Guideline No. 425b: Cannabis Use Throughout Women's Lifespans - Part 2: Pregnancy, the Postnatal Period, and Breastfeeding

Risk assessment of trace elements in human breastmilk in a Northern Italy population

BACKGROUND

Breastfeeding is the main source of nutrition in newborns, thus risk assessment of dietary intake of trace elements represents a relevant public health topic.

METHODS

Using a cross-sectional study design, we recruited mother-infant pairs from women who gave birth between 2015 and 2017 at the Obstetrics and Gynecology Unit of the University Hospital of Modena, Northern Italy. We investigated sociodemographic and pregnancy characteristics of mothers and newborns and we collected human mature milk samples between 30 and 40 days after childbirth to evaluate content of trace elements (As, Cd, Cr, Cu, Fe, Mn, Ni, Pb, Se and Zn) using inductively coupled plasma mass spectrometry. We assessed the estimated dietary intake (EDI) of trace elements and compared results with both reference values suggested by main regulatory agencies.

RESULTS

In the 195 mother-infant pairs, the mean women age was 33.1 years, mainly resident in urban areas (80 %). As regards smoking status, 3.6 % and 31.3 % of women were current and former smokers. Median trace elements concentrations (in µg/L) were As: 0.09; Cd: 0.02, Cr: 0.09; Cu: 408.0; Fe: 265.25; Mn:2.48; Ni: 1.20; Pb: 0.02; Se: 11.14; Zn: 2264. We found a positive association with maternal age for Fe and Ni, and slightly higher concentrations of Cu, Fe, Ni and Se in mothers living in urban areas. Current smokers showed the highest concentrations of As, Cu, Fe, Mn, but the lowest of Se. Risk assessment comparing EDI with reference values from regulatory agencies showed generally adequate intake, and all median EDIs were below the upper levels. However, when considering 95th of EDIs, some elements demonstrated values closer to the corresponding upper limit, namely Zn, Pb, As, and Cu.

CONCLUSIONS

Our findings indicate a general safe dietary intake of the investigated trace elements, but highlight the need to strengthen the recommendations to avoid smoking during pregnancy and lactation and to continuously monitor human milk content to protect newborns.

Associations of maternal peripregnancy cannabis use with behavioral and developmental outcomes in children with and without symptoms of autism spectrum disorder: Study to Explore Early Development

Some studies report increased prevalence of autism spectrum disorder (ASD) and associated symptoms with prenatal cannabis exposure. We examined whether associations of maternal cannabis use from 3 months preconception through delivery ("peripregnancy") with behavior and development in the offspring varied with the presence of ASD symptoms. Children ages 30-68 months with ASD symptoms (i.e., met study criteria for ASD or had ASD symptoms on standardized assessments or community ASD diagnosis, N = 2734) and without ASD symptoms (other developmental delay/disorders or general population sample, N = 3454) were evaluated with the Child Behavior Checklist and Mullen Scales of Early Learning. We examined cannabis use during three time periods: peripregnancy, pregnancy, and only preconception. Peripregnancy cannabis exposure was reported for 6.0% of children with and 4.6% of children without ASD symptoms. Preconception-only cannabis use (versus no use) was associated with more aggressive behavior, emotional reactivity, and sleep problems in children with ASD symptoms, but not in children without ASD symptoms. Cannabis use during pregnancy was associated with increased attention and sleep problems in children with ASD symptoms; these associations did not differ significantly by ASD symptoms. Peripregnancy cannabis use was not associated with child developmental abilities regardless of ASD symptoms. In summary, associations of peripregnancy cannabis use with some behavioral outcomes differed in children with and without ASD symptoms. With rising cannabis use among pregnant women, future studies that examine a range of developmental risks associated with timing and patterns of cannabis use prior to conception as well as during pregnancy could inform clinical guidance.

