Association between marijuana use and adverse obstetrical and neonatal outcomes

Cannabis Use in Pregnancy and Neonatal Outcomes: A Systematic Review and Meta-Analysis

Objective: To determine whether prenatal cannabis use alone increases the likelihood of fetal and neonatal morbidity and mortality. Study Design: We searched bibliographic databases, such as PubMed, Embase, Scopus, Cochrane reviews, PsycInfo, MEDLINE, Clinicaltrials.gov, and Google Scholar from inception through February 14, 2022. Cohort or case-control studies with prespecified fetal or neonatal outcomes in pregnancies with prenatal cannabis use. Primary outcomes were preterm birth (PTB; <37 weeks of gestation), small-for-gestational-age (SGA), birthweight (grams), and perinatal mortality. Two independent reviewers screened studies. Studies were extracted by one reviewer and confirmed by a second using a predefined template. Risk of bias assessment of studies, using the Newcastle-Ottawa Quality Assessment Scale, and Grading of Recommendations Assessment, Development, and Evaluation for evaluating the certainty of evidence for select outcomes were performed by two independent reviewers with disagreements resolved by a third. Random effects meta-analyses were conducted, using adjusted and unadjusted effect estimates, to compare groups according to prenatal exposure to cannabis use status. Results: Fifty-three studies were included. Except for birthweight, unadjusted and adjusted meta-analyses had similar results. We found very-low- to low-certainty evidence that cannabis use during pregnancy was significantly associated with greater odds of PTB (adjusted odds ratio [aOR], 1.42; 95% confidence interval [CI], 1.19 to 1.69; I2, 93%; p=0.0001), SGA (aOR, 1.76; 95% CI, 1.52 to 2.05; I2, 86%; p<0.0001), and perinatal mortality (aOR, 1.5; 95% CI, 1.39 to 1.62; I2, 0%; p<0.0001), but not significantly different for birthweight (mean difference, -40.69 g; 95% CI, -124.22 to 42.83; I2, 85%; p=0.29). Because of substantial heterogeneity, we also conducted a narrative synthesis and found comparable results to meta-analyses. Conclusion: Prenatal cannabis use was associated with greater odds of PTB, SGA, and perinatal mortality even after accounting for prenatal tobacco use. However, our confidence in these findings is limited. Limitations of most existing studies was the failure to not include timing or quantity of cannabis use. This review can help guide health care providers with counseling, management, and addressing the limited existing safety data. Protocol Registration: PROSPERO CRD42020172343.

The association between prenatal cannabis use and congenital birth defects in offspring: A cumulative meta-analysis

OBJECTIVE

To examine the association between prenatal cannabis use and structural birth defects in exposed offspring.

METHODS

In line with the preregistered protocol (PROSPERO: CRD42022368623), we systematically searched PubMed/Medline, CINHAL, EMBASE, Web of Science, ProQuest, Psych-Info, and Google Scholar for published articles until 25 January 2024. The methodological quality of the included studies was appraised by the Newcastle-Ottawa Quality Assessment Scale (NOS). A meta-analysis was carried out to report the pooled effect estimates from the included studies. We further performed subgroup, leave-one-out sensitivity, and meta-regression analyses, which increased the robustness of our findings.

RESULTS

In this cumulative meta-analysis, thirty-six observational studies, consisting of 18 case-control and 18 cohort studies, with 230, 816 cases of birth defects and 18,049,013 controls (healthy babies) were included in the final analysis. We found that offspring exposed to maternal prenatal cannabis are at greater risks of a wide range of structural birth defects: cardiovascular/heart [OR = 2.35: 95 % CI 1.63 - 3.39], gastrointestinal [OR = 2.42: 95 % CI 1.61 - 3.64], central nervous system [OR = 2.87: 95 % CI 1.51 - 5.46], genitourinary [OR = 2.39: 95 % CI 1.11 - 5.17], and any (unclassified) birth defects [OR = 1.25: 95 % CI 1.12 - 1.41].

CONCLUSION

The findings from the current study suggest that maternal prenatal cannabis exposure is associated with a higher risk of different forms of structural birth defects in offspring. The findings underscore the significance of implementing preventive strategies, including enhanced preconception counselling, to address cannabis use during pregnancy and mitigate the risk of birth defects in offspring.

Birth, cognitive and behavioral effects of intrauterine cannabis exposure in infants and children: A systematic review and meta-analysis

BACKGROUND AND AIMS

Δ9-tetrahydrocannabinol (THC), the principal psychoactive component of cannabis, has been implicated in affecting fetal neurodevelopment by readily crossing the placenta. However, little is known regarding the long-term effects of intrauterine cannabis exposure. This systematic review and meta-analysis synthesized prospective and cross-sectional human studies to measure the effects of intrauterine cannabis exposure on birth, behavioral, psychological and cognitive outcomes in infancy until early childhood.

METHODS

Reporting according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement, cross-sectional and prospective studies published from database inception until June 2023, investigating developmental outcomes of infants, toddlers and young children with intrauterine cannabis exposure were considered. All articles were obtained from PubMed or PsycINFO databases.

RESULTS

The literature search resulted in 932 studies, in which 57 articles met eligibility criteria. The meta-analysis revealed that intrauterine cannabis exposure increases the risk of preterm delivery [odds ratio (OR) = 1.68, 95% confidence interval (CI) = 1.05-2.71, P = 0.03], low birth weight (OR = 2.60, CI = 1.71-3.94, P < 0.001) and requirement for neonatal intensive care unit (NICU) admission (OR = 2.51, CI = 1.46-4.31; P < 0.001). Our qualitative synthesis suggests that intrauterine cannabis exposure may be associated with poorer attention and externalizing problems in infancy and early childhood. We found no evidence for impairments in other cognitive domains or internalizing behaviors.

CONCLUSIONS

Prenatal cannabis use appears to be associated with lower birth weight, preterm birth and neonatal intensive care unit admission in newborns, but there is little evidence that prenatal cannabis exposure adversely impacts behavioral or cognitive outcomes in early childhood, with the exception of attention and externalizing problems.

Prenatal Exposure to Cannabis: Effects on Childhood Obesity and Cardiometabolic Health

PURPOSE OF REVIEW

To consolidate information on the obesogenic and cardiometabolic effects of prenatal exposure to cannabis.

RECENT FINDINGS

A PubMed search strategy updated from January 1, 2014, through 14 June 2023, produced a total of 47 epidemiologic studies and 12 animal studies. Prenatal exposure to cannabis is consistently associated with small for gestational age and low birth weight. After birth, these offspring gain weight rapidly and have increased adiposity and higher glucose (fat mass percentage) in childhood. More preclinical and prospective studies are needed to deepen our understanding of whether these associations vary by sex, dose, timing, and composition of cannabis (e.g., ratio of delta-Δ9-tetrahydrocannabinol [Δ9-THC] to cannabidiol [CBD]). Addressing these gaps may help to solidify causality and identify intervention strategies. Based on the available data, clinicians and public health officials should continue to caution against cannabis use during pregnancy to limit its potential obesogenic and adverse cardiometabolic effects on the offspring.

The impact of pregnancy and associated hormones on the pharmacokinetics of Δ9-tetrahydrocannabinol

INTRODUCTION

(-)-Δ9-tetrahydrocannabinol (THC) is the main psychoactive component of cannabis. Cannabis is the most widely used drug of abuse by pregnant individuals, but its maternal-fetal safety is still unclear. The changes in THC disposition during pregnancy may affect THC safety and pharmacology.

AREAS COVERED

This review summarizes the current literature on THC metabolism and pharmacokinetics in humans. It provides an analysis of how hormonal changes during pregnancy may alter the expression of cannabinoid metabolizing enzymes and THC and its metabolite pharmacokinetics. THC is predominately (>70%) cleared by hepatic metabolism to its psychoactive active metabolite, 11-OH-THC by cytochrome P450 (CYP) 2C9 and to other metabolites (<30%) by CYP3A4. Other physiological processes that change during pregnancy and may alter cannabinoid disposition are also reviewed.

EXPERT OPINION

THC and its metabolites disposition likely change during pregnancy. Hepatic CYP2C9 and CYP3A4 are induced in pregnant individuals and in vitro by pregnancy hormones. This induction of CYP2C9 and CYP3A4 is predicted to lead to altered THC and 11-OH-THC disposition and pharmacodynamic effects. More in vitro studies of THC metabolism and induction of the enzymes metabolizing cannabinoids are necessary to improve the prediction of THC pharmacokinetics in pregnant individuals.

The Effects of Cannabis Use during Pregnancy on Low Birth Weight and Preterm Birth: A Systematic Review and Meta-analysis

OBJECTIVE

 Our objective was to summarize the literature regarding the effects of cannabis use during pregnancy on low birth weight (LBW), preterm birth (PTB), and small for gestational age (SGA).

STUDY DESIGN

 This is a systematic review and meta-analysis. A literature search was conducted in PubMed, Scopus, EBSCO, and Web of Science in May 2021 and updated in November 2021. Only studies that assessed the isolated use of cannabis during pregnancy, controlling for cigarette smoking, and other illicit drug use were included. Data were synthesized using a narrative summary and pooled adjusted estimates, and 95% confidence intervals (CIs) were calculated for each outcome. Data were analyzed using Stata 13.0 with METAN software package, using random effects. Statistical heterogeneity was assessed using Cochran's Q and Higgins I2 tests.

