CaseMs. L, a 32-year-old G5 P2 A2 (gravida 5, para 2, abortions 2) woman, is admitted to hospital because of premature rupture of membranes at an estimated 34 weeks of gestation. She has had only intermittent prenatal care and no prenatal tests. This is an unplanned pregnancy, and she is not sure of the time of conception. Her 2 older children have been in foster care since birth, because child welfare authorities assessed her ability to parent as inadequate at the time; 1 child is in the process of adoption. Although child welfare authorities have documented a history of problem drinking, the woman denies any drinking during the current pregnancy. Her physical and neurologic examinations are unremarkable. Although she has sought routine prenatal care only periodically during her pregnancy, she describes developing a desire to parent this child in recent weeks. She denies any "recent" use of alcohol or cocaine, but will not be more specific. Informed consent for drug testing is obtained; no alcohol is detected in her blood, and a urine toxic screen is negative for cocaine, heroin, amphetamines and cannabinoids. Her hemoglobin level is 130 g/L, leukocyte count is 8.5 × 10 9 /L, mean corpuscular volume is 82 fL, electrolytes and creatinine levels are normal, and gamma glutamyl transferase level is 75 (normally < 45) U/L. The woman's baby is delivered vaginally. His Apgar score is 8 at 1 minute and 10 at 5 minutes. His birth weight is 1.1 kg (below the third percentile for age) and head circumference 28.5 cm (fifth percentile for age). Findings from the physical and neurologic examinations of the baby are unremarkable, and he does not require assisted ventilation. Breastfeeding is started successfully.What aspects of this case make you concerned that this child is at risk of fetal alcohol spectrum disorder (FASD)? What additional screens or laboratory tests might further indicate the possibility of FASD? What physical and neurodevelopmental deficits might present later in life if the child has FASD?
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