth at home, in which postpartum mothers and newborns were taken care of by their friends, family and hired midwives. [ 5 ] [ 6 ]  As such, 97% of births in 1892 were given at home in Sweden. [ 20 ]  In 1832, the Boston Lying-In Hospital in the United States was built as one of the first hospitals where women could give birth. [ 5 ] [ 21 ]  The  Progressive Era  during the late 19th century in the United States led to increasingly favourable views of hospitals as a place of birth. [ 5 ]


Hospitalisation for childbirth was normalised during the 1940s due to the impacts of World War II (WWII). [ 5 ]  The Emergency Maternal and Infant Care program initiated by the United States government in 1944 subsidised postpartum care for wives of men in the military. This led to the increased accessibility and popularity of giving birth at hospitals. By 1945, 78.8% of American women gave birth at hospitals. [ 7 ]  During WWII, financial support such as the Emergency Maternal and Infant Care program in the United States and increases in birth rate led to shortages of staff and maternity beds in hospitals. These shortages forced hospitals to discharge mothers after a short postpartum period of 24 hours. [ 7 ]  Before the 1940s, average hospital stay was around 10 to 14 days for vaginal delivery but the effects of WWII led to the decrease in hospital days to around three to five days. [ 5 ]


During the 1970s, 1980s and 1990s, the length of postnatal hospital stay had steadily decreased in western countries such as the United States, Australia, United Kingdom and Sweden due to improved infrastructure and scientific advancements. [ 10 ]  The increasing trend of short postnatal hospital stays, often referred to as drive-through deliveries, led to the enactment of early postnatal discharge laws at the state and federal level in the United States between 1995 and 1998. [ 22 ]  32 states passed early postnatal discharge laws which typically included the prohibition of limiting insurance plan coverage of less than 48 hours for vaginal delivery and 96 hours for  cesarean delivery . As a result, states which had enacted early postnatal discharge laws saw rapid increases in the length of postnatal hospital stay than states which later enacted these laws or states which had no law at all. [ 22 ]


Since the 2000s, there has been a further international trend of decreasing length of postnatal hospital stay due to cost saving ability, availability of physical infrastructure such as less hospital beds and a movement away from medical intervention of childbirth. [ 2 ]  Western countries such as Australia indicate that 20% of mothers were discharged less than two days postpartum in 2013, compared with 11% in 2003, showing a decreasing trend of postnatal hospital stays. [ 23 ]  Similarly, postnatal hospital stays have declined to 2.3 days in Sweden, 2.1 days in the Netherlands and 2.0 days in the United States, Ireland and New Zealand in 2010. [ 24 ]


The effects of early postnatal hospital discharge on mothers and newborns have been studied since the early 1960s when the first report on randomly controlled trial of early postnatal hospital discharge was published by Hellman and Palmer in 1962. [ 10 ] [ 16 ]  Since then, there have been controversies on the safety of mothers and newborns regarding early postnatal discharge, in which studies have concluded adverse effects while others suggest no significant effects and positive effects. [ 2 ] [ 10 ] [ 16 ] [ 25 ] [ 26 ]  These divergent conclusions have been suggested to result from varying definitions of what constitutes early postnatal hospital discharge, differences in methodologies and clinical heterogeneity of interventions and programs. [ 8 ]


Mothers participating in early discharge programs which include home-based follow-up care have been found to have higher rates of breastfeeding at three months postpartum as well as exclusive breastfeeding compared to later discharged mothers. [ 12 ] [ 13 ]  Additionally, it has been found that mothers were significantly more satisfied with initiation of breastfeeding when they were discharged early, compared to mothers discharged later. [ 14 ]


In contrast, it has been suggested that mothers who were discharged early felt reduced positive emotions towards breastfeeding compared to mothers who were not discharged early postpartum. [ 9 ]  The length of postnatal hospital discharge has also been found to be a predictor of breastfeeding cessation, in which mothers discharged early were more likely to cease breastfeeding compared to mothers who were discharged at a conventional duration. [ 11 ]


No association between the duration of breastfeeding initiation and of the length of hospital stay postpartum has been found. [ 10 ]  In addition, it has also been suggested that the length of postnatal hospital stay does not influence breastfeeding rates and duration, in which mothers who were discharged early were equally likely to breastfeed their newborns at a similar rate as the mothers who were discharged later. [ 2 ] [ 14 ]


Early postnatal hospital discharge may influence depression in mothers. [ 15 ]  Depression amongst mothers who were discharged within 48 hours of giving birth were found to be more likely at five to six months postpartum compared to mothers who were discharged after five days. [ 10 ] [ 15 ]


In contrast, findings have also suggested that mothers' depression and  anxiety  are not influenced by early postnatal hospital discharge. It has been found that depression and anxiety measured by the hospital anxiety and depression scale showed no differences between mothers who were discharged early and mothers who were discharged later. [ 13 ]  This was also found to be the case for mothers within the first six weeks after birth, in which the proportion of depressed moods reported did not differ between mothers who were discharged early and mothers who were discharged later. [ 14 ]


Although conclusions on the effects of early postnatal hospital discharge on morbidity of newborns remain unclear, it has been suggested that newborns discharged within 24 hours of birth are more likely to require readmission by one month compared to newborns discharged after 24 hours. [ 13 ] [ 15 ]  The main reason for newborn readmission was  jaundice , which occurred at a higher rate than newborns discharged later. be re-hospitalised for jaundice. [ 17 ]  It has also been suggested that there are higher rates of  dehydration  in early discharged newborns compared to newborns discharged later. [ 13 ] [ 15 ]


In contrast, a systematic literature review has found no significant differences in complication rates, type and occurrence of newborn morbidities between newborns who were discharged early and those who were discharged later on. [ 18 ]  Even after three weeks, no differences of complication rates were found between newborns who were discharged early and newborns who stayed at the hospital for a conventional duration. [ 16 ]


The Healthy Babies Healthy Children program initiated by the Ontario Ministry of Health and Long-Term Care includes a policy for hospitals to provide mothers with the option of staying at the hospital postpartum for up to 60 hours. [ 27 ]  The policy was put in place in 1999, supported by the provision of government funds as a part of the Healthy Babies Healthy Children Postpartum Enhancement, which aims to encourage hospital care for all mothers and newborns. [ 27 ]  This policy of guaranteed optional 60 hours postnatal hospital stay was implemented due to a case in which a newborn died after being discharged from hospital early, as well as pronouncements made by the  Canadian Paediatric Society . [ 28 ]


The Canadian Paediatric Society provides a statement which aims to guide the facilitation of postnatal hospital discharge. [ 29 ]  This position statement offers discharge readiness checklists for the newborn and mother, such as the need for a physical examination of the newborn during the first 24 to 72 hours after birth before they are discharged. [ 29 ]


In the United States, the  Newborns' and Mothers' Health Protection Act of 1996  requires health insurance providers and health plans to provide benefits for hospital stays related to childbirth of less than 48 hours for vaginal delivery and 96 hours for cesarean delivery. Early discharge is permitted as an exception if both the insurance or health plan provider and mother are in agreement. [ 30 ]


The  American Academy of Pediatrics  (AAP) provides 17 guidelines and recommendations for early postnatal hospital discharge of healthy infants. AAP suggests that these 17 criteria should be met before the discharge of an infant following an uncomplicated pregnancy and delivery. [ 1 ]


The Heart of England NHS Foundation Trust (HEFT) offers guidelines of early postnatal discharge for obstetric and midwifery staff within HEFT. HEFT requires that the minimum time for infant discharge following delivery is two hours, with criteria involving the need for normal labor and no adverse medical or obstetric history. [ 31 ]