RESULTS

 In total, 32 studies were included with data from approximately 5.5 million women with the LBW outcome and 23 million with the PTB and SGA outcomes. Pregnant women using cannabis are at increased risk for LBW (adjusted odds ratio [aOR] = 1.52; 95% CI = [1.18; 1.96]), PTB (aOR = 1.39; 95% CI = [1.28; 1.51]), and SGA (aOR = 1.47; 95% CI = [1.38; 1.58]). Studies that assessed the type of PTB and gestational age at birth indicate higher risks of spontaneous PTB and of early or very-early PTBs associated with cannabis use during pregnancy. The few studies that assessed the timing and frequency of consumption suggest a dose-response effect, with higher odds of negative outcomes among women who reported heavy use and with continued use during the second and third trimesters of gestation.

CONCLUSION

 There is an effect of cannabis irrespective of other illicit drugs and tobacco despite high heterogeneity and low quality of evidence. There is a need to discuss public policies regarding cannabis' regulation and how it influences its consumption. Future studies should focus on the effects of cannabis's type (medicinal or recreational), timing, and dosage during pregnancy on perinatal outcomes.

KEY POINTS

· Cannabis use during pregnancy is increasing.. · Cannabis has an independent effect on PTB, LBW, and SGA.. · Future studies should focus on the timing of exposure during pregnancy, mode of use, and dosage..

The association between preconception cannabis use and gestational diabetes mellitus: The Preconception Period Analysis of Risks and Exposures Influencing health and Development (PrePARED) consortium

BACKGROUND

The metabolic changes that ultimately lead to gestational diabetes mellitus (GDM) likely begin before pregnancy. Cannabis use might increase the risk of GDM by increasing appetite or promoting fat deposition and adipogenesis.

OBJECTIVES

We aimed to assess the association between preconception cannabis use and GDM incidence.

METHODS

We analysed individual-level data from eight prospective cohort studies. We identified the first, or index, pregnancy (lasting ≥20 weeks of gestation with GDM status) after cannabis use. In analyses of pooled individual-level data, we used logistic regression to estimate study-type-specific odds ratios (OR) and 95% confidence intervals (CI), adjusting for potential confounders using random effect meta-analysis to combine study-type-specific ORs and 95% CIs. Stratified analyses assessed potential effect modification by preconception tobacco use and pre-pregnancy body mass index (BMI).

RESULTS

Of 17,880 participants with an index pregnancy, 1198 (6.7%) were diagnosed with GDM. Before the index pregnancy, 12.5% of participants used cannabis in the past year. Overall, there was no association between preconception cannabis use in the past year and GDM (OR 0.97, 95% CI 0.79, 1.18). Among participants who never used tobacco, however, those who used cannabis more than weekly had a higher risk of developing GDM than those who did not use cannabis in the past year (OR 2.65, 95% CI 1.15, 6.09). This association was not present among former or current tobacco users. Results were similar across all preconception BMI groups.

CONCLUSIONS

In this pooled analysis of preconception cohort studies, preconception cannabis use was associated with a higher risk of developing GDM among individuals who never used tobacco but not among individuals who formerly or currently used tobacco. Future studies with more detailed measurements are needed to investigate the influence of preconception cannabis use on pregnancy complications.

Marijuana Use among Pregnant and Nonpregnant Women of Reproductive Age, 2013-2019

BACKGROUND

Marijuana is the most commonly used federally illicit substance among reproductive-age women in the United States. Updated information on marijuana use in this population can inform clinical and public health interventions.

METHODS

Data from the 2013-2019 National Survey on Drug Use and Health was used to report weighted prevalence estimates of marijuana use in the past month, past 2-12 months, and past year among women aged 18-44 years with self-reported pregnancy status. Bivariate analyses and general linear regression models with Poisson distribution using appropriate survey procedures identified factors associated with past-year marijuana use by pregnancy status.

RESULTS

Among pregnant women, 4.9% (95% confidence interval [CI]: 4.1-5.6) reported marijuana use in the past month, 10.4% (95% CI: 9.3-11.5) in the past 2-12 months, and 15.2% (95% CI: 13.9-16.6) in the past year. Among nonpregnant women, 11.8% (95% CI: 11.5-12.0) reported marijuana use in the past month, 7.8% (95% CI: 7.6-8.0) in the past 2-12 months, and 19.5% (95% CI: 19.2-19.9) in the past year. After adjusting for sociodemographic characteristics, past-year marijuana use was 2.3-5.1 times more likely among pregnant, and 2.1 to 4.6 times more likely among nonpregnant women who reported past-year tobacco smoking, alcohol use, or other illicit drug use compared to those reporting no substance use.

CONCLUSIONS

Pregnant and nonpregnant women reporting marijuana use, alone or with other substances, can benefit from substance use screening and treatment facilitation.

Prenatal Exposure to Cannabis and Risk of Major Structural Birth Defects: A Systematic Review and Meta-analysis

OBJECTIVE

To review and perform a meta-analysis of observational studies that examined associations between prenatal cannabis exposure and major structural birth defects.

DATA SOURCES

Information sources included Google Scholar, BIOSIS, PubMed/MEDLINE, EMBASE CINAHL, and ClinicalTrials.gov.

METHODS OF STUDY SELECTION

Study titles and abstracts were reviewed with Abstrackr software. We included observational studies that examined the risk of major structural birth defects in people who used cannabis during pregnancy compared with those who had not used cannabis. We excluded case reports, ecologic studies, conference abstracts, manuscript preprints, studies designed to examine effects of cannabis used concurrently with other drugs, and studies that included synthetic cannabinoids. This process yielded 23 studies that analyzed data from birth years 1968-2021.

TABULATION, INTEGRATION, AND RESULTS

We clustered and meta-analyzed measures of association for birth defects by anatomic group. Eleven articles reported an association between cannabis use and the risk of a nonspecific outcome (eg, congenital anomaly). We estimated a pooled odds ratio of 1.33 (95% CI 1.14-1.56) and a pooled adjusted odds ratio (aOR) of 1.22 (95% CI 1.00-1.50). Anatomic groups examined were cardiac (nine studies), oral cleft (three studies), digestive (four studies), genitourinary (three studies), musculoskeletal (seven studies), and nervous system (five studies). Across most outcomes, we reported positive pooled unadjusted associations that were usually attenuated after the inclusion of only adjusted estimates. Two specific anomalies, with limited data, had pooled effect estimates that did not attenuate to the null after adjustment: Ebstein anomaly (two studies, aOR 2.19, 95% CI 1.25-3.82) and gastroschisis (five studies, aOR 2.50, 95% CI 1.09-5.740).

CONCLUSION

Studies examining associations between prenatal exposure to cannabis and major structural birth defects were heterogeneous. Most published effect estimates were unadjusted and scored low on our risk-of-bias assessment. Overall, we found inconsistent evidence to suggest that prenatal cannabis exposure is associated with birth defects. However, findings related to specific anomalies should be considered in further research.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42022319041.

Cannabis and Pregnancy: A Review

Importance

Prenatal cannabis use is rising and is a major public health issue. Cannabis use in pregnancy and during lactation has been associated with increased maternal and offspring morbidity and mortality.

Objective

This review aims to summarize the existing literature and current recommendations for cannabis use during pregnancy or lactation.

Evidence Acquisition

A PubMed, Cochrane Library, and Google Scholar literature search using the following terms was performed to gather relevant data: "cannabis," "cannabinoid," "delta-9-tetrahydrocannabinol," "THC," "cannabidiol," "fetal outcomes," "perinatal outcomes," "pregnancy," and "lactation."

Results

Available studies on cannabis use in pregnancy and during lactation were reviewed and support an association with increased risk of preterm birth, neonatal intensive care unit admission, low birth weight, and small-for-gestational-age infants.

Conclusion and Relevance

There is a critical need for research on the effects of cannabis use in pregnancy and during lactation. This is a necessary first step before furthering patient education, developing interventions, and targeting antenatal surveillance to ameliorate the adverse impacts on maternal and fetal health.

The effect of prenatal cannabis exposure on offspring preterm birth: a cumulative meta-analysis

BACKGROUND AND AIMS

Mixed results have been reported on the association between prenatal cannabis exposure and preterm birth. This study aimed to examine the magnitude and consistency of associations reported between prenatal cannabis exposure and preterm birth.

METHODS

This review was guided by the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. We performed a comprehensive search of the literature on the following electronic databases: PubMed, EMBASE, SCOPUS, Psych-INFO and Web of Science. The revised version of the Newcastle-Ottawa Scale (NOS) was used to appraise the methodological quality of the studies included in this review. Inverse variance weighted random-effects cumulative meta-analysis was undertaken to pool adjusted odds ratios (aOR) after sequential inclusion of each newly published study over time. The OR and 95% confidence interval (CI) limits required (stability threshold) for a new study to move the cumulative odds ratio to the null were also computed.

RESULTS

A total of 27 observational studies published between 1986 and 2022 were included in the final cumulative meta-analysis. The sample size of the studies ranged from 304 to 4.83 million births. Prenatal cannabis exposure was associated with an increased risk of preterm birth (pooled aOR = 1.35, 95% CI = 1.24-1.48). The stability threshold was 0.74 (95% CI limit = 0.81) by the end of 2022.

