Pregnancy Inpatient and Outpatient Withdrawal Management

Alcohol withdrawal occurs when chronic, heavy alcohol consumption suddenly stops, or is significantly reduced. Common symptoms include rapid heart rate, fever, tremor, nausea, vomiting, and sweating. It may also be accompanied by anxiety, agitation, and sleep disturbance or insomnia.

It is strongly recommended that people who are pregnant and have AUD undergo withdrawal management in inpatient settings where they can receive symptom-triggered treatment with close monitoring of withdrawal symptoms and fetal health in order to minimize obstetric risks. Pregnant individuals’ heightened susceptibility to alcohol withdrawal symptoms can lead to falls and seizures as well as adverse fetal effects, including distress, placental abruption, preterm labour, and fetal death. However, inpatient care is not always feasible, due to patient preference, availability of beds, or geography. If outpatient withdrawal management is a feasible or preferred option, clinicians are advised to monitor the patient closely throughout the process to ensure early intervention for any adverse effects to the pregnant person or the fetus. It’s important to note that there are no studies assessing the safety of outpatient alcohol withdrawal management in pregnant patients. The guidance here was based on clinical expertise from the national guidance committee.

See the BCCSU Pregnancy Supplement and the general withdrawal page for more information.

Outpatient Withdrawal Management

Patient Criteria for Outpatient Alcohol Withdrawal Management

To determine whether a patient can be safely managed in an outpatient setting, please consider the following criteria:

All of the following criteria should be met:

PAWSS score is less than 4
Ability to follow up for the first 3–5 days and alternating days thereafter. Can be in-person, by phone, or by virtual health.
They have a safe place to store medications and a place where they can rest*
Has a reliable person (e.g., family member, friend) who can monitor symptoms during the acute withdrawal period (i.e., 3–5 days) and support adherence to medications*

Contraindications to outpatient management:

History of seizure or delirium tremens
Concurrent use of other substances, particularly CNS depressants. Simultaneous withdrawal from another substance
Any severe medical condition that could present a health or safety risk during withdrawal

*Note: Patients who do not have support from family or community or who are unstably housed due to poverty and systemic barriers are not to be denied treatment. Patients can be accommodated through strategies such as daily clinic visits, home visits, connection to a local pharmacist, or virtual care.

Planning Considerations

Start treatment on a day that causes the least disruption to the patient’s schedule. Consider pharmacy hours and clinician availability during the treatment duration.
Provide patients with a phone number or alternative contact that they can call in the event of an emergency.
Recommend vitamins before and during withdrawal. Clinicians should consult the relevant formulary to determine if coverage is available for these vitamins. If feasible, clinicians can stock vitamins and offer them to patients who are not able to afford them.
Folic acid 1mg daily
Thiamine 100-200mg daily
Pyridoxine B6 2mg minimum daily, in multivitamin or other source. Doses can be higher if needed to manage nausea or vomiting.
- Recommend increased fluid and electrolyte intake, restricted diet consisting of light, mild foods (e.g. lower in sugar or fat), and minimal exercise.
- Review risks and benefits of natural remedies, caffeine, or any activity that increases sweating (e.g., hot baths, showers, or saunas), with respect for and understanding of the importance of cultural healing practices for some patients (e.g., sweat lodges).
- Advise patients not to drive until their withdrawal symptoms subside.
For parents with children, ensure that there are alternate caregivers present during the duration of withdrawal.

Overview of Medications for Treating Alcohol Withdrawal

Gabapentin can be used when there is a low risk for withdrawal complications.
Benzodiazepines should be reserved for moderate risk of withdrawal complications. However, they can be used in low risk cases based on clinician judgment.
- A longer-acting benzodiazepine like diazepam can be used in pregnancy except in the late third trimester.
- A shorter-acting benzodiazepine like lorazepam should be used in the late third trimester to minimize benzodiazepine intoxication in the newborn.
  - Prescribe these medications on a short-term, tapered schedule (5–7 days). Arrange for daily dispensing or blister packaging. A patient’s history of reliability and adherence to clinical recommendations should be considered as a factor in this decision. If using symptom-based dosing, provide close monitoring and instructions for self-assessing symptom severity using SAWS. Enlisting family members or other caregivers to assess symptom severity and dispense medication is recommended.
- For dosing and additional details, see Withdrawal Medications table.
- For minor symptoms such as nausea, vomiting, and mild pain:
  - Over-the-counter pain relievers, such as acetaminophen (up to 4g per day), may be used. NSAIDS should be avoided after 20 weeks of gestation, but can be used in the short-term if necessary at the clinician’s discretion.
  - Anti-diarrheal medications and anti-emetics may be used, such as combination doxylamine and pyridoxine.
Advise patients on proper nutrition and hydration.

Monitoring

Assess the patient daily during the acute phase of withdrawal (i.e., 3–5 days), evaluate, and adjust the follow-up schedule thereafter as appropriate.

At each follow-up, assess for:
- - Vital signs
  - Withdrawal symptoms, using CIWA-Ar
  - Hydration
  - Cognition
  - Emotional status
  - Overall physical condition
  - Pregnancy-related symptoms (contractions, fetal movement, fluid loss, or bleeding)
  - Fetal heart rate monitoring may be warranted for early detection of fetal distress
If withdrawal symptoms worsen or medical complications arise, refer client to inpatient treatment or emergency department for assessment and stabilization. Examples of complications:
- - CIWA-Ar scores increasing
  - Tremor not improving/worsening
  - Tachycardia (HR greater than 120bpm)
  - Hypertension (elevation of systolic or diastolic blood pressure 20–30mmHg above baseline)
  - Repeated vomiting or profuse sweating
  - Seizures, confusion, hallucinations, delusions, or agitation
  - Obstetrical issues including contractions, decreased or no fetal movement, vaginal bleeding, vaginal fluid leaking/loss

Discharge and Transition Planning

Once the patient is stabilized, collaboratively develop a care plan with the client to support discharge from services. This care plan should factor in community supports, the patient’s chosen family, and a community-based care team, as appropriate.
The care plan should be informed by the patient’s self-identified treatment goals.
Ensure that the client is aware of the spectrum of treatment options available to them, including pharmacotherapy, psychosocial interventions, and culture-based care.
Clinicians should discuss relapse prevention strategies, provide information on harm reduction services, and offer further guidance tailored to the client’s substance use patterns.
Provide the client with contact information for ongoing substance use services if they are not already connected.

Medications for Withdrawal Management

There is limited research on pharmacotherapeutic withdrawal management in pregnant individuals. This is partly due to the ethical concerns restricting clinical investigation in this population. Most research focuses on benzodiazepines, but there is also emerging evidence in support of gabapentin. Together, the research that does exist suggests the harms of acute alcohol withdrawal are greater than the potential risks associated with pharmacological treatment with benzodiazepines or gabapentin. The table below provides guidance for prescribing these medications.

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