One study done by John Bowers and Helen Cheyne in the U.K. investigated if reducing the length of the patients stay could be possible and safe. [ 32 ]  In the U.K. having a baby is the number one reason for hospital visits, with 800,000 babies being born annually. These numbers are costing the NHS (National Health Service) 2.5 billion pounds per year. They considered making the stay shorter due to the number of women who use midwives and have access to postnatal care, without hospital involvement. Their study found that while they could reduce the postnatal stay without jeopardizing the patients it would not save the hospitals enough money to make the reduction worthwhile. [ citation needed ]


A UK study based on interviews with 40 pregnant women highlighted a fear of having to leave the hospital too early or having to stay too long. According to their feedback, the ideal situation would be more control over the length of stay and making a joint decision with staff. [ 33 ] [ 34 ]


Campbell, Cegolon, Macleod and Benova in 2016 investigated the average duration of hospital stay after facility births in 92 countries. [ 35 ]  Data was gathered using existing database and health surveys from the Organisation for Economic Co-operation and Development (OECD), Demographic and Health Surveys (DHS), Multiple Indicator Cluster Surveys (MICS) and the US Centers for Disease Control and Prevention Reproductive Health Survey (CDC-RHS). The average length of postnatal hospital stay for vaginal delivery ranged from 0.5 days (Egypt) to 6.2 days (Ukraine) in 71 countries whereas cesarean delivery ranged from 2.5 to 9.3 days in 30 countries. [ 35 ]


In a study done by Kay M. Tomashek et al., they researched the rate of infant morbidity in  late preterm  and term infants and their discharge time. [ 36 ]  Of the 1004 late preterm and 24,320 term infants in our study, 4.3% and 2.7% of infants, respectively, were either readmitted or had an observational stay. Late preterm infants were 1.5 times more likely to require hospital-related care and 1.8 times more likely to be readmitted than term infants. Among infants who were breastfed, late preterm infants were 1.8 times more likely than term infants to require hospital-related care and 2.2 times more likely to be readmitted. Jaundice and infection accounted for the majority of readmission's. Their findings suggest that late preterm infants discharged early experience significantly more neonatal morbidity than term infants discharged early; however, this may be true only for breastfed infants. [ citation needed ]


A study done by Gabriella Malagon-Maldonado et al., researched the antepartum, intrapartum, and postpartum predictors of discharge readiness, including nursing educational practices that are predictive of postpartum mothers' perceptions of readiness for hospital discharge. [ 37 ]  Their results found that mothers with three or more children, delivery mode, bottle-feeding, the delivery of education, and the difference between educational content received and needed, were significant predictors that accounted for 42% of the variance in readiness for hospital discharge. Nurses' skill in teaching and educational content received were significant predictors even with parity, feeding, and delivery mode in the model. [ citation needed ]


Echogenic intracardiac focus  ( EIF ) is a small bright spot seen in the baby's heart on an  ultrasound  exam.  This is thought to represent mineralization, or small deposits of calcium, in the muscle of the heart. EIFs are found in about 3–5% of normal pregnancies and cause no health problems.


EIFs themselves have no impact on health or heart function. Often the EIF is gone by the third trimester. If there are no problems or  chromosome  abnormalities, EIFs are considered normal changes, or variants.


Researchers have noted an association between an EIF and a chromosome problem in the baby. [ 1 ]  Types of chromosome problems that are occasionally seen include trisomy 13 ( Patau syndrome ) or trisomy 21 ( Down syndrome ). [ 1 ]  In the case of an isolated EIF, and no other ultrasound findings, some studies show that the risk for a chromosome abnormality is approximately two times a woman's background risk.  Other studies report up to a 1% risk for  Down syndrome  when an EIF is seen on a second trimester fetal ultrasound exam.


An EIF is one clue which can contribute to the chances of a chromosome problem existing. Generally the risks are low if there are no other risk factors. Many babies with chromosome problems do not show any signs on ultrasound. Other factors are discussed in counseling include:


The best available evidence suggests that an isolated echogenic intracardiac focus in the fetus of an otherwise low risk woman does not confer an increased risk of fetal aneuploidy. Although some studies have reported that the number or location of echogenic foci affects the risk of fetal aneuploidy (higher risk with biventricular or right ventricular involvement), the general consensus is that these factors have not been proven to matter. When an echogenic intracardiac focus is identified in an otherwise normal second trimester fetus, a normal cell-free DNA test can be very reassuring and obviate the need for invasive testing.


Amniocentesis  is a test to check a baby's chromosomes. A small amount of amniotic fluid, which contains some fetal cells, is removed and tested. Amniocentesis is very accurate; however, there is a  risk of miscarriage  which occur in 0.5–1% of women who have amniocentesis. [ 2 ]  Results take about two weeks.  A normal amniocentesis result means the EIF is not significant and there would be no other concerns about it. That is usually done between 15 and 20 weeks of pregnancy (during the second trimester).


An EIF in the fetal heart may indicate an increased chance of the baby having a chromosome problem. It does not affect the development of the baby or the function of the heart. If the baby has normal chromosomes, there would be no associated problems to be concerned about. No special treatment or tests are needed at delivery.


It is important to remember that with an isolated EIF, chances are strongly in favor of a normal pregnancy outcome, but the patient is entitled to further counseling and testing options.


An  engineered uterus  is an  organ cultured  or  tissue engineered   uterus  in vitro.  Organ culture is the cultivation of either whole organs or parts of organs in vitro. Using engineered uterus is not yet tried to human, but successful  childbirth  in  rabbit  was observed. [ 1 ]


The use of a bioengineered uterus may be regarded as more ethical than the  uterus transplant  of donated uterus. [ 2 ] [ why? ]


The  estimated date of delivery  ( EDD ), also known as  expected date of confinement , [ 1 ]  and  estimated due date  or simply  due date , is a term describing the estimated delivery date for a  pregnant   woman . [ 2 ]  Normal pregnancies last between 38 and 42 weeks. [ 3 ]  Children are delivered on their expected due date about 4% of the time. [ 4 ]


Confinement  is a traditional term referring to the period of pregnancy when an upper-class, noble, or royal woman would withdraw from society in medieval and Tudor times and be confined to their rooms with midwives, ladies-in-waiting and female family members only to attend them. [ 5 ]  This was believed to calm the mother and reduce the risk of premature delivery. "Lying-in" or bedrest is no longer a standard part of  antenatal  care.


Due date estimation basically follows two steps:


According to  American College of Obstetricians and Gynecologists , the main methods to calculate gestational age are: [ 7 ]


Childbirth on average occurs at a gestational age of 280 days (40 weeks), which is therefore often used as a standard estimation for individual pregnancies. However, alternative durations as well as more individualized methods have also been suggested. There is in any case considerable variation among individual pregnancies.


Given that these gestation lengths are only estimates of an average, it is helpful to consider gestation time as a range of dates rather than as a single "due date". The median is merely a guideline for the day at which half of all births occur earlier, and half of all births occur later. Births rarely occur  on  a due date, but they are clustered  around  due dates. [ 12 ]  A study of singleton live births in the US came to the result that childbirth has a  standard deviation  of 14 days when gestational age is estimated by first trimester ultrasound, and 16 days when estimated directly by last menstrual period. [ 11 ]


Naegele's rule  is a standard way of calculating the due date for a  pregnancy  when assuming a gestational age of 280 days at childbirth. The rule estimates the expected date of delivery (EDD) by adding a year, subtracting three months, and adding seven days to the origin of gestational age. [ 13 ] [ 14 ]  The result is approximately 280 days (40 weeks) from the start of the last menstrual period. Another method is by adding 9 months and 7 days to the first day of the last menstrual period.


Naegele's rule is named after  Franz Karl Naegele , the German  obstetrician  who devised the rule. Naegele was born July 12, 1778, in Düsseldorf, Germany. In 1806, Naegele became ordinary professor and director of the lying-in hospital in Heidelberg. His  Lehrbuch der Geburtshilfe , published in 1830 for midwives, enjoyed a successful 14 editions.