CONCLUSIONS

Offspring exposed to maternal prenatal cannabis use was associated with higher risk of preterm birth, which warrants public health messages to avoid such exposure, particularly during pregnancy.

Prevalence and Factors Associated With Low Birth Weight in the Solomon Islands: Evidence From the 2015 Solomon Islands Demographic and Health Survey data

Low birth weight (LBW) has contributed to more than 80% of under-5 deaths worldwide, most occurring in low- and middle-income countries. We used the 2015 Solomon Islands Demographic and Health Survey data to identify the prevalence and risks associated with LBW in the Solomon Islands. Low birth weight prevalence estimated was 10%. After adjustment for potential confounders, we found the risk of LBW for women with a history of marijuana and kava use was 2.6 times, adjusted relative risk (aRR) 2.64 at a 95% confidence interval [0.64, 10.95] and 2.5 times [aRR: 2.50 (0.63, 9.88)] than among unexposed women, respectively. Polygamous relationship, no antenatal care, decision-making by another person were 84% [aRR: 1.84 (1.15, 2.93)], 73% [aRR: 1.73 (0.96, 3.13)], and 73% [aRR: 1.73 (0.96, 3.13)] than among unexposed women, respectively. We also found that 10% and 4% of LBW cases in the Solomon Islands were attributable to a household of more than 5 members and tobacco and cigarette use history. We concluded that LBW in the Solomon Islands relied more on behavioral risk factors, including substance use and health and social risk factors. We recommended further study on kava use and its impact on pregnancy and LBW.

Consequences of the exposome to gestational diabetes mellitus

The exposome is the cumulative measure of environmental influences and associated biological responses throughout the lifespan, including those from the environment, diet, behaviour, and endogenous processes. The exposome concept and the 2030 Agenda for the Sustainable Development Goals (SDGs) from the United Nations are the basis for understanding the aetiology and consequences of non-communicable diseases, including gestational diabetes mellitus (GDM). Pregnancy may be developed in an environment with adverse factors part of the immediate internal medium for fetus development and the external medium to which the pregnant woman is exposed. The placenta is the interface between maternal and fetal compartments and acts as a protective barrier or easing agent to transfer exposome from mother to fetus. Under and over-nutrition in utero, exposure to adverse environmental pollutants such as heavy metals, endocrine-disrupting chemicals, pesticides, drugs, pharmaceuticals, lifestyle, air pollutants, and tobacco smoke plays a determinant role in the development of GDM. This phenomenon is worsened by metabolic stress postnatally, such as obesity which increases the risk of GDM and other diseases. Clinical risk factors for GDM development include its aetiology. It is proposed that knowledge-based interventions to change the potential interdependent ecto-exposome and endo-exposome could avoid the occurrence and consequences of GDM.

The ethics and management of cannabis use in pregnancy following decriminalisation and licensing for medical use: narrative review

AIMS AND METHOD

As drug policies pertaining to cannabis use become more liberalised, the prevalence of cannabis use in pregnancy could increase. However, there is limited guidance available for clinicians. This paper presents a narrative review of literature published in the past 16 years (2006-2021) to (a) address the impact of legalisation and decriminalisation on the risks, ethics and support of women who use cannabis during pregnancy and (b) develop guidance for clinicians.

RESULTS

Both national and international trends suggest increased use of cannabis over the past decade, while the risks of cannabis use for recreational or medicinal purposes in pregnancy remain unmitigated.

CLINICAL IMPLICATIONS

This review confirmed that the recommendation of cannabinoid-based products for pregnant and breast-feeding women is currently premature. More research is needed to address safety concerns. We discussed navigating ethical concerns and suggest targeted management strategies for clinicians treating pregnant women who choose to use cannabis.

Association between Prenatal Marijuana and Tobacco Smoke Exposures and Small for Gestational Age at Birth

OBJECTIVE

The aim of this study was to determine the association of prenatal marijuana exposure with and without tobacco smoke exposure and small for gestational age (SGA) at birth.

STUDY DESIGN

We conducted a secondary analysis of the prospective Lifestyle and Early Achievement in Families (LEAF) cohort enrolled from 2010 to 2015. We included singleton nonanomalous liveborn pregnancies. We assessed marijuana use inclusive of any pregnancy urine specimen with a Δ9-THC-COOH concentration of more than 15 ng/mL by mass spectrometry, self-report on questionnaire, and/or electronic health record; and self-reported maternal tobacco use. Because of the high co-frequency of marijuana with tobacco exposure in pregnancy and the known association between tobacco and fetal growth restriction, we modeled the exposure as: both marijuana and tobacco (hereafter "co-use"), only marijuana, only tobacco, and neither (reference). Incidence of SGA in each group was compared with the neither group. The primary outcome was SGA less than 10th percentile, and secondarily less than 5th percentile, using parity-specific definitions per 2017 US natality reference data.

RESULTS

Among 325 assessed mothers, 46% had neither exposure, 11% had only prenatal marijuana exposure, 20% only tobacco exposure, and 23% co-use exposure. A third (33%) of infants were SGA less than 10th percentile and 20% SGA less than 5th percentile. Marijuana exposure only was associated with an increased risk of SGA less than 10th percentile (43 vs. 26%; adjusted relative risk [aRR]: 1.66; 95% confidence interval [CI]: 1.02-2.69), and SGA less than5th percentile (30 vs. 13%; aRR: 2.26; 95% CI: 1.15-4.47). Tobacco was not associated with SGA less than 10th percentile, but was with SGA less than 5th percentile (26 vs. 13%; aRR: 2.01; 95% CI: 1.13, 3.56). Co-use was not associated with increased SGA risk in multivariate analysis, but was in sensitivity analysis when tobacco use was defined using a cotinine assay rather than self-report (SGA <10th percentile, aRR: 1.97; 95% CI: 1.24-3.15) and (SGA <5th percentile, aRR: 2.03; 95% CI: 1.09-3.78).

CONCLUSION

Prenatal marijuana exposure in addition to tobacco may increase the risk of SGA. Given the rising prevalence of marijuana use in pregnancy, further research is warranted to understand how in utero marijuana exposure may impact fetal growth and birth weight with and without tobacco exposure.

KEY POINTS

· Marijuana and tobacco are commonly used together in pregnancy.. · Prenatal marijuana and tobacco exposure may increase the risk of a small for gestational age infant.. · Further research is warranted to understand how in utero marijuana exposure impacts fetal growth..

Marijuana use, fetal growth, and uterine artery Dopplers

OBJECTIVE

Marijuana (MJ) use is associated with adverse effects on fetal growth. We aimed to investigate the timing of suboptimal fetal growth onset in MJ-exposed pregnancies. In addition, we aimed to explore the relationship between MJ-exposure and both abnormal uterine artery (UtA) Doppler parameters and small for gestational age (SGA).

STUDY DESIGN

This was a secondary analysis of a prospective multicenter cohort that enrolled nulliparous individuals delivering non-anomalous fetuses beyond 20 weeks' gestation. Marijuana exposure was ascertained by self-report or clinical urine toxicology testing. Ultrasound estimated fetal weights (EFWs) were assessed in participants at both 16w0d-21w6d and 22w0d-29w6d. EFWs and birth weight (BW) were converted to weight percentiles (wPCT). EFW and BW wPCTs were calculated using population-based standards. Additionally, a customized standard designed to be applicable to both EFWs and BWs within the same model was also used to allow for EFW to BW percentile trajectories. The primary outcome, longitudinal wPCT, was compared between individuals with and without MJ use in a linear mixed-effects regression model adjusting for tobacco. For modeling, wPCT was smoothed across gestational age; MJ was estimated as an intercept and linear difference in the slope of gestational age. UtA Doppler notching, resistance index (RI), and pulsatility index (PI) at 16w0d-21w6d were compared using t-test and χ2. SGA at delivery was also compared.

RESULTS

Nine thousand one hundred and sixty-three individuals met inclusion criteria; 136 (1.5%) used MJ during pregnancy. Individuals who used MJ were more likely to be younger, identify as non-Hispanic Black, and have had less education. Fetuses exposed to MJ had lower wPCT beginning at 28 weeks using population-based and customized standards, when compared to those without exposure. UtA notching, PI, and RI were similar between groups. SGA was more frequent in neonates exposed to MJ using both population-based (22 vs. 9%, p<.001) and customized (25 vs. 14%, p<.001) curves.

CONCLUSIONS

MJ-exposed fetuses were estimated to be smaller than unexposed fetuses starting at 28 weeks' gestation across both growth standards without a difference in UtA Doppler parameters.