Risk thresholds for the frequency of cannabis use during pregnancy and adverse neonatal outcomes: protocol for a systematic review and dose-response meta-analysis

BACKGROUND

Cannabis use during pregnancy has been increasing and is associated with adverse neonatal outcomes, such as low birth weight (LBW) and preterm birth (PTB). It remains largely unknown whether the association between cannabis use in pregnancy and increased risk of adverse neonatal outcomes is impacted by the frequency of cannabis use and whether thresholds exist below which risk is not significantly increased. The objective of this systematic review is to assess whether the association between cannabis use during pregnancy and the risk of adverse neonatal outcomes is dependent on the frequency of use and whether risk thresholds exist.

METHODS

For this systematic review and dose-response meta-analysis, the Embase, MEDLINE, PsycINFO, CINAHL, and Web of Science databases will be searched for relevant studies published in English from January 2010 onwards. Studies that include pregnant individuals with singleton pregnancies and evaluate the association between cannabis use in pregnancy and adverse neonatal outcomes using case-control, cohort, or cross-sectional designs will be considered for inclusion. Studies must include information on cannabis use frequency reported according to at least three of the pre-defined categories of no use, yearly (1-11 days per year), monthly (1-3 days per month), weekly (1-4 days per week), and daily/near daily use (5-7 days per week). At least one of the following neonatal outcomes must be reported, according to the frequency of cannabis use: LBW (< 1500 g), PTB (before 37 weeks gestation), neonatal intensive care unit (NICU) admission, and mortality. Studies will be included that report results as risk ratios (RR), odds ratios (OR), hazard ratios (HR), or that include the raw data to be able to calculate them. A two-stage dose-response meta-analysis will be conducted. The risk of bias of included studies will be assessed using the JBI tools for cohort, case-control, and cross-sectional studies. Certainty of the evidence will be reported according to the GRADE approach and the review will be reported according to PRISMA guidelines.

DISCUSSION

The frequency of cannabis is one factor that may influence the relationship between cannabis use in pregnancy and adverse neonatal outcomes. This review will quantify this relationship by determining whether risk thresholds exist.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42023479978.

Predictors for cannabis cessation during pregnancy: a 10-year cohort study

The aim of this study is to determine factors associated with cannabis discontinuation, to assess the impact of mental health and addiction interventions on cannabis discontinuation during pregnancy and to investigate the neonatal impact of cannabis discontinuation. This is a 10-year cohort study in a tertiary hospital in Barcelona, Spain, including women with self-reported cannabis use during pregnancy. Main outcome was cannabis discontinuation based on biological sample testing. Secondary outcomes were neonatal intensive care unit (NICU) admission, preterm birth, birth weight and bottle-feeding. When cannabis use was detected during pregnancy, 32 out of 81 (38.3%) discontinued cannabis during pregnancy vs. four out of 61 (6.6%) when detected at birth (p < .001). Multivariate binary logistic regression showed that null parity (OR: 6.95, p = .011), detection of cannabis use during pregnancy (OR: 5.35, p = .018) and early detection and referral to mental health care for counseling on cannabis cessation and interventions on the first trimester (OR: 25.46, p < .001) increased cannabis discontinuation. Risk for preterm birth <37 weeks (11.4% vs. 30.8%) and NICU admission (25.7% vs. 54.2%) were lower when discontinuation. Early detection of cannabis use during pregnancy, cessation counseling with mental health interventions, and null parity are predictors for cannabis discontinuation during pregnancy.

Counseling About Cannabis Use During Pregnancy and Lactation: A Qualitative Study of Patient and Clinician Perspectives

INTRODUCTION

Legalization in many jurisdictions has increased the prevalence of cannabis use, including during pregnancy and lactation. Accordingly, clinicians providing perinatal and infant care are increasingly required to counsel about this topic, even if they do not feel comfortable or prepared for this conversation. The aim of this research was to explore how prenatal clinicians and pregnant and lactating women interact with cannabis consumption.

METHODS

Using qualitative description, we conducted semi-structured interviews with 75 individuals in Canada: 23 clinicians who provide pregnancy and lactation care, and 52 individuals who made cannabis consumption decisions during pregnancy and/or lactation. Data were analyzed using inductive content analysis.