Here's the formula to calculate your Estimated Due Date using Naegele's rule :
 Date of Last Menstrual Period + 7 Days + 9 Calendar Months = Date of Estimated Date of Delivery


Example:
LMP = 8 May 2020


280 days past the start of the last menstrual period is found by checking the day of the week of the LMP and adjusting the calculated date to land on the same day of the week. Using the example above, 8 May 2020 is a Friday. The calculated date (15 February) is a Monday; adjusting to the closest Friday produces 12 February, which is exactly 280 days past 8 May. The calculation method does not always result in 280 days because not all calendar months are the same length; it does not account for leap years.


Mobile apps  essentially always give consistent estimations compared to each other and correct for  leap year , while pregnancy wheels made of paper can differ from each other by 7 days and generally do not correct for leap year. [ 15 ]


Etiology, Concept and Prophylaxis of Childbed Fever  ( German :  Die Ätiologie, der Begriff und die Prophylaxis des Kindbettfiebers ) is a pioneering medical book written by  Ignaz Semmelweis  and published in 1861, which explains how hygiene in hospitals can drastically reduce unnecessary deaths. The book and concept saved millions of mothers from a preventable streptococcal infection. [ citation needed ]


The book is 524 pages long and includes studies in hospitals conducted in Vienna in 1847. It is claimed to be one of the most comprehensive medical studies ever published. It was translated into English in 1983 by Dr. K. Codell Carter.


Semmelweis's findings challenged conventional ideas about  the  incidence  of  puerperal fever  (also known as  postpartum infections  or childbed fever), finding that it could be drastically reduced by requiring hand disinfection in  obstetrical  clinics. He also cites bed hygiene by washing linens after each patient.


Puerperal fever was a deadly infection, common in mid-19th-century hospitals. Semmelweis proposed the practice of  washing hands  with  chlorinated lime solutions  in 1847 while working in  Vienna General Hospital 's First Obstetrical Clinic, where doctors' wards had three times the mortality of  midwives'  wards. [ 1 ]


Semmelweis had his life ruined at the time of publication because his ideas, though now proved and trusted, seemed impossible. The book contains a 100-page section purely dedicated to disproving many of the claims his critics had made about his research and ideas. Due to said critique, Semmelweis's personal life fell apart, leading to behavioral issues and his eventual death. [ citation needed ]


Despite this, in today's world Semmelweis is described as the "saviour of mothers." [ 2 ]


This article about a  medical book  is a  stub . You can help Wikipedia by  expanding it .


The  Ferguson reflex  (also called the fetal ejection reflex) is the neuroendocrine reflex comprising the self-sustaining cycle of  uterine contractions  initiated by pressure at the  cervix , more precisely, the internal end of cervix, or  vaginal walls . It is an example of  positive feedback  in biology. The Ferguson reflex occurs in mammals.


Upon application of pressure to the internal end of the cervix,  oxytocin  is released (therefore increase in contractile proteins), which stimulates uterine contractions, which in turn increases pressure on the cervix (thereby increasing oxytocin release, etc.), until the baby is delivered.


Sensory information regarding mechanical stretch of the cervix is carried in a sensory neuron, which synapses in the  dorsal horn  before ascending to the brain in the  anterolateral columns  (ipsilateral and contralateral routes). Via the  medial forebrain bundle , the efferent reaches the  PVN  and  SON  of the  hypothalamus . The  posterior pituitary  releases oxytocin due to increased firing in the  hypothalamo-hypophyseal tract . Oxytocin acts on the  myometrium , on receptors which have been  upregulated  by a functional increase of the estrogen-progesterone ratio. This functional ratio change is mediated by a decrease in myometrial sensitivity to progesterone, due to a decrease in  progesterone receptor A , and a concurrent increase in myometrial sensitivity to estrogen, due to an increase in  estrogen receptor α . This causes myometrial contraction and further positive feedback on the reflex. [ 1 ] [ 2 ]


Studies among  ewes  demonstrated that the Ferguson reflex is blocked by epidural anesthesia. [ 3 ]  In their studies among mice, Niles Newton and colleagues demonstrated the importance of  cortical  influences. [ 4 ]  They enlarged the topic by introducing the term  fetus ejection reflex .


The concept of cortical influences provided reasons to raise questions about the process of  parturition  among humans, characterized by a high  encephalization quotient .   Michel Odent  had observed that women can experience such a reflex, characterized by a birth after a short series of irresistible and powerful contractions without any room for voluntary movements, resulting in a painless birth.  For such a hormonal cascade to occur requires sufficient psychological safety, as occurs in normal or undisturbed birth.  The higher the intervention rate, such as induction or caesarian section, the lower the likelihood of the Ferguson Reflex occurring.  In contrast, the lower the incidence of intervention, such as is found in those  countries with high rate of home births   Archived  2020-11-11 at the  Wayback Machine , and birth centers worldwide, the higher the likelihood of the Ferguson Reflex occurring.  This may explain the lack of research, considering the public health benefits of such education to both hospitals and the general public.


Fetal alcohol spectrum disorders  ( FASDs ) are a group of conditions that can occur in a person who is exposed to  alcohol  during  gestation . [ 1 ]  FASD affects 1 in 20 Americans, but is highly mis- and under-diagnosed. [ 9 ]


The several forms of the condition (in order of most severe to least severe) are:  fetal alcohol syndrome  (FAS), partial fetal alcohol syndrome (pFAS),  alcohol-related neurodevelopmental disorder  (ARND), [ 1 ]  and neurobehavioral disorder associated with prenatal alcohol exposure (ND-PAE). [ 10 ]  Other terms used are fetal alcohol effects (FAE), partial fetal alcohol effects (PFAE), alcohol-related birth defects (ARBD), [ 1 ] [ 11 ]  and static  encephalopathy , [ 12 ]  but these terms have fallen out of favor and are no longer considered part of the spectrum. [ 13 ]


Not all infants exposed to alcohol in utero will have detectable FASD or pregnancy complications. The risk of FASD increases with amount consumed, the frequency of consumption, and the longer duration of alcohol consumption during pregnancy, particularly  binge drinking . The variance seen in outcomes of alcohol consumption during pregnancy is poorly understood. Diagnosis is based on an assessment of growth, facial features, central nervous system, and alcohol exposure by a multi-disciplinary team of professionals. The main criteria for diagnosis of FASD is nervous system damage and alcohol exposure, with FAS including congenital malformations of the lips and growth deficiency. FASD is often misdiagnosed as or comorbid with ADHD.


Almost all experts recommend that the mother abstain from alcohol use during pregnancy to prevent FASDs. As the woman may not become aware that she has conceived until several weeks into the pregnancy, it is also recommended to abstain while attempting to become pregnant. Although the condition has no known cure, treatment can improve outcomes. Treatment needs vary but include psychoactive medications, behavioral interventions, tailored accommodations, case management, and public resources.
Globally, one in 10 women drink alcohol during pregnancy, and the prevalence of having any FASD disorder is estimated to be at least 1 in 20. The rates of alcohol use, FAS, and FASD are likely to be underestimated, because of the difficulty in making the diagnosis and the reluctance of clinicians to label children and mothers. Some have argued that the FAS label stigmatizes alcohol use, while authorities point out that the risk is real. The condition has appeared in several works of fiction.