Objective Identification of Cannabis Use Levels in Clinical Populations Is Critical for Detecting Pharmacological Outcomes

Introduction: Cannabis is widely used for recreational and medical purposes, but its therapeutic efficacy remains unresolved for many applications as data from retrospective studies show dramatic discrepancy. We hypothesized that false self-reporting of cannabis use and lack of differentiation of heavy users from light or occasional users contribute to the conflicting outcomes. Objective: The goal of this study was to develop an objective biomarker of cannabis use and test how application of such biomarker impacts clinical study outcomes and dose-response measures. Methods and Analysis: Population pharmacokinetic (PK) models of (-)-trans-Δ9-tetrahydrocannabinol (THC) and its metabolites 11-hydroxy-Δ9-tetrahydrocannabinol (11-OH-THC) and 11-nor-9-carboxy-Δ9-tetrahydrocannabinol (11-COOH-THC) were developed based on published studies reporting cannabinoid disposition in individual subjects following intravenous administration or smoking of cannabis. Plasma 11-COOH-THC concentration distributions in different cannabis user groups smoking cannabis were generated via Monte Carlo simulations, and plasma concentration cutoff values of 11-COOH-THC were developed to differentiate light and heavy daily cannabis users in clinical studies. The developed cutoff value was then applied to a retrospective study that assessed the impact of cannabis use on T cell activation in subjects with HIV who self-reported as either nonuser or daily user of cannabis. Results: The developed population PK models established plasma 11-COOH-THC concentration of 73.1 μg/L as a cutoff value to identify heavy daily users, with a positive predictive value of 80% in a mixed population of equal proportions of once daily and three times a day users. The stratification allowed detection of changes in T cell activation in heavy users which was not detected based on self-reporting or detectability of plasma cannabinoids. A proof-of-concept power analysis demonstrated that implementation of such cutoff value greatly increases study power and sensitivity to detect pharmacological effects of cannabis use. Conclusions: This study shows that the use of plasma 11-COOH-THC concentration cutoff value as an objective measure to classify cannabis use in target populations is critical for study sensitivity and specificity and provides much needed clarity for addressing dose-response relationships and therapeutic effects of cannabis.

Prenatal marijuana exposure and neonatal outcomes: a retrospective cohort study

OBJECTIVES

Previous literature on the effects of marijuana exposure on neonatal outcomes has been limited by the reliance on maternal self-report. The objective of this study was to examine the relationship of prenatal marijuana exposure on neonatal outcomes in infants with marijuana exposure confirmed with meconium drug testing.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

Meconium drug screens obtained on infants born in a hospital system in the Pacific Northwest in the USA over a 2.5-year period. 1804 meconium drug screens were initially obtained, with 1540 drug screens included in the analysis.

PRIMARY AND SECONDARY OUTCOME MEASURES

Neonates with meconium drug screens positive for delta-9-tetrahydrocannabinol (THC) only were compared with neonates with negative drug screens. The following neonatal outcomes were examined: gestational age, preterm birth (<37 weeks), birth weight, low birth weight (defined as birth weight <2.5 kg), length, head circumference, Apgar scores and admission to the neonatal intensive care unit (NICU). Using multivariable logistical and linear regression, we controlled for confounding variables.

RESULTS

1540 meconium drug screens were included in the analysis, with 483 positive for delta-9-THC only. Neonates exposed to delta-9-THC had significantly lower birth weight, head circumference and length (p<0.001). Neonates with THC exposure had 1.9 times the odds (95% CI 1.3 to 2.7, p=0.001) of being defined as low birth weight. Birth weight was on average 0.16 kg lower (95% CI 0.10 to 0.22, p<0.001) in those exposed to THC.

CONCLUSIONS

Prenatal marijuana exposure was significantly associated with decreases in birth weight, length and head circumference, and an increased risk of being defined as low birth weight. These findings add to the previous literature demonstrating possible negative effects of prenatal marijuana use on neonatal outcomes.

The Impact of Self-Reported Alcohol, Tobacco, and Recreational Drug Use during Pregnancy on Adverse Pregnancy Outcomes in First-Time Mothers

OBJECTIVE

 The objective of this study was to derive profiles of alcohol, tobacco, and recreational drug use during pregnancy for first-time mothers with latent class growth analysis (LCGA) and determine the association of these classes with the risk of adverse pregnancy outcomes (APO).

STUDY DESIGN

 A secondary analysis of a prospective cohort of Nulliparous Outcomes in Pregnancy: Monitoring Mothers-to-Be was conducted in eight medical centers across the United States from September 30, 2010, to September 23, 2013. Self-reported use of any alcohol, tobacco, or recreational drugs in the 1 month prior to the visit was assessed at up to four visits throughout pregnancy, and APOs included a composite of preterm birth, hypertensive disorder of pregnancy (HDP), small for gestational age (SGA) infant, or stillbirth, and each adverse outcome separately.

RESULTS

 Four latent classes were identified from the LCGA for 10,031 nulliparous pregnant women that were on average 26.9 years old (standard deviation [SD] = 5.7) and mostly non-Hispanic White (59.7%). Classes included consistent tobacco users (N = 517, 5.2%), nonusers (N = 8,945, 89.2%), alcohol users (N = 500, 5.0%), and a combination of alcohol/tobacco/drug users (N = 69, 0.7%). Logistic regression demonstrated that the class of tobacco users was more likely to have an APO (odds ratio [OR] = 1.48, 95% confidence interval [CI] = 1.22-1.81), preterm birth (OR = 1.53, 95% CI = 1.15-2.02), and SGA (OR = 1.79, 95% CI = 1.36-2.35) relative to the class of nonusers. The class of alcohol users was more likely to have HDP (OR = 1.37, 95% CI = 1.11-1.70) and less likely to have preterm birth (OR = 0.59, 95% CI = 0.38-0.90) and SGA (OR = 0.61, 95% CI = 0.40-0.93) compared to nonusers.

CONCLUSION

 Trajectories of substance use are associated with APOs; thus, interventions to mitigate the use when encountered early in pregnancy are warranted.

KEY POINTS

· Four classes of substance use were identified.. · Tobacco users were at a higher risk of APO and alcohol users were at higher risk of HDP.. · Mitigation strategies are warranted to reduce APO..

Prenatal Exposure to Delta-9-tetrahydrocannabinol (THC) Alters the Expression of miR-122-5p and Its Target Igf1r in the Adult Rat Ovary

As cannabis use during pregnancy increases, it is important to understand its effects on the developing fetus. Particularly, the long-term effects of its psychoactive component, delta-9-tetrahydrocannabinol (THC), on the offspring’s reproductive health are not fully understood. This study examined the impact of gestational THC exposure on the miRNA profile in adult rat ovaries and the possible consequences on ovarian health. Prenatal THC exposure resulted in the differential expression of 12 out of 420 evaluated miRNAs. From the differentially expressed miRNAs, miR-122-5p, which is highly conserved among species, was the only upregulated target and had the greatest fold change. The upregulation of miR-122-5p and the downregulation of its target insulin-like growth factor 1 receptor (Igf1r) were confirmed by RT-qPCR. Prenatally THC-exposed ovaries had decreased IGF-1R-positive follicular cells and increased follicular apoptosis. Furthermore, THC decreased Igf1r expression in ovarian explants and granulosa cells after 48 h. As decreased IGF-1R has been associated with diminished ovarian health and fertility, we propose that these THC-induced changes may partially explain the altered ovarian follicle dynamics observed in THC-exposed offspring. Taken together, our data suggests that prenatal THC exposure may impact key pathways in the developing ovary, which could lead to subfertility or premature reproductive senescence.

Reasons Washington State Women Use Marijuana During Pregnancy/Breastfeeding, Their Trusted Information Sources, and Communication Strategies for Informed Decision-Making

OBJECTIVE

To understand reproductive-aged women's marijuana use beliefs and attitudes.

METHODS

Qualitative research (10 focus groups and 2 bulletin boards) with 95 Washington State women, aged 18 to 44 years, segmented by marijuana-using pregnant/breastfeeding; marijuana-using not-pregnant/breastfeeding; and nonmarijuana users. Participants completed up to 10 survey questions. We used deductive and inductive coding to analyze findings.

RESULTS

Marijuana-using pregnant/breastfeeding participants use marijuana to manage physical/mental pain and because of stigma, feel guilty, and sometimes hide use. Medicines have failed to address symptoms. Participants perceived marijuana safer than alcohol, tobacco, and illicit substances. Participants believed in the legitimacy of marijuana for health maintenance and want others to take their personally experienced benefits seriously. Participants interpreted lack of conclusive research as marijuana use not being unsafe. They want more information. All segments preferred hearing from other women about marijuana use experiences, with the marijuana-using pregnant/breastfeeding segment feeling strongest about this.

CONCLUSIONS

Personal experiences with, and anecdotes from family/friends about, the effects of marijuana use during pregnancy/breastfeeding influence marijuana-using participants' decision making.

NURSING IMPLICATIONS

It is important to speak with perinatal patients in a nonjudgmental/nonthreatening manner that acknowledges why reproductive-aged women may use marijuana and that conveys validation of patients' positive experiences with marijuana and a harm-reduction goal.

"It's so Natural It Goes Hand in Hand": A Qualitative Study of Maternal Perceptions of Cannabis Use during Pregnancy

As the market continues to embrace marijuana as a holistic product, perceptions about its uses are increasingly contradictory to public health recommendations. The purpose of this research was to qualitatively analyze the perceived risks and benefits of cannabis use during pregnancy via in-depth semi-structured interviews conducted with nine women. This research is intended to inform patient-provider interactions regarding cannabis use in prenatal clinical settings.

Directive clinique no 425b : Le cannabis aux différentes périodes de la vie des femmes - Partie 2 : Grossesse, période postnatale et allaitement

OBJECTIF

Fournir aux fournisseurs de soins les meilleures données probantes sur l'utilisation de cannabis et la santé des femmes. Les domaines d'intérêt sont le dépistage, la dépendance et le sevrage; la communication et la tenue de dossier; la grossesse (y compris les issues fœtales et maternelles); la gestion de la douleur maternelle; les soins postnataux (y compris la fumée secondaire et la parentalité); et l'allaitement.