RESULTS

Three phases of the clinical encounter influenced decision-making about cannabis consumption: initiation of a discussion about cannabis, sense-making, and the outcome of the encounter. Patients and clinicians described similar ideals for a counseling encounter about cannabis consumption during pregnancy or lactation: open, patient-centered conversation grounded in an informed decision-making model to explore the benefits, risks, and alternatives to cannabis. While clinicians described these values as reflecting real clinical interactions, patients reported that in their experience, actual interactions did not live up to these ideals.

CONCLUSION

Clinicians and pregnant and lactating people report desiring the same things from a counseling interaction about cannabis: sharing of information, identification of values, and facilitation of a decision. Both groups endorse an open, nonjudgemental counseling approach that explores the reasons why a patient is considering cannabis consumption and reflects these reasons against available evidence and alternatives known to be safe.

Making informed choices about cannabis use during pregnancy and lactation: A qualitative study of information use

BACKGROUND

Cannabis use during pregnancy and lactation continues to increase as some perceive cannabis to be helpful for symptom management and coping. As such, pregnant and lactating people are faced with challenging decisions, weighing benefits against the potential risks of cannabis use. To help clinicians facilitate informed choices, we explored the self-identified information needs of pregnant and lactating people who are deciding whether or not to use cannabis. We aimed to describe the modes and sources of their information-seeking and their satisfaction with the information they found.

METHODS

We interviewed 52 people in Canada who made the decision to start, stop, or continue using cannabis during pregnancy and lactation. Participants were recruited from advertisements in prenatal clinics and on social media. We utilized an inductive approach to analysis focused on information used in decision-making about cannabis use, including the process of seeking and evaluating that information.

RESULTS

Participants were deliberate in their search for information, most commonly seeking information on risks of use. Information sources were mainly online material or people in their social networks. Clinicians were not commonly described as a knowledgeable or supportive source of information. Overwhelmingly, participants described the information they found as insufficient and emphasized the need for more comprehensive and trustworthy sources of information.

CONCLUSIONS

Participants identified distinct and unmet information needs associated with their decision to use cannabis. They described a desire for clear evidence about the impact of cannabis use, including information about how to balance the benefits they perceived from cannabis use with the risks of harm.

Influence of prenatal cannabinoid exposure on early development and beyond

Public perception surrounding whether cannabis use is harmful during pregnancy often diverges greatly from the recommendations of doctors and healthcare providers. In contrast to the medical guidance of abstinence before, during, and after pregnancy, many women of reproductive age believe cannabis use during pregnancy is associated with little potential harm. Legalization and social cues support public perceptions that cannabis use during pregnancy is safe. Moreover, pregnant women may consider cannabis to be a safe alternative for treating pregnancy related ailments, including morning sickness. Compounding the problem is a lack of medical and federal guidance on safe, low, or high-risk levels of cannabis use. These issues mirror the continuing debate surrounding alcohol use and health, in particular, whether there are safe or lower risk levels of alcohol consumption during pregnancy. Clinical studies to date suffer from several limitations. First, most human studies are correlative in nature, meaning that causal associations cannot be made between in utero cannabis exposure and health and behavioral outcomes later in life. Due to obvious ethical constraints, it is not possible to randomly assign pregnant mothers to cannabis or other drug exposure conditions-a requirement needed to establish causality. In addition, clinical studies often lack quantitative information on maternal exposure (i.e., dose, frequency, and duration), include a small number of individuals, lack replication of outcome measures across cohorts, rely on self-report to establish maternal drug use, and suffer from unmeasured or residual confounding factors. Causal associations between maternal cannabis exposure and offspring outcomes are possible in preclinical cohorts but there is a large amount of heterogeneity across study designs and developmental differences between rodents and humans may limit translatability. In this review, we summarize research from human and preclinical models to provide insight into potential risks associated with prenatal cannabinoid exposure (PCE). Finally, we highlight gaps in knowledge likely to contribute to the growing divide between medical guidance and public attitudes regarding cannabis use during pregnancy.