The key signs of fetal alcohol syndrome (FAS) required for diagnosis include:


Popova et al. identified 428  ICD-10  conditions as co-occurring in individuals with FAS. Excluding conditions used in FAS diagnosis, co-occurring conditions with 50% prevalence or greater include: [ 16 ]


Other FASD conditions are partial expressions of FAS where the central nervous system shows clinical deficits. In these other FASD conditions, an individual may be at greater risk for adverse outcomes because brain damage is present without associated visual cues of poor growth or the "FAS face" that might ordinarily trigger an FASD evaluation. Such individuals may be misdiagnosed with primary  mental health disorders  such as  ADHD  or  oppositional defiance disorder  without appreciation that brain damage is the underlying cause of these disorders, which requires a different treatment paradigm than typical mental health disorders. While other FASD conditions may not yet be included as an  ICD  or  DSM-IV-TR  diagnosis, they nonetheless pose significant impairment in  functional behavior  because of underlying brain damage. [ 17 ]  Many indications of fetal alcohol spectrum disorders are developmental. Therefore, although a child may appear 'normal' at birth, intellectual disabilities caused by alcohol before birth may not appear until the child begins school. [ 18 ]


More broadly, alcohol use during pregnancy is also associated with: [ 1 ] [ 19 ]


Alcohol can also harm the fertility of women who are planning for pregnancy. Adverse effects of alcohol can lead to malnutrition, seizures, vomiting and dehydration. The mother can suffer from anxiety and depression which can result in child abuse/neglect. It has also been observed that when the pregnant mother withdraws from alcohol, its effects are visible on the infant as well. The baby remains in an irritated mood, cries frequently, does not sleep properly, weakening of sucking ability and increased hunger. [ 26 ]


In 2019, a study found that individuals with FASD have a higher risk of  hypertension  independent of race/ethnicity and obesity. [ 27 ]


Fetal alcohol spectrum disorders are caused by alcohol exposure during gestational development. [ 1 ]  If an individual was not exposed to alcohol before birth, they will not have FASD. [ 28 ]  However, not all infants exposed to alcohol in utero will have detectable FAS, FASD, or pregnancy complications. [ 29 ]


No safe level of fetal alcohol exposure has been established. [ 30 ]  Because alcohol is a known  teratogen , it is considered unethical to do randomized controlled trials on pregnant women to determine the precise toxicity effects of alcohol. [ 31 ]  Among women who consume any quantity of alcohol during pregnancy, the risk of giving birth to a child with FASD is about 15%, and to a child with FAS about 1.5%. Drinking 2  standard drinks  a day, or 6 standard drinks in a short time, carries a 4.3% risk of a FAS birth (i.e. one of every 23 heavy-drinking pregnant women will deliver a child with FAS). Furthermore, alcohol-related congenital abnormalities occur at an incidence of roughly one out of 67 women who drink alcohol during pregnancy. [ 29 ]  Among those mothers who have an alcohol use disorder, an estimated one-third of their children have FAS. [ 32 ]  The variance seen in outcomes of alcohol consumption during pregnancy is poorly understood. Aggravating factors may include  advanced maternal age ,  smoking , poor diet, [ 33 ] [ 34 ]  genetics, and social risk factors. [ 35 ]


The risk of FASD increases with amount consumed, the frequency of consumption, and longer duration of alcohol consumption during pregnancy. [ 35 ] [ 34 ] [ 36 ]   Blood alcohol concentration  has been identified as a relevant factor. [ 37 ]  All forms of alcohol, such as beer, wine, and liquor, pose similar risk. [ 38 ]   Binge drinking  increases the chances and severity of FASD to such an extent that Svetlana Popova has stated that "binge drinking is the direct cause of FAS or FASD". [ 39 ]   Small amounts of alcohol may not cause an abnormal appearance, however, small amounts of alcohol consumption while pregnant may cause behavioral problems and also increases the risk of miscarriage. [ 40 ] [ 32 ] [ 41 ] [ 42 ]  Quasi-experimental studies provide moderately strong evidence that prenatal alcohol exposure causes detrimental cognitive outcomes, and some evidence of reduced birthweight, although no study was fully rated at low risk of bias and quantity of studies was limited. [ 43 ]


The evidence is inconsistent and contradictory regarding the effects of low-to-moderate drinking, for example less than 12 grams of ethanol per day. [ 44 ]  Many studies find no significant effect, but some find beneficial associations, and others find detrimental associations, even on the same outcomes. Summarizing studies by country shows some similarity in results, due to using the same data sources. The definition of low alcohol consumption varies significantly among studies and often fails to incorporate all aspects of timing, dose, and duration. Recall bias and socioeconomic and psychosocial factors have been controlled for in most studies, but it is likely that residual confounding due to missing factors and variation in methods still exists and is larger than any observed effects. [ 45 ] [ 46 ] [ 32 ] [ 47 ] [ 23 ] [ 19 ]


Fathers who consume alcohol prior to conception may contribute to FAS through long term  epigenetic  modification of the father's sperm. [ 32 ] [ 48 ] [ 49 ]


Almost all experts recommend that the mother abstain from alcohol use during pregnancy to prevent FASDs. [ 4 ] [ 13 ] [ 50 ]  A pregnant woman may not become aware that she has conceived until several weeks into the pregnancy, so it is also recommended to abstain from alcohol while attempting to become pregnant. [ 51 ]  The recommendations of abstaining from alcohol during pregnancy and while attempting to become have been made by the  Surgeon General of the United States , [ 52 ] [ 51 ]  the Centers for Disease Control, [ 23 ]  the American College of Obstetricians and Gynecologists, the  American Academy of Pediatrics , [ 38 ]  the  World Health Organization , [ 53 ]  the United Kingdom's  National Institute for Health and Clinical Excellence , [ 54 ]  and many others. [ 38 ]  In the United States, federal legislation has required that warning labels be placed on all alcoholic beverage containers since 1988 under the  Alcoholic Beverage Labeling Act . [ 55 ]


The most current advocacy perspectives encourage people and systems to approach FASD with interventions and support for individuals who are already living with FASD. Focusing on prevention often only further stigmatizes individuals with FASD and their birth parents. Advocates say, if a person is supporting people currently living with FASD then that person is spreading the awareness needed for successful prevention efforts; "Intervention is Prevention". Many  social determinants of health  impact the effects of PAE: [ 56 ]


Women can experience serious symptoms that accompany alcohol withdrawal during pregnancy. According to the World Health Organization, these symptoms can be treated during pregnancy with brief use of  benzodiazepine   tranquilizers . [ 21 ]  Currently, the FDA has approved three medications—naltrexone, acamprosate, and disulfiram—for the treatment of  alcohol use disorder  (AUD).  However, there is insufficient data regarding the safety of these medications for pregnant women. [ 57 ]


American Psychiatric Association  guidelines recommend that medications not be used to treat alcohol use disorder in pregnant women except in cases of acute alcohol withdrawals or other co-existing conditions. [ 61 ]  Instead, behavioral interventions are usually preferred as treatments for pregnant women with AUD. Medications should only be used for pregnant women after carefully considering potential risks and harms of the medications versus the benefits of alcohol cessation. [ 57 ]


After a pregnant woman consumes alcohol, the alcohol crosses through the placenta and umbilical cord to the developing fetus. Alcohol metabolizes slowly in the fetus and remains for a long time when compared to an adult. [ 62 ] [ 37 ]  A human fetus appears to be at triple risk from maternal alcohol consumption: [ 63 ] [ 64 ]


Although alcohol is known to be a  teratogen  (causing birth defects), the exact biological mechanisms for the development of FAS or FASD are unknown. However, clinical and animal studies have identified a broad spectrum of pathways through which maternal alcohol can negatively affect the outcome of a pregnancy. Clear conclusions with universal validity are difficult to draw, since different ethnic groups show considerable  genetic polymorphism  for the hepatic enzymes responsible for ethanol detoxification. [ 65 ]  Genetic examinations have revealed a continuum of long-lasting molecular effects that are not only timing specific but are also dosage specific; with even moderate amounts being able to cause alterations. [ 66 ]  Additionally, ethanol may alter fetal development by interfering with  retinoic acid  signaling as acetaldehyde can compete with retinaldehyde and prevents its oxidation to retinoic acid. [ 67 ]


Different body systems in the infant grow, mature and develop at specific times during gestation. The effect of consumption of alcohol differs during each of these developmental stages: [ 18 ]


Fetal alcohol spectrum disorders encompass a range of  physical  and  neurodevelopmental  problems which can result from prenatal alcohol exposure. Diagnosis is based on the signs and symptoms in the person and evidence of alcohol use. [ 1 ]  These diagnoses of fetal alcohol spectrum disorders are currently recognized:


As of 2016, the  Swedish Agency for Health Technology Assessment and Assessment of Social Services  accepts only FAS as a diagnosis, seeing the evidence as inconclusive with respect to other types. The agency feels it is unclear if identifying a FASD-related condition benefits the diagnosed individual. [ 70 ]


Presently, four FASD diagnostic systems that diagnose FAS and other FASD conditions have been developed in North America:


Each diagnostic system requires an assessment of four key features: growth, facial features, central nervous system, and alcohol exposure. To determine any FASD condition, a  multi-disciplinary  evaluation is necessary to assess each of the four key features for assessment. Generally, a trained  physician  will determine growth deficiency and FAS facial features. While a qualified physician may also assess central nervous system structural abnormalities or neurological problems, usually central nervous system damage is determined through  psychological ,  speech-language , and  occupational therapy  assessments to ascertain clinically significant impairments in three or more of the Ten Brain Domains. [ 73 ]  Prenatal alcohol exposure risk may be assessed by a qualified physician,  psychologist ,  social worker , or chemical health counselor. These professionals work together as a team to assess and interpret data of each key feature for assessment and develop an integrative, multi-disciplinary report to diagnose FAS (or other FASD conditions) in an individual. [ 74 ]


A positive finding on all four features is required for a diagnosis of FAS, and the four diagnostic systems essentially agree on criteria for fetal alcohol syndrome (FAS). However, there are differences among systems when full criteria for FAS are not met. Prenatal alcohol exposure and central nervous system damage are the critical elements of the spectrum of FASD, and a positive finding in these two features is sufficient for an FASD diagnosis in all FASD systems. [ 75 ]  But different researchers and systems may use a wide variety of terminology to describe an individual's FASD condition, as the nomenclature is still evolving. Most individuals with deficits resulting from prenatal alcohol exposure do not express all features of FAS and fall into other FASD conditions. [ 19 ]  The Canadian guidelines recommend the assessment and descriptive approach of the "4-Digit Diagnostic Code" for each key feature of FASD and the terminology of the IOM in diagnostic categories, excepting ARBD. [ 2 ]


The most severe condition is called Fetal Alcohol Syndrome (FAS), [ 1 ]  which refers to individuals who have a specific set of birth defects and neurodevelopmental disorders characteristic of the diagnosis. [ 22 ]  The following criteria must be fully met for an FAS diagnosis: [ 2 ] [ 19 ] [ 71 ] [ 72 ]


FAS is the only expression of FASD that has garnered consensus among experts to become an official  ICD-9  and  ICD-10  diagnosis.


Partial FAS (pFAS) was previously known as atypical FAS in the 1997 edition of the "4-Digit Diagnostic Code". People with pFAS have a confirmed history of prenatal alcohol exposure, but may lack growth deficiency or the complete facial stigmata. Central nervous system damage is present at the same level as FAS. These individuals have the same functional disabilities but "look" less like FAS. [ 76 ]


The following criteria must be fully met for a diagnosis of Partial FAS: [ 2 ] [ 19 ] [ 71 ]


Growth or height may range from normal to deficient. [ 14 ]


Alcohol-related neurodevelopmental disorder (ARND) is the specific diagnosis of the non-dysmorphic type of FASD, where a majority of the symptoms are witnessed. [ 77 ]  The diagnosis was initially suggested by the Institute of Medicine to replace the terms FAE (fetal alcohol effects). It focuses on central nervous system damage, rather than growth deficiency or FAS facial features. The Canadian guidelines also use this diagnosis and the same criteria. While the "4-Digit Diagnostic Code" includes these criteria for three of its diagnostic categories, it refers to this condition as  static encephalopathy . The behavioral effects of ARND are not necessarily unique to alcohol however, so use of the term must be within the context of confirmed prenatal alcohol exposure. [ 13 ]  ARND may be gaining acceptance over the terms FAE and ARBD to describe FASD conditions with central nervous system abnormalities or behavioral or cognitive abnormalities or both due to prenatal alcohol exposure without regard to growth deficiency or FAS facial features. [ 13 ] [ 78 ]


The following criteria must be fully met for a diagnosis of ARND or static encephalopathy: [ 2 ] [ 19 ] [ 71 ]


Growth or height may range from normal to minimally deficient. [ 14 ]


Neurobehavioral disorder associated with prenatal alcohol exposure (ND-PAE) is the spectrum-wide term for the psychiatric, behavioral, and neurological symptoms of all FASDs. It was introduced into the DSM-V as a "condition for further study" and as a specified condition under, "other specified neurodevelopmental disorders" as a way to better study the behavioral aspects of all FASD disorders. [ 77 ]


In terms of FASD,  growth  deficiency is defined as significantly below average  height ,  weight  or both due to prenatal alcohol exposure and can be assessed at any point in the  lifespan . Growth measurements must be adjusted for parental height,  gestational age  (for a  premature infant ), and other  postnatal  insults (e.g.,  poor nutrition ), although birth height and weight are the preferred measurements. [ 71 ]  Deficiencies are documented when height or weight falls at or below the 10th percentile of standardized growth charts appropriate to the population. [ 14 ]  Prenatal or postnatal presentation of growth deficits can occur, but are most often postnatal. [ 79 ]


Criteria for FASD are least specific in the  Institute of Medicine  (IOM) diagnostic system ("low birth weight..., decelerating weight not due to nutrition..., [or] disproportional low weight to height" p. 4 of executive summary), [ 19 ]  while the CDC use the 10th percentile as a cut-off to determine growth deficiency. [ 72 ]  The "4-Digit Diagnostic Code" allows for mid-range gradations in growth deficiency (between the 3rd and 10th percentiles) and severe growth deficiency at or below the 3rd percentile. [ 71 ]  Growth deficiency (at severe, moderate, or mild levels) contributes to diagnoses of FAS and pFAS, but not ARND or static encephalopathy. [ citation needed ]


The "4-Digit Diagnostic Code" from 2004 ranks growth deficiency as follows: [ 71 ]


In the initial studies that described FAS, growth deficiency was a requirement for inclusion in the studies; thus, all the original people with FAS had growth deficiency as an  artifact  of  sampling  characteristics used to establish criteria for the syndrome. [ citation needed ]  That is, growth deficiency is a key feature of FASD because growth deficiency was a criterion for inclusion in the study that defined FAS. Growth deficiency may be less critical for understanding the disabilities of FASD than the neurobehavioral sequelae to the brain damage. [ 19 ]  Canadian guidelines updated in 2016 deleted growth as a diagnostic criterion. [ 80 ]


Several characteristic  craniofacial  abnormalities are often visible in individuals with FAS. [ 81 ]  The presence of FAS facial features indicates  brain damage , although brain damage may also exist in their absence. FAS facial features (and most other visible, but non-diagnostic, deformities) are believed to be caused mainly during the 10th to 20th week of gestation. [ 82 ]


Refinements in diagnostic criteria since 1975 have yielded three distinctive and diagnostically significant facial features which distinguish FAS from other disorders with partially overlapping characteristics. [ 83 ] [ 84 ]  The three FAS facial features are:


Measurement of FAS facial features uses criteria developed by the  University of Washington . The lip and philtrum are measured by a trained physician with the Lip-Philtrum Guide, [ 85 ]  a five-point  Likert scale  with representative photographs of lip and philtrum combinations ranging from normal (ranked 1) to severe (ranked 5). Palpebral fissure length (PFL) is measured in millimeters with either  calipers  or a clear ruler and then compared to a PFL growth chart, also developed by the University of Washington. [ 15 ]


Ranking FAS facial features is complicated because the three separate facial features can be affected independently by prenatal alcohol. A summary of the criteria follows: [ 71 ] [ 86 ]