POPULATION CIBLE

Femmes enceintes, allaitantes ou qui planifient une grossesse. BéNéFICES, RISQUES ET COûTS: Discuter de l'utilisation de cannabis avec les femmes enceintes, allaitantes ou qui planifient une grossesse les aide à faire des choix éclairés. D'après des données probantes limitées, il faut éviter l'utilisation de cannabis pendant la grossesse ou l'allaitement, ou réduire la consommation au maximum si l'abstention n'est pas un objectif atteignable, étant donné l'absence de données sur l'innocuité et le suivi à long terme des grossesses et nourrissons exposés au cannabis. DONNéES PROBANTES: Les auteurs ont interrogé les bases de données PubMed et Cochrane Library pour extraire des articles sur l'utilisation de cannabis pendant la grossesse et l'allaitement publiés entre le 1^er janvier 2018 et le 5 février 2021. Les termes de recherche ont été déterminés à partir de termes de recherche MeSH, de mots clés et de leurs variantes : cannabis, cannabinoids, cannabidiol, CBD, THC, marijuana, edible, pregnancy, pregnant, prenatal, perinatal, postnatal, breastfeed, breastfed, lactation, nursing, fetus, fetal, neonatal, newborn et child. Les auteurs ont inclus toutes les publications des types suivants : essais cliniques, études observationnelles, revues (y compris les revues systématiques et les méta-analyses), directives cliniques et déclarations de conférences de consensus. Les principaux critères d'inclusion étaient les femmes enceintes et allaitantes, comme population cible, et l'exposition au cannabis, comme intervention d'intérêt. MéTHODES DE VALIDATION: Les auteurs ont évalué la qualité des données probantes et la force des recommandations en utilisant le cadre méthodologique d'évaluation, de développement et d'évaluation (GRADE). Voir l'annexe A en ligne (tableau A1 pour les définitions et tableau A2 pour l'interprétation des recommandations fortes et faibles). PROFESSIONNELS CONCERNéS: Tous les fournisseurs de soins de santé qui prodiguent des soins aux femmes en âge de procréer. DÉCLARATIONS SOMMAIRES: RECOMMANDATIONS.

Beliefs about marijuana use during pregnancy and breastfeeding held by residents of a Latino-majority, rural region of California

Marijuana use among pregnant and breastfeeding women is on the rise and carries risks for infant health and well-being. Decisions to use marijuana while pregnant and breastfeeding are motivated by beliefs that use poses minimal risk to infants and offers benefits to maternal users. Misperceptions and usage trend higher among disadvantaged populations. This study surveyed 401 community residents on beliefs about risks and benefits of marijuana use by pregnant and breastfeeding women. The study utilized techniques to enhance recruitment of Latino and disadvantaged residents of rural communities in California, a state where recreational marijuana use is legal. Analyses revealed substantial endorsement of beliefs about benefits and low risks of marijuana use while pregnant and breastfeeding, many of which run counter to current evidence. Misperceptions were particularly prevalent for cannabis users and male respondents. Trends in valid beliefs, while modest, were higher for Latinos and parents.

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

OBJECTIVE

To provide health care providers with the best evidence on cannabis use and women's health. Areas of focus include screening, dependence, and withdrawal; communication and documentation; pregnancy (including maternal and fetal outcomes); maternal pain control; postpartum care (including second-hand smoking and parenting); and breastfeeding.

TARGET POPULATION

The target population includes women who are planning a pregnancy, pregnant, or breastfeeding.

BENEFITS, HARMS, AND COSTS

Discussing cannabis use with women who are planning a pregnancy, pregnant, or breastfeeding allows them to make informed choices about their cannabis use. Based on the limited evidence, cannabis use in pregnancy or while breastfeeding should be avoided, or reduced as much as possible if abstaining is not feasible, given the absence of safety and long-term follow up data on cannabis-exposed pregnancies and infants.

EVIDENCE

PubMed and Cochrane Library databases were searched for articles relevant to cannabis use during pregnancy and breastfeeding published between January 1, 2018, and February 5, 2021. The search terms were developed using the MeSH terms and keywords and their variants, including cannabis, cannabinoids, cannabidiol, CBD, THC, marijuana, edible, pregnancy, pregnant, prenatal, perinatal, postnatal, breastfeed, breastfed, lactation, nursing, fetus, fetal, neonatal, newborn, and child. In terms of publication type, all clinical trials, observational studies, reviews (including systematic reviews and meta-analyses), guidelines, and conference consensus statements were included. The main inclusion criteria were pregnant and breastfeeding women as the target population, and exposure to cannabis as the intervention of interest.

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 health care providers who care for women of reproductive age.

SUMMARY STATEMENTS

RECOMMENDATIONS.

Marijuana use in Pregnant Women with Disabilities in the United States

OBJECTIVES

While perinatal marijuana use is increasing, limited research exists related to its use during pregnancy among vulnerable subpopulations of women with disabilities. The purpose of this study is to assess marijuana use in pregnant U.S. women with disabilities.

METHODS

The analytic sample using 2015-2019 National Survey on Drug Use and Health (NSDUH) data included 3657 pregnant women. Descriptive statistics were performed and adjusted logistic regression models estimated the size and direction of the association between the type of disability and marijuana use.

RESULTS

Approximately 13.0% of pregnant women with disabilities used marijuana in the past month, which was higher than pregnant women without disabilities (4.4%). The highest prevalence of past month marijuana use was observed among pregnant women with sensory disabilities (17.2%) followed by women with cognitive disabilities (14.6%) and daily living limitations (11.7%). Marijuana use was also associated with younger age (≤ 25 years old), Black non-Hispanic, high school education or less, non-married, and past month alcohol/tobacco use. Overall, pregnant women with any disability, and particularly those with sensory disabilities (AOR 2.32, 95% CI 1.21, 4.47), were significantly more likely (AOR 1.65, 95% CI 1.02, 2.69) to use marijuana than their counterparts without disabilities.

CONCLUSIONS

The higher prevalence of marijuana use among pregnant women with disabilities in this study supports the American College of Obstetricians and Gynecologists recommendations for universal screening of maternal substance use. Screening for marijuana use in vulnerable populations is crucial and it may require training of health care providers to administer such screenings to women with disabilities.

Birth Outcomes of Neonates Exposed to Marijuana in Utero: A Systematic Review and Meta-analysis

IMPORTANCE

While some studies have found an association between marijuana use and adverse neonatal outcomes, results have not been consistent across all trials.

OBJECTIVE

To assess available data on neonatal outcomes in marijuana-exposed pregnancies.

DATA SOURCES

PubMed, Medline, ClinicalTrials.gov, Cochrane, Scopus, and Web of Science were searched from each database's inception until August 16, 2021.

STUDY SELECTION

All interventional and observational studies that included pregnant women who were exposed to marijuana compared with pregnant women who were not exposed to marijuana and that reported neonatal outcomes were included.

DATA EXTRACTION AND SYNTHESIS

Reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses guideline. Data were extracted by 2 authors for all outcomes, which were pooled using a random-effects model as mean difference or risk ratio (RR) and 95% CI. Data were analyzed from August through September 2021.

MAIN OUTCOMES AND MEASURES

All outcomes were formulated prior to data collection. Outcomes included incidence of birth weight less than 2500 g, small for gestational age (defined as less than the fifth percentile fetal weight for gestational age), rate of preterm delivery (defined as before 37 weeks' gestation), gestational age at time of delivery, birth weight, incidence of neonatal intensive care unit (NICU) admission, Apgar score at 1 minute, Apgar score at 5 minutes, incidence of an Apgar score less than 7 at 5 minutes, fetal head circumference, and fetal length.

RESULTS

Among 16 studies including 59 138 patients, there were significant increases in 7 adverse neonatal outcomes among women who were exposed to marijuana during pregnancy vs those who were not exposed during pregnancy. These included increased risk of birth weight less than 2500 g (RR, 2.06 [95% CI, 1.25 to 3.42]; P = .005), small for gestational age (RR, 1.61 [95% CI, 1.44 to 1.79]; P < .001), preterm delivery (RR, 1.28 [95% CI, 1.16 to 1.42]; P < .001), and NICU admission (RR, 1.38 [95% CI, 1.18 to 1.62]; P < .001), along with decreased mean birth weight (mean difference, -112.30 [95% CI, -167.19 to -57.41] g; P < .001), Apgar score at 1 minute (mean difference, -0.26 [95% CI, -0.43 to -0.09]; P = .002), and infant head circumference (mean difference, -0.34 [95% CI, -0.63 to -0.06] cm; P = .02).

CONCLUSIONS AND RELEVANCE

This study found that women exposed to marijuana in pregnancy were at a significantly increased risk of some adverse neonatal outcomes. These findings suggest that increasing awareness about these risks may be associated with improved outcomes.

Attitudes Toward Cannabis Use During Labor in the United States

Objective: Little is known about women's attitudes toward cannabis use during labor. We aim to address this gap by (1) reporting on attitudes toward cannabis use during labor, including cannabis use during most recent childbirth; and (2) examining the extent to which attitudes, willingness to use cannabis during labor, and cannabis use during most recent childbirth vary across state-level cannabis policies.

Methods: In Spring 2021, we recruited biological women of reproductive age (18–40 years) for an online survey. We collected sociodemographic information and asked women about their attitudes toward cannabis use during labor, willingness to use cannabis during labor, and prior cannabis use during most recent childbirth. We ran descriptive statistics and used Fisher's exact tests to examine the association between state cannabis policies and attitudes toward cannabis use during labor, including willingness to use cannabis during labor.