Pharmacokinetics of Cannabis and Its Derivatives in Animals and Humans During Pregnancy and Breastfeeding

Cannabis is one of the most widely used illicit drugs during pregnancy and lactation. With the recent legalization of cannabis in many countries, health professionals are increasingly exposed to pregnant and breastfeeding women who are consuming cannabis on a regular basis as a solution for depression, anxiety, nausea, and pain. Cannabis consumption during pregnancy can induce negative birth outcomes such as reduced birth weight and increased risk of prematurity and admission to the neonatal intensive care unit. Yet, limited information is available regarding the pharmacokinetics of cannabis in the fetus and newborn exposed during pregnancy and lactation. Indeed, the official recommendations regarding the use of cannabis during these two critical development periods lack robust pharmacokinetics data and make it difficult for health professionals to guide their patients. Many clinical studies are currently evaluating the effects of cannabis on the brain development and base their groups mostly on questionnaires. These studies should be associated with pharmacokinetics studies to assess correlations between the infant brain development and the exposure to cannabis during pregnancy and breastfeeding. Our project aims to review the available data on the pharmacokinetics of cannabinoids in adults, neonates, and animals. If the available literature is abundant in adult humans and animals, there is still a lack of published data on the exposure of pregnant and lactating women and neonates. However, some of the published information causes concerns on the exposure and the potential effects of cannabis on fetuses and neonates. The safety of cannabis use for non-medical purpose during pregnancy and breastfeeding needs to be further characterized with proper pharmacokinetic studies in humans feasible in regions where cannabis has been legalized. Given the available data, significant transfer occurs to the fetus and the breastfed newborn with a theoretical risk of accumulation of products known to be biologically active.

Guideline No. 425a: Cannabis Use Throughout Women's Lifespans - Part 1: Fertility, Contraception, Menopause, and Pelvic Pain

OBJECTIVE

To provide health care providers with the best evidence on cannabis use with respect to women's health. Areas of focus include general patterns of cannabis use as well as safety of use; care for women who use cannabis; stigma; screening, brief intervention, and referral to treatment; impact on hormonal regulation; reproductive health, including contraception and fertility; sexual function; effects on perimenopausal and menopausal symptoms; and use in chronic pelvic pain syndromes.

TARGET POPULATION

The target population includes all women currently using or contemplating using cannabis.

OUTCOMES

Open, evidence-informed dialogue about cannabis use, which will lead to improvement in patient care.

BENEFITS, HARMS, AND COSTS

Exploring cannabis use through a trauma-informed approach provides the health care provider and patient with an opportunity to build a strong, collaborative, therapeutic alliance. This alliance empowers women to make informed choices about their own care. It also allows for the diagnosis and possible treatment of cannabis use disorders. Use should not be stigmatized, as stigma leads to poor "partnered care" (i.e., the partnership between the patient and care provider). Multiple side effects of cannabis use may be mistaken for other disorders. Currently, use of cannabis to treat women's health issues is not covered by public funding; as a result, individual users must pay the direct cost. The indirect costs of cannabis use are unknown. Thus, health care providers and patients must understand the role of cannabis in women's health issues, so that women can make knowledgeable decisions.

EVIDENCE

PubMed, EMBASE, and grey literature were searched to identify studies of "cannabis use and effect on infertility, contraception, perimenopause and menopausal symptoms, and pelvic pain" published between January 1, 2018 and February 18, 2021. All clinical trials, observational studies, reviews (including systematic reviews and meta-analyses), guidelines, and conference consensus statements were included. Publications were screened for relevance. The search terms were developed using the Medical Subject Headings (MeSH) terms and keywords (and variants), including cannabis, cannabinoids, marijuana, dexanabinol, dronabinol, tetrahydrocannabinol; the specific terms to capture women's health were estrogen, estradiol, medroxyprogesterone acetate, vaginal contraception, oral contraceptives, fertilization, amenorrhea, oligomenorrhea, pelvic pain, dysmenorrhea, endometriosis, interstitial cystitis, vulvodynia, and menopause.

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations).

INTENDED AUDIENCE

All heath care providers who care for women.

SUMMARY STATEMENTS

RECOMMENDATIONS.