Central nervous system  (CNS) damage is the primary feature of any FASD diagnosis. Prenatal alcohol exposure, which is classified as a  teratogen , can damage the brain across a continuum of gross to subtle impairments, depending on the amount, timing, and frequency of the exposure as well as genetic predispositions of the fetus and mother. [ 19 ] [ 87 ]  While functional abnormalities are the behavioral and cognitive expressions of the FASD disability, CNS damage can be assessed in three areas: structural, neurological, and functional impairments. [ citation needed ]


All four diagnostic systems allow for assessment of CNS damage in these areas, but criteria vary. The IOM system requires structural or neurological impairment for a diagnosis of FAS, but also allows a "complex pattern" of functional anomalies for diagnosing PFAS and ARND. [ 19 ]  The "4-Digit Diagnostic Code" and CDC guidelines allow for a positive CNS finding in any of the three areas for any FASD diagnosis, but functional anomalies must measure at two standard deviations or worse in three or more functional domains for a diagnosis of FAS, PFAS, and ARND. [ 71 ] [ 72 ]  The "4-Digit Diagnostic Code" also allows for an FASD diagnosis when only two functional domains are measured at two standard deviations or worse. [ 71 ]  The "4-Digit Diagnostic Code" further elaborates the degree of CNS damage according to four ranks:


Structural abnormalities of the brain are observable, physical damage to the brain or brain structures caused by prenatal alcohol exposure. Structural impairments may include  microcephaly  (small head size) of two or more standard deviations below the average, or other abnormalities in brain structure (e.g.,  agenesis of the corpus callosum ,  cerebellar hypoplasia ). [ 19 ]


Microcephaly is determined by comparing head circumference (often called occipitofrontal circumference, or OFC) to appropriate OFC growth charts. [ 14 ]  Other structural impairments must be observed through  medical imaging  techniques by a trained physician. Because imaging procedures are expensive and relatively inaccessible to most people, diagnosis of FAS is not frequently made via structural impairments, except for microcephaly. [ citation needed ]


Evidence of a CNS structural impairment due to prenatal alcohol exposure will result in a diagnosis of FAS, and neurological and functional impairments are highly likely. [ 2 ] [ 19 ] [ 71 ] [ 72 ]


During the first trimester of pregnancy, alcohol interferes with the migration and organization of  brain cells , which can create structural deformities or deficits within the brain. [ 88 ]  During the third trimester, damage can be caused to the  hippocampus , which plays a role in memory, learning, emotion, and encoding visual and auditory information, all of which can create neurological and functional CNS impairments as well. [ 89 ]


As of 2002, there were 25 reports of  autopsies  on infants known to have FAS. The first was in 1973, on an infant who died shortly after birth. [ 90 ]  The examination revealed extensive brain damage, including microcephaly, migration anomalies,  corpus callosum  dysgenesis, and a massive  neuroglial ,  leptomeningeal   heterotopia  covering the left hemisphere. [ 91 ]


In 1977, Clarren described a second infant whose mother was a binge drinker. The infant died ten days after birth. The autopsy showed severe  hydrocephalus , abnormal neuronal migration, and a small corpus callosum. [ 91 ]  FAS has also been linked to  brainstem  and cerebellar changes, agenesis of the corpus callosum and  anterior commissure , neuronal migration errors, absent  olfactory bulbs ,  meningomyelocele , and  porencephaly . [ 91 ]


When structural impairments are not observable or do not exist, neurological impairments are assessed. In the context of FASD,  neurological impairments  are caused by prenatal alcohol exposure which causes general neurological damage to the  central nervous system  (CNS), the  peripheral nervous system , or the  autonomic nervous system . A determination of a neurological problem must be made by a trained physician, and must not be due to a postnatal insult, such as  meningitis ,  concussion ,  traumatic brain injury , etc. [ citation needed ]


All four diagnostic systems show virtual agreement on their criteria for CNS damage at the neurological level, and evidence of a CNS neurological impairment due to prenatal alcohol exposure will result in a diagnosis of FAS or pFAS, and functional impairments are highly likely. [ 2 ] [ 19 ] [ 71 ] [ 72 ]


Neurological problems are expressed as either hard signs, or diagnosable disorders, such as  epilepsy  or other  seizure disorders , or soft signs. Soft signs are broader, nonspecific neurological impairments, or symptoms, such as impaired  fine motor skills ,  neurosensory   hearing loss , poor  gait ,  clumsiness , and poor  eye–hand coordination . Many soft signs have  norm-referenced criteria , while others are determined through clinical judgment. "Clinical judgment" is only as good as the clinician, and soft signs should be assessed by either a pediatric neurologist, a pediatric neuropsychologist, or both. [ citation needed ]


When structural or neurological impairments are not observed, all four diagnostic systems allow CNS damage due to prenatal alcohol exposure to be assessed in terms of functional impairments. [ 2 ] [ 19 ] [ 71 ] [ 72 ]  Functional impairments are deficits, problems, delays, or abnormalities due to prenatal alcohol exposure (rather than hereditary causes or postnatal insults) in observable and measurable domains related to daily functioning, often referred to as  developmental disabilities . There is no consensus on a specific pattern of functional impairments due to prenatal alcohol exposure [ 19 ]  and only CDC guidelines label developmental delays as such, [ 72 ]  so criteria (and FASD diagnoses) vary somewhat across diagnostic systems.


The four diagnostic systems list various CNS domains that can qualify for functional impairment that can determine an FASD diagnosis:


A recent [ when? ]  effort to standardize assessment of functional CNS damage has been suggested by an experienced FASD diagnostic team in Minnesota. The proposed framework attempts to harmonize IOM, 4-Digit Diagnostic Code, CDC, and Canadian guidelines for measuring CNS damage vis-à-vis FASD evaluations and diagnosis. The standardized approach is referred to as the Ten Brain Domains and encompasses aspects of all four diagnostic systems' recommendations for assessing CNS damage due to prenatal alcohol exposure. The framework provides clear definitions of brain dysfunction, specifies empirical data needed for accurate diagnosis, and defines intervention considerations that address the complex nature of FASD with the intention to avoid common secondary disabilities. [ 73 ]


The proposed Ten Brain Domains include: [ 73 ]


The Fetal Alcohol Diagnostic Program (FADP) uses unpublished Minnesota state criteria of performance at 1.5 or more  standard deviations  on  standardized testing  in three or more of the Ten Brain Domains to determine CNS damage. However, the Ten Brain Domains are easily incorporated into any of the four diagnostic systems' CNS damage criteria, as the framework only proposes the domains, rather than the cut-off criteria for FASD. [ 92 ]


Prenatal alcohol exposure is determined by interview of the biological mother or other family members knowledgeable of the mother's alcohol use during the pregnancy (if available), prenatal health records (if available), and review of available birth records, court records (if applicable),  chemical dependency treatment  records (if applicable), chemical biomarkers, [ 93 ]  or other reliable sources.


Exposure level is assessed as  confirmed exposure ,  unknown exposure , and  confirmed absence of exposure  by the IOM, CDC and Canadian diagnostic systems. The "4-Digit Diagnostic Code" further distinguishes confirmed exposure as  High Risk  and  Some Risk : [ citation needed ]


Evidence is insufficient for the use of chemical biomarkers to detect prenatal alcohol exposure. [ 95 ]  Biomarkers being studied include fatty acid ethyl esters (FAEE) detected in the meconium (first feces of an infant) and hair. FAEE may be present if chronic alcohol exposure occurs during the second and third trimester since this is when the meconium begins to form. Concentrations of FAEE can be influence by medication use, diet, and individual genetic variations in FAEE metabolism however. [ 93 ] [ 96 ]


The CDC reviewed nine  syndromes  that have overlapping features with FAS; however, none of these syndromes include all three FAS facial features, and none are the result of prenatal alcohol exposure: [ 72 ]


Other disorders that have overlapping behavioral symptoms that might be comorbid to fetal alcohol spectrum disorder might include: [ 97 ]


Most people with an FASD have most often been misdiagnosed with ADHD due to the large overlap between their behavioral deficits.