Results: In our sample (N = 163), most women reported they would either consider using (47.85%) or previously used (3.07%) cannabis during labor. Compared with women who would not use, women who reported willingness to use or prior use of cannabis during labor were more likely to report a lower annual household income (p = 0.001) and education level (p < 0.001). Women willing to consider cannabis use were also more likely to report prenatal cannabis use (p < 0.001) and reside in a state with recreational cannabis legalization (p = 0.003). Women who would not consider using cannabis during labor were more likely to perceive one or more risks of use compared with women who would consider using cannabis during labor (90.00% vs. 72.29%, respectively; p = 0.005). In fully illegal states, 66% of women reported they would be more likely to use cannabis during labor if it were legal.

Conclusions: Future research is urgently needed to guide clinical practice. To mitigate adverse health outcomes, prenatal care providers should discuss cannabis use during labor with their patients.

Lived experiences of women with low birth weight infants in the Solomon Islands: A descriptive qualitative study

Every year, around 20 million women worldwide give birth to low birth weight (LBW) infants, with majority of these births occurring in low-and middle-income countries, including the Solomon Islands. Few studies have explored the pregnancy lived experience of women who deliver LBW infants. The aim of the study is to understand the lived experience of women in the Solomon Islands who gave birth to LBW infants by exploring their personal (socio-demographic and health), behavioural, social and environmental contexts. We used a qualitative descriptive approach and purposely selected 18 postnatal women with LBW infants in the Solomon Islands for an in-depth interview. All data were analysed using thematic analysis in NVivo. We identified six themes reported as being related to LBW: health issues, diet and nutrition, substance use, domestic violence, environmental conditions and antenatal care. Our findings suggest that women in the Solomon Islands are exposed to various personal, behavioural, social and environmental risk factors during pregnancy that can impact birth outcomes, particularly LBW. We recommend further research should be redirected to look at the factors/themes identified in the interviews.

Effects of marijuana on reproductive health: preconception and gestational effects

PURPOSE OF REVIEW

Recent widespread legalization changes have promoted the availability of marijuana and its increased potency and perceived safety. The limited evidence on reproductive and perinatal outcomes from marijuana exposure is enough to warrant concern and action. The objective of this review is to provide a current and relevant summary of the recent literature surrounding this topic.

RECENT FINDINGS

The available published studies on the effect of marijuana exposure on reproductive health and pregnancy outcomes are conflicting. Human studies are often observational or retrospective and confounded by self-report and polysubstance use. However, the current, limited evidence suggests that marijuana use adversely affects male and female reproductive health. Additionally, prenatal marijuana exposure has been reported to be associated with an increased risk of preterm birth and small for gestational age infants.

SUMMARY

With the increasing prevalence of marijuana use, there is an urgent need for evidence-driven recommendations and guidelines for couples interested in conception, affected by infertility or who are expecting. At this time, no amount of marijuana use during conception or pregnancy is known to be well tolerated and the limited available evidence suggests that the safest choice is to abstain.

Marijuana liberalization policies and perinatal health

We studied the effect of marijuana liberalization policies on perinatal health with a multiperiod difference-in-differences estimator that exploited variation in effective dates of medical marijuana laws (MML) and recreational marijuana laws (RML). We found that the proportion of maternal hospitalizations with marijuana use disorder increased by 23% (0.3 percentage points) in the first three years after RML implementation, with larger effects in states authorizing commercial sales of marijuana. This growth was accompanied by a 7% (0.4 percentage points) decline in tobacco use disorder hospitalizations, yielding a net zero effect over all substance use disorder hospitalizations. RMLs were not associated with statistically significant changes in newborn health. MMLs had no statistically significant effect on maternal substance use disorder hospitalizations nor on newborn health and fairly small effects could be ruled out. In absolute numbers, our findings implied modest or no adverse effects of marijuana liberalization policies on the array of perinatal outcomes considered.

Cannabis Use in Pregnancy: A State of the Science Review

With a growing number of states legalizing recreational use, cannabis consumption during pregnancy is increasing. Population-based data and rigorous studies examining the association of cannabis use in pregnancy with perinatal outcomes are limited, but trends include preterm prelabor rupture of membranes, placenta previa, and an increased length of hospital stay. Neonates of pregnant persons who used cannabis during their pregnancy can be at increased risk of low birth weight, preterm birth, neonatal intensive care unit admission, neurocognitive deficits, and infectious and neurologic morbidity and mortality. This state of the science review examines the prevalence of cannabis use in pregnancy, its pharmacodynamics and how that is influenced by pregnancy, and associated adverse perinatal and neonatal outcomes. Implications for health care providers caring for pregnant persons using cannabis, especially in legalized states, are discussed.

Major Phytocannabinoids and Their Related Compounds: Should We Only Search for Drugs That Act on Cannabinoid Receptors?

The most important discoveries in pharmacology, such as certain classes of analgesics or chemotherapeutics, started from natural extracts which have been found to have effects in traditional medicine. Cannabis, traditionally used in Asia for the treatment of pain, nausea, spasms, sleep, depression, and low appetite, is still a good candidate for the development of new compounds. If initially all attention was directed to the endocannabinoid system, recent studies suggest that many of the clinically proven effects are based on an intrinsic chain of mechanisms that do not necessarily involve only cannabinoid receptors. Recent research has shown that major phytocannabinoids and their derivatives also interact with non-cannabinoid receptors such as vanilloid receptor 1, transient receptor ankyrin 1 potential, peroxisome proliferator-activated receptor-gamma or glitazone receptor, G55 protein-coupled receptor, and nuclear receptor, producing pharmacological effects in diseases such as Alzheimer's, epilepsy, depression, neuropathic pain, cancer, and diabetes. Nonetheless, further studies are needed to elucidate the precise mechanisms of these compounds. Structure modulation of phytocannabinoids, in order to improve pharmacological effects, should not be limited to the exploration of cannabinoid receptors, and it should target other courses of action discovered through recent research.

Marijuana Use Among Women of Reproductive Age With Disabilities

INTRODUCTION

Despite the increasing prevalence and potential adverse health outcomes associated with marijuana use, limited research exists related to its use in women of reproductive age with disabilities. The purpose of this study is to examine the past-month marijuana use in women of reproductive age with disabilities.

METHODS

Data from the 2015-2019 National Survey on Drug Use and Health included 76,765 women of reproductive age (18-44 years). Descriptive statistics and adjusted logistic regression analyses were conducted to assess the associations between past-month marijuana use and overall disability, including the type of disability.

RESULTS

In this sample, 12.6% of women reported past-month marijuana use. Approximately, 21% of women with disabilities reported past-month marijuana use, compared with only 11.1% of women without a disability. Marijuana use was more prevalent in women with disabilities who were younger (aged ≤25 years), who were non-Hispanic White, who were nonmarried, who had at least some college education, and who used alcohol or tobacco. Women with disabilities had 1.68 (95% CI=1.57, 1.80) higher odds of reporting past-month marijuana use than those with no disabilities. The odds of past-month marijuana use were higher among those with cognitive (AOR=1.78, 95% CI=1.64, 1.94), sensory (AOR=1.30, 95% CI=1.12, 1.51), and daily activities-related (AOR=1.64, 95% CI=1.49, 1.80) disabilities than among their counterparts without disabilities.

CONCLUSIONS

This study found an increased prevalence of past-month marijuana use among women of reproductive age with disabilities. Enhanced screening and counseling using evidence-based practices during routine care for women with disabilities may be necessary to mitigate marijuana use.

Pregnant people's experiences discussing their cannabis use with prenatal care providers in a state with legalized cannabis

BACKGROUND

As cannabis legalization spreads, so do concerns about potential harms from use during pregnancy. Legalization may facilitate improved patient-provider interactions about cannabis use. Yet little is known about pregnant people's discussions of cannabis use with healthcare providers in an environment where recreational cannabis is legal.

METHODS

In May-August 2019, we conducted semi-structured in-depth interviews with 33 pregnant or postpartum people in California who used cannabis during pregnancy, and explored their discussions with healthcare providers about their cannabis use. We audio-recorded and transcribed interviews, and conducted thematic analysis using inductive and deductive methods.

RESULTS

Participants were diverse by age, race/ethnicity, and socio-economic position. Most reported daily cannabis use, both before and during pregnancy. Most participants did not disclose their cannabis use to their prenatal care providers, due to fears of being reported to child protective services (CPS), or fears of provider judgment. Participants reported that few providers initiated any discussions about cannabis use in pregnancy with them; some participants interpreted this omission as tacit endorsement of cannabis use in pregnancy. When participants and providers did discuss cannabis use in pregnancy, participants heard a wide range of sometimes-conflicting health messages, as well as some legal threats.

CONCLUSIONS

This study documents notable deficits in patient-provider interactions about cannabis. Pregnant patients' fears of being reported to CPS and separated from their children for cannabis use persist despite cannabis legalization. Providers' role as potential reporters to CPS appears to pose a significant barrier to comprehensive, compassionate counseling and education on cannabis use in pregnancy.

Marijuana use and perinatal outcomes in obstetric patients at a safety net hospital

OBJECTIVE

To characterize the association between antepartum marijuana exposure and maternal and neonatal outcomes at our institution.

STUDY DESIGN

Retrospective chart review identified an obstetric cohort of singleton gestations. Women with self-reported marijuana use were compared with non-users. Demographic characteristics, risk factors, and maternal-fetal outcomes were evaluated. Associations between outcomes and marijuana use were assessed with regression analysis.

RESULTS

Of 2792 deliveries, 5.4% reported marijuana use. Compared to non-users, marijuana users entered prenatal care later, were younger, non-Hispanic, and used other illicit substances. Marijuana users had a higher rate of cesarean delivery (p = 0.01). After adjusting for confounders, marijuana use remained associated with 4.1-fold risk of delivering a small for gestational age (SGA) infant and 2.89-fold risk of neonatal oxygen use.

CONCLUSION

At a safety net hospital, antepartum marijuana use is significantly associated with cesarean delivery, SGA and supplemental oxygen use at birth. Healthcare disparities associated with marijuana use make this a population of critical interest.

Association between preconception cannabis use and risk of postpartum depression: Findings from an Australian longitudinal cohort

BACKGROUND AND AIM

Evidence suggests a positive association between cannabis use and depression however whether preconception cannabis use is associated with postpartum depression (PPD) remains unknown. This study examined the association using a longitudinal design.

METHODS

Participants were from the Australian Longitudinal Study on Women's Health (cohort born in 1989-95), a sample broadly representative of similarly aged Australian women. The association of past year cannabis use at 3-15 months prior to pregnancy with PPD at ages 19-24 to 22-27 was examined in 516 women with 570 singleton live births. The associations of chronicity, recency, and initiation of cannabis use before pregnancy with PPD at ages 21-26 to 24-29 were investigated in 538 women with 590 singleton live births. PPD was ascertained from self-report of doctor diagnosis for each birth. Relative risk (RR) and 95 % confidence interval (CI) were used to calculate the associations of interest.

RESULTS

Compared with no cannabis use, any past-year cannabis use at 3-15 months before pregnancy may be associated with an increased risk of PPD (1.50, 0.99-2.28). Compared with no cannabis use in the first three annual surveys before pregnancy, chronic use (a past year user in ≥ 2 surveys) was associated with an 80 % higher risk of incident PPD for births in the following 1-4 years (1.80, 1.22-2.68). Compared to never users at ages 20-25, former users who had no use within the past year had no increased risk; past year users had 73 % higher risk (1.73, 1.07-2.81); and past year users who initiated cannabis use at or after age 18 had twice the risk of incident PPD for births in the following 1-4 years (2.02, 1.17-3.49).

CONCLUSION

This study provides evidence that preconception cannabis use is associated with increased risk of PPD. More studies are warranted to confirm this finding before cannabis cessation policies can be reinforced on reducing the risk of PPD.

The Impact of Early Life Exposure to Cannabis: The Role of the Endocannabinoid System

Cannabis use during pregnancy has continued to rise, particularly in developed countries, as a result of the trend towards legalization and lack of consistent, evidence-based knowledge on the matter. While there is conflicting data regarding whether cannabis use during pregnancy leads to adverse outcomes such as stillbirth, preterm birth, low birthweight, or increased admission to neonatal intensive care units, investigations into long-term effects on the offspring’s health are limited. Historically, studies have focused on the neurobehavioral effects of prenatal cannabis exposure on the offspring. The effects of cannabis on other physiological aspects of the developing fetus have received less attention. Importantly, our knowledge about cannabinoid signaling in the placenta is also limited. The endocannabinoid system (ECS) is present at early stages of development and represents a potential target for exogenous cannabinoids in utero. The ECS is expressed in a broad range of tissues and influences a spectrum of cellular functions. The aim of this review is to explore the current evidence surrounding the effects of prenatal exposure to cannabinoids and the role of the ECS in the placenta and the developing fetus.

Cannabis-related diagnosis in pregnancy and adverse maternal and infant outcomes

BACKGROUND

Cannabis use and cannabis use disorders are increasing in prevalence, including among pregnant women. The objective was to evaluate the association of a cannabis-related diagnosis (CRD) in pregnancy and adverse maternal and infant outcomes.

METHODS

We queried an administrative birth cohort of singleton deliveries in California between 2011-2017 linked to maternal and infant hospital discharge records. We classified pregnancies with CRD from International Classification of Disease codes. We identified nicotine and other substance-related diagnoses (SRD) in the same manner. Outcomes of interest included maternal (hypertensive disorders) and infant (prematurity, small for gestational age, NICU admission, major structural malformations) adverse outcomes.

RESULTS

From 3,067,069 pregnancies resulting in live births, 29,112 (1.0 %) had a CRD. CRD was associated with an increased risk of all outcomes studied; the strongest risks observed were for very preterm birth (aRR 1.4, 95 % CI 1.3, 1.6) and small for gestational age (aRR 1.4, 95 % CI 1.3, 1.4). When analyzed with or without co-exposure diagnoses, CRD alone conferred increased risk for all outcomes compared to no use. The strongest effects were seen for CRD with other SRD (preterm birth aRR 2.3, 95 % CI 2.2, 2.5; very preterm birth aRR 2.6, 95 % CI 2.3, 3.0; gastrointestinal malformations aRR 2.0, 95 % CI 1.6, 2.6). The findings were generally robust to unmeasured confounding and misclassification analyses.

CONCLUSIONS

CRD in pregnancy was associated with increased risk of adverse maternal and infant outcomes. Providing education and effective treatment for women with a CRD during prenatal care may improve maternal and infant health.

Assessing the prevalence and correlates of prenatal cannabis consumption in an urban Canadian population: a cross-sectional survey

BACKGROUND

Recreational cannabis use was legalized in Canada in October 2018. We aimed to determine the prevalence and correlates of cannabis consumption among pregnant individuals in a single Canadian city following national legalization.

METHODS

Over the period May to October 2019, we distributed an anonymous cross-sectional survey to pregnant patients attending family practice, midwifery, and low-risk and high-risk obstetrics clinics in Hamilton, Ontario. Eligibility was based on English literacy and current pregnancy. The survey included questions regarding lifetime and in-pregnancy cannabis use, intent for postpartum use and patterns of use. We also collected demographic information. We calculated descriptive statistics and performed logistic regression analyses to explore the relations between cannabis consumption and demographic characteristics.

RESULTS

Of 531 pregnant individuals approached, 478 agreed and were able to participate, for a 90% participation rate. Among these 478 respondents, 54 (11%) reported consuming cannabis at some point during the pregnancy and 20 (4%) reported currently consuming cannabis. Among the 460 respondents who intended to breastfeed, 23 (5%) planned to consume cannabis during the postpartum period. Of 20 current users, 13 (65%) reported consuming cannabis at least weekly and 19 (95%) reported nausea, sleep problems or anxiety as reasons for use. Respondents without postsecondary education had 10.0-fold (95% confidence interval [CI] 4.6-23.5) greater odds of prenatal cannabis consumption than university-educated respondents. In addition, respondents who reported that their partners used cannabis had 3.9-fold (95% CI 2.2-7.3) greater odds of prenatal cannabis consumption than those who reported that their partners did not use cannabis.

INTERPRETATION

Lower educational attainment and partners' cannabis consumption were associated with greater odds of inpregnancy cannabis use. These results may help to inform early intervention strategies to decrease cannabis consumption during this vulnerable period of fetal and neonatal development.

Effects of prenatal synthetic cannabinoid exposure on the cerebellum of adolescent rat offspring

Cannabis is the most commonly used illicit drug worldwide. Recently, cannabis use among young pregnant women has greatly increased. However, prenatal cannabinoid exposure leads to long-lasting cognitive, motor, and behavioral deficits in the offspring and alterations in neural circuitry through various mechanisms. Although these effects have been studied in the hippocampus, the effects of prenatal cannabinoid exposure on the cerebellum are not well elucidated. The cerebellum plays an important role in balance and motor control, as well as cognitive functions such as attention, language, and procedural memories. The aim of this study was to investigate the effects of prenatal cannabinoid exposure on the cerebellum of adolescent offspring. Pregnant rats were treated with synthetic cannabinoid agonist WIN55,212-2, and the offspring were evaluated for various cerebellar markers of oxidative stress, mitochondrial function, and apoptosis. Additionally, signaling proteins associated with glutamate dependent synaptic plasticity were examined. Administration of WIN55,212-2 during pregnancy altered markers of oxidative stress by significantly reducing oxidative stress and nitrite content. Mitochondrial Complex I and Complex IV activities were also enhanced following prenatal cannabinoid exposure. With regard to apoptosis, pP38 levels were significantly increased, and proapoptotic factor caspase-3 activity, pERK, and pJNK levels were significantly decreased. CB1R and GluA1 levels remained unchanged; however, GluN2A was significantly reduced. There was a significant decrease in MAO activity although tyrosine hydroxylase activity was unaltered. Our study indicates that the effects of prenatal cannabinoid exposure on the cerebellum are unique compared to other brain regions by enhancing mitochondrial function and promoting neuronal survival. Further studies are required to evaluate the mechanisms by which prenatal cannabinoid exposure alters cerebellar processes and the impact of these alterations on behavior.

Frequency of cannabis use during pregnancy and adverse infant outcomes, by cigarette smoking status - 8 PRAMS states, 2017

BACKGROUND

Research on prenatal cannabis use and adverse infant outcomes is inconsistent, and findings vary by frequency of use or cigarette use. We assess (1) the prevalence of high frequency (≥once/week), low frequency (<once/week), and any cannabis use during pregnancy by maternal characteristics and adverse infant outcomes; (2) the prevalence of infant outcomes by cannabis use frequency, stratified by cigarette smoking; and (3) the association between cannabis use frequency and infant outcomes, stratified by cigarette smoking.

METHODS

Cross-sectional data from 8 states' 2017 Pregnancy Risk Assessment Monitoring System (n = 5548) were analyzed. We calculated adjusted prevalence ratios (aPR) between cannabis use frequency and infant outcomes with Modified Poisson regression.

RESULTS

Approximately 1.7 % and 2.6 % of women reported low and high frequency prenatal cannabis use, respectively. Prevalence of use was higher among women with small-for-gestational age (SGA) (10.2 %) and low birthweight (9.7 %) deliveries, and cigarette use during pregnancy (21.2 %). Among cigarette smokers (aPR: 1.8; 95 % CI: 1.1-3.0) and non-smokers (aPR: 2.1; 95 % CI: 1.1-3.9), high frequency cannabis use doubled the risk of low birthweight delivery but did not increase preterm or SGA risk. Regardless of cigarette use, low frequency cannabis use did not significantly increase infant outcome risk.

CONCLUSIONS

Prenatal cannabis use was more common among women who smoked cigarettes during pregnancy. High frequency cannabis use was associated with low birthweight delivery, regardless of cigarette use. Healthcare providers can implement recommended substance use screening and provide evidence-based counseling and cessation services to help pregnant women avoid tobacco and cannabis use.

Association of Recreational Cannabis Legalization With Maternal Cannabis Use in the Preconception, Prenatal, and Postpartum Periods

IMPORTANCE

Recent studies have revealed increases in population-level cannabis use after legalization of recreational cannabis. However, the association of cannabis legalization with maternal cannabis use during important life stages remains unknown.

OBJECTIVE

To investigate the association of legalization of recreational cannabis with maternal cannabis use during the preconception, prenatal, and postpartum periods.

DESIGN, SETTING, AND PARTICIPANTS

This repeated cross-sectional study used state-level data on women who delivered live-born infants in the US from the Pregnancy Risk Assessment Monitoring System from January 2004 to December 2018. Data from 2 states that had legalized recreational cannabis (Alaska and Maine) and 2 states that had not legalized recreational cannabis (New Hampshire and Vermont) were used. Women completed surveys 2 to 6 months after delivery, reporting preconception, prenatal, and postpartum cannabis use.

EXPOSURE

State recreational cannabis legalization.

MAIN OUTCOMES AND MEASURES

The 3 primary outcomes were self-reported cannabis use during the 12 months before pregnancy (preconception), during pregnancy (prenatal), and the 2 to 6 months after pregnancy (postpartum). A difference-in-differences analysis was used to compare changes in the prevalence of maternal cannabis use during each period before and after state legalization of recreational cannabis, controlling for maternal characteristics (age, race/ethnicity, educational level, income, cigarette smoking, and breastfeeding) and state fixed effects. State-specific survey weights were used.

RESULTS

The analytic sample included 23 082 women in the preconception period, 23 859 in the prenatal period, and 26 610 in the postpartum period. In each analysis, most women were married (range among all groups, 63.9%-64.8%), aged 25 to 34 years (preconception, 55.4%; prenatal, 55.9%; postpartum, 56.1%), and had an annual household income less than $50 000 (preconception, 55.7%; prenatal, 56.3%; postpartum, 55.5%). In adjusted analyses, preconception and postpartum cannabis use increased significantly in states that had legalized recreational cannabis compared with states that had not legalized it (preconception risk difference, 0.0457 [95% CI, 0.0013-0.0900]; P = .04; postpartum risk difference, 0.0539 [95% CI, 0.0259-0.0818]; P < .001). The risk difference for prenatal cannabis use was not significant (0.0070; 95% CI, -0.0120 to 0.0260; P = .47).

CONCLUSIONS AND RELEVANCE

In this repeated cross-sectional study, recreational cannabis legalization was associated with changes in maternal cannabis use before and after pregnancy. The findings suggest that future studies should undertake an interdisciplinary approach to maximize benefit and application of findings to future public health, health care, and policy sectors.

Association between gestational cannabis exposure and maternal, perinatal, placental, and childhood outcomes

Globally, the availability and formulations for the administration of cannabis are changing with decriminalization or legalization of recreational use in some jurisdictions, and the prescription of cannabis also occurring. These changes are likely to affect the prevalence of use, including by women of childbearing age. The effects of in utero and infant alcohol and tobacco exposure are well-documented, but the outcomes of cannabis exposure are less certain. The content of delta-9-tetrahydrocannabinol (THC), the psychoactive component of cannabis has progressively increased over several decades. This review explores the limited knowledge surrounding the epidemiology of gestational and postnatal cannabis exposure and implications for the mother-placenta-fetus/neonate triad. We examine cannabis' effects from antenatal and lactation exposure on (a) pregnancy and perinatal outcomes, (b) placental health, and (c) longer term cardiometabolic and neurodevelopmental risks and outcomes. Though definitive outcomes are lacking, gestational cannabis has been associated with increased risk of other substance use during pregnancy; impaired placental blood flow; increased risk of small for gestational age births; and associated complications. Childhood and adolescent outcomes are sparsely assessed, with suggested outcomes including increased risk of depression and attention-deficit hyperactivity disorder. Cardiometabolic implications of gestational cannabis use may include maternal fatty liver, obesity, insulin resistance, and increased risk of gestational diabetes mellitus (GDM), with potential consequences for the fetus. Clinical implications for pediatric practice were explored in a bid to understand any potential risk or impact on child health and development.

Substance use during pregnancy: impact on Colorado community hospital

Background

Neonatal Abstinence Syndrome (NAS) leads to increased length of stay (LOS), which leads to increased healthcare costs, and can cause financial burdens for hospitals. The purpose of the study was to determine the impact of substance use by pregnant women on a Colorado (CO) community hospital after state legalization of recreational cannabis.

Methods

Data were gathered retrospectively through the electronic health record at an inpatient facility and described 607 mothers and 419 newborns (total N = 1026) who tested positive for drugs (urinalysis or blood for mother and urine, meconium, or cord blood for newborns). Screening for drugs was at discretion of healthcare provider if mother reported use or newborn showed symptoms of NAS. The patients who were not screened or tested negative were excluded from consideration. Newborns exposed to cannabis were compared to those exposed to other drugs (opioids, methadone, cocaine, barbiturates, benzodiazepines, amphetamines) on costs of newborn hospitalization, based on type of newborn bed and length of stay (LOS). Group comparisons were done using Cochran-Armitage chi-square tests and two-sample t-tests.

Results

The proportion of screened patients testing positive for illicit and prescribed substances increased significantly from 2013 (33.4%) to 2017 (50.2%) (p < 0.001). The LOS of drug-exposed newborns increased significantly over the years (p < 0.0001). Newborns testing positive for cannabis were more likely to remain in a normal newborn nursery (NSY) bed (69.8%) than those testing positive for other drugs (27.7%), with an average hospital LOS (4.6 days) significantly shorter (p < 0.001) than that of other-drug exposed newborns (14.2 days). Combined healthcare costs for other-drug exposed newborns ($23,495,221) were significantly higher (p < 0.001) than for cannabis-exposed newborns ($2,885,139); both groups had significantly higher costs (p < 0.001) than normal healthy newborns ($2,166,649).

Conclusion

Drug-exposed newborns have a significant financial impact on hospital healthcare costs, largely due to more expensive bed placement and longer LOS.

Neural Stem Cells and Cannabinoids in the Spotlight as Potential Therapy for Epilepsy

Epilepsy is one of the most common brain diseases worldwide, having a huge burden in society. The main hallmark of epilepsy is the occurrence of spontaneous recurrent seizures, having a tremendous impact on the lives of the patients and of their relatives. Currently, the therapeutic strategies are mostly based on the use of antiepileptic drugs, and because several types of epilepsies are of unknown origin, a high percentage of patients are resistant to the available pharmacotherapy, continuing to experience seizures overtime. Therefore, the search for new drugs and therapeutic targets is highly important. One key aspect to be targeted is the aberrant adult hippocampal neurogenesis (AHN) derived from Neural Stem Cells (NSCs). Indeed, targeting seizure-induced AHN may reduce recurrent seizures and shed some light on the mechanisms of disease. The endocannabinoid system is a known modulator of AHN, and due to the known endogenous antiepileptic properties, it is an interesting candidate for the generation of new antiepileptic drugs. However, further studies and clinical trials are required to investigate the putative mechanisms by which cannabinoids can be used to treat epilepsy. In this manuscript, we will review how cannabinoid-induced modulation of NSCs may promote neural plasticity and whether these drugs can be used as putative antiepileptic treatment.

Demographic Discrepancies in Prenatal Urine Drug Screening in Washington State Surrounding Recreational Marijuana Legalization and Accessibility

OBJECTIVES

This study evaluated demographic patterns related to prenatal cannabinoid urine drug screening (UDS) over a 5-year period during which recreational marijuana was legalized and became accessible in Washington State.

METHODS

Using electronic health record data, we performed a retrospective analysis for deliveries occurring over a 5-year period that encapsulated the transitions to marijuana legalization and legal access. For three cohorts of