Although the condition has no available cure, treatment can improve outcomes. [ 1 ] [ 3 ]  Because CNS damage, symptoms, secondary disabilities, and needs vary widely by individual, there is no one treatment type that works for everyone. [ 33 ]


Between 2017 and 2019 researchers made a breakthrough when they discovered a possible cure using neural stem cells (NSCs); they propose that if applied to a newborn, the damage can be reversed and prevent any lasting effects in the future. [ 98 ]


Psychoactive drugs  are frequently tried as many FASD symptoms are mistaken for or overlap with other disorders, most notably  ADHD . Medications are used to specifically treat symptoms of FASDs and not FAS entirely. Some of the medications used are antidepressants, stimulants, neuroleptics and anti-anxiety drugs. [ 99 ]


Early intervention  from birth to age 3 has been shown to improve the development of a child born with FASD. [ 96 ]  Interventions may include  parent–child interaction therapy , efforts to modify child behavior, and drugs. [ 5 ]   Behavioral  interventions are based on the  learning theory , which is the basis for many parenting and  professional  strategies and interventions. [ 78 ]  Along with ordinary  parenting styles , such strategies are frequently used by default for treating those with FAS, as the diagnoses  oppositional defiance disorder  (ODD),  conduct disorder ,  reactive attachment disorder  (RAD) often overlap with FAS (along with  ADHD ), and these are sometimes thought to benefit from behavioral interventions. Frequently, a person's poor academic achievement results in  special education  services, which also utilizes principles of  learning theory ,  behavior modification , and  outcome-based education . [ citation needed ]


Children with FAS benefit from behavioral and functional training, social skill training and tutoring. Support groups and talk therapy not only help the children suffering from FAS, but also help the parents and siblings of these children. [ citation needed ]


Many books and handouts on FAS recommend a developmental approach, based on  developmental psychology , even though most do not specify it as such and provide little theoretical background. Optimal human development generally occurs in identifiable stages (e.g.,  Jean Piaget 's  theory of cognitive development ,  Erik Erikson 's  stages of psychosocial development ,  John Bowlby 's  attachment framework , and other  developmental stage theories ). FAS interferes with normal development, [ 100 ]  which may cause stages to be delayed, skipped, or immaturely developed. Over time, an unaffected child can negotiate the increasing demands of life by progressing through stages of development normally, but not so for a child with FAS. [ 100 ]


By knowing what developmental stages and tasks children follow, treatment and interventions for FAS can be tailored to helping a person meet developmental tasks and demands successfully. [ 100 ]  If a person is delayed in the  adaptive behavior  domain, for instance, then interventions would be recommended to target specific delays through additional education and practice (e.g., practiced instruction on tying shoelaces), giving reminders, or making accommodations (e.g., using slip-on shoes) to support the desired functioning level. This approach is an advance over behavioral interventions, because it takes the person's developmental context into account while developing interventions. [ citation needed ]


The  advocacy  model takes the point of view that someone is needed to actively mediate between the environment and the person with FAS. [ 13 ]  Advocacy activities are conducted by an advocate (for example, a family member, friend, or  case manager ) and fall into three basic categories. An advocate for FAS: (1) interprets FAS and the disabilities that arise from it and explains it to the environment in which the person operates, (2) engenders change or accommodation on behalf of the person, and (3) assists the person in developing and reaching attainable goals. [ 13 ]


The advocacy model is often recommended, for example, when developing an  individualized education program  (IEP) for the person's progress at school. [ 99 ]


An understanding of the developmental framework would presumably inform and enhance the advocacy model, but advocacy also implies interventions at a systems level as well, such as educating schools, social workers, and so forth on best practices for FAS. However, several organizations devoted to FAS also use the advocacy model at a  community practice  level as well. [ 101 ]


Treating FAS at the  public health  and  public policy  level promotes FAS prevention and diversion of  public resources  to assist those with FAS. [ 13 ]  It is related to the advocacy model but promoted at a systems level (rather than with the individual or family), such as developing community education and supports, state or province level prevention efforts (e.g., screening for maternal alcohol use during  OB/GYN  or prenatal medical care visits), or national awareness programs. Several organizations and state agencies in the U.S. are dedicated to this type of intervention. [ 101 ]


The prognosis of FASD is variable depending on the type, severity, and if treatment is issued. [ citation needed ]  Prognostic disabilities are divided into primary and secondary disabilities.


The primary disabilities of FAS are the functional difficulties with which the child is born as a result of CNS damage due to prenatal alcohol exposure. [ 102 ]


Often, primary disabilities are mistaken as  behavior problems , but the underlying CNS damage is the originating source of a functional difficulty, [ 103 ]  rather than a mental health condition, which is considered a secondary disability. The exact mechanisms for functional problems of primary disabilities are not always fully understood, but  animal studies  have begun to shed light on some correlates between functional problems and brain structures damaged by prenatal alcohol exposure. [ 13 ]  Representative examples include:


Functional difficulties may result from CNS damage in more than one domain, but common functional difficulties by domain include: [ 13 ] [ 78 ] [ 100 ] [ 103 ]  Note that this is not an exhaustive list of difficulties.


The secondary disabilities of FAS are those that arise later in life secondary to CNS damage. These disabilities often emerge over time due to a mismatch between the primary disabilities and environmental expectations; secondary disabilities can be ameliorated with early interventions and appropriate supportive services. [ 102 ]


Six main secondary disabilities were identified in a University of Washington research study of 473 subjects diagnosed with FAS, PFAS (partial fetal alcohol syndrome), and ARND (alcohol-related neurodevelopmental disorder): [ 13 ] [ 102 ]


Two additional secondary disabilities exist for adults: [ 13 ] [ 102 ]


Eight factors were identified in the same study as universal protective factors that reduced the incidence rate of the secondary disabilities: [ 13 ] [ 102 ]


Malbin (2002) has identified the following areas of interests and talents as strengths that often stand out for those with FASD and should be utilized, like any strength, in treatment planning: [ 78 ]


One study found that the people with FAS had a significantly shorter  life expectancy . [ 6 ]  With the average life span of 34 years old, a study found that 44% of the deaths were of "external cause", with 15% of deaths being suicides.


Globally, one in 10 women drink alcohol during pregnancy. Out of this population, 20%  binge drink  and have four or more alcoholic drinks per single occasion. [ 39 ]  The use of alcohol during pregnancy occurs at different rates across the world, potentially due to various cultural differences and legislation. The five countries with the highest prevalence of alcohol use during pregnancy are Ireland (60%), Belarus (47%), Denmark (46%), the UK (41%), and the Russian Federation (37%). [ 29 ]


In a recent count, the prevalence of having any FASD disorder was 1 person out of 20, but some people estimate it could be as high as 1 in 7. [ 7 ]  The rates of FAS and FASD are likely to be underestimated, because of the difficulty in making the diagnosis and the reluctance of clinicians to label children and mothers. [ 107 ]


FASD among  Australian  youth is more common in  indigenous Australians . [ 108 ]  The only states that have registered birth defects in Australian youth are  Western Australia ,  New South Wales ,  Victoria  and  South Australia . [ 109 ]  In Australia, only 12% of Australian health professionals are aware of the diagnostics and symptoms of FASD. [ 108 ]  In Western Australia, the rate of births resulting in FASD is 0.02 per 1,000 births for non-Indigenous Australians, however among indigenous births the rate is 2.76 per 1,000 births. [ 109 ]  In Victoria, there have been no registered FASD related births for indigenous Australians, but the rate for the general population in Victoria is 0.01–0.03 per 1000 births. [ 109 ]  There have been no dedicated FASD clinics within Western Australia, but there are also no nationally supported diagnostic criteria anywhere in Australia. [ 110 ]  Passive surveillance is a prevention technique used within Australia to assist in monitoring and establishing detectable defects during pregnancy and childhood. [ 109 ]


A 2015 review article estimated the overall costs to Canada from FASD at $9.7 billion (including from crime, healthcare, education, etc.). [ 111 ]


In South Africa, some populations have rates as high as 9%. [ 11 ]


In the United States, alcohol use at some point during  pregnancy  is common and appears to be rising in prevalence. [ 112 ] [ 113 ] [ 114 ] [ 35 ]  In 2006–2010, an estimated 7.6% of pregnant women used alcohol, while 1.4% of pregnant women reported binge drinking during their pregnancy. The highest prevalence estimates of reported alcohol use during pregnancy were among women who are aged 35–44 years (14.3%), white (8.3%), college graduates (10.0%), or employed (9.6%). [ 115 ]  In 2015, about 10% of pregnant women drank alcohol in the past month, and 20% to 30% drank at some point during the pregnancy. [ 34 ]  Of pregnant American women, 3.6% met criteria for an alcohol use disorder in a 2001 epidemiological study. [ 40 ]  As of 2016, the US Centers for Disease Control estimated 3 million women in the United States are at risk of having a baby with FASD. [ 116 ]


FASD is estimated to affect between 1-2% and 5% of people in the United States and Western Europe. [ 117 ]  FAS is believed to occur in between 0.2 and 9 per 1,000 live births in the United States. [ 117 ]  Using medical and other records, CDC studies have identified 0.2 to 1.5 infants with FAS for every 1,000 live births in certain areas of the United States. [ 118 ]  A more recent CDC study of 2010 data analyzed medical and other records and found FAS in 0.3 out of 1,000 children from 7 to 9 years of age. [ 119 ]


The lifetime cost per child with FAS in the United States was estimated at $2 million (for an overall cost across the country of over $4 billion) by the  CDC  in 2002. [ 117 ]


Some hold that ancient sources describe the negative effects of alcohol during pregnancy, [ 11 ]  identifying admonitions from  ancient Greek ,  Roman , the  Talmud , and the  Bible . [ 120 ]  For example,  Plato  writes in his fourth-century B.C.  Laws  (6.775): "Drinking to excess is a practice that is nowhere seemly ... nor yet safe. ... It behooves both bride and bridegroom to be sober ... in order to ensure, as far as possible, in every case that the child that is begotten may be sprung from the loins of sober parents." The sixth-century AD  Talmud  ( Kethuboth  60b) cautions, "One who drinks intoxicating liquor will have ungainly children." However, ancient sources rarely if ever distinguish maternal alcohol consumption from paternal, and are more concerned with conception than pregnancy. The sources can often be viewed as expressing  heredity , that children are likely to turn out like their (alcoholic) parents, rather than presenting the modern viewpoint that alcohol itself has an impact. [ 121 ] [ 90 ]


In 1725, in the midst of the  Gin Craze , British physicians petitioned the  House of Commons  on the effects of strong drink when consumed by pregnant women saying that such drinking is "too often the cause of weak, feeble, and distempered children, who must be, instead of an advantage and strength, a charge to their country". [ 122 ]  There are many other such historical references during that period. [ 123 ]  Gin specifically was implicated as affecting children's health and causing stillbirth and infant mortality, as depicted in William Hogarth's  Gin Lane . In contrast, Hogarth's  Beer Street  shows commerce and happiness, suggesting that the alcohol in beer was not known to have deleterious effects at this time. [ 121 ]


In Gaelic Scotland, according to  Martin Martin , the mother and nurse were not allowed to consume  ale  during pregnancy and breastfeeding. [ citation needed ]


In the 19th century,  Benjamin Rush  and  Thomas Trotter  lobbied against alcohol consumption during pregnancy to avoid dependence and mental deficiency in children. [ 121 ]  The  teetotalism  and  temperance movements  popularized these and other claims, [ 124 ] [ 125 ]  including the teratogenic effects of alcohol on animal embryos, [ 121 ]  but they were often sensationalized, so much so that any finding that alcohol was harmful was largely denounced as propaganda. [ 123 ]  A prominent observation of possible links between maternal alcohol use and fetal damage was made in 1899 by Dr. William Sullivan, a  Liverpool  prison physician who noted higher rates of  stillbirth  for 120 alcoholic female prisoners than their sober female relatives. He suggested the causal agent to be alcohol use. [ 126 ]  This contradicted the predominating belief at the time that heredity caused intellectual disability, poverty, and criminal behavior, which contemporary studies on the subjects usually concluded. [ 13 ]  A case study by  Henry H. Goddard  of  the Kallikak family —popular in the early 1900s—represents this earlier perspective, [ 127 ]  though later researchers have suggested that the Kallikaks almost certainly had FAS. [ 128 ]  General studies and discussions on alcoholism throughout the mid-1900s were typically based on a heredity argument. [ 129 ]  Researchers were often temperance advocates and funded by like-minded organizations such as the  Anti-Saloon League , so clinicians viewed all such research with heavy skepticism. The temperance movement effectively shut down serious research into the subject for nearly 50 years after Prohibition. [ 121 ]


From the 1960s to the 1980s, alcohol was commonly used as a  tocolytic , a method to stop preterm labor (born at less than 37 weeks gestation). The method originated with Dr.  Fritz Fuchs , the chairman of the department of obstetrics and gynecology at Cornell University Medical College. [ 130 ] [ 131 ]  Doctors recommended a small amount of alcohol to calm the uterus during contractions in early pregnancy or Braxton Hicks contractions. In later stages of pregnancy, the alcohol was administered intravenously and often in large amounts. "Women experienced similar effects as occur with oral ingestion, including intoxication, nausea and vomiting, and potential alcohol poisoning, followed by hangovers when the alcohol was discontinued." [ 132 ]  Vomiting put the mother at a high risk for aspiration and was "a brutal procedure for all involved". [ 130 ]  Because the alcohol was being given intravenously, the doctor could continue giving the treatment to the mother long after she had passed out, resulting in her being more intoxicated than would otherwise be possible. Such heavy intoxication was highly likely to contribute to FASD. [ 130 ]  In a 2015 review, ethanol was found to be no better than placebo (sugar water) in suppressing preterm birth and neonatal mortality. Not only was ethanol worse than other beta-mimetic drugs (tocolytic agents) at postponing birth, it also led to a higher rate of low birthweight babies, babies with breathing problems at birth, and neonatal death. [ 133 ]


In France in 1957, Jacqueline Rouquette had described 100 children whose parents were alcoholics in a thesis, which was not published. "She gave a good description in certain cases of the facies" according to her mentor, Paul Lemoine. [ 134 ]
In 1968, Paul Lemoine of  Nantes , himself published a study in a French medical journal about children with distinctive features whose mothers were alcoholics. [ 135 ]


Independently, in the U.S., Christy Ulleland at  University of Washington  Medical School conducted an 18-month study in 1968–1969 documenting the risk of maternal alcohol consumption among the offspring of 11 alcoholic mothers. [ 136 ]  This study is arguably the true source of the modern understanding. [ 123 ]  The infants were studied by  dysmorphologists  Kenneth Lyons Jones and  David Weyhe Smith , colleagues of Ulleland at University of Washington, [ 123 ]  who identified a pattern of "craniofacial, limb, and cardiovascular defects associated with prenatal onset growth deficiency and developmental delay" in eight children. The pattern of malformations indicated that the damage was prenatal. They named these defects "fetal alcohol syndrome". [ 137 ]  News of the discovery shocked some, while others were skeptical of the findings. [ 138 ]  While many  syndromes  are  eponymous , i.e. named after the physician first reporting the association of symptoms, Smith named FAS after the causal agent of the symptoms. [ 139 ]  He reasoned that doing so would encourage prevention, believing that if people knew maternal alcohol consumption caused the syndrome, then abstinence during pregnancy would follow from  patient education  and public awareness. [ 139 ]  At the time, nobody was aware of the full range of possible birth defects from FAS or its rate of prevalence. [ 139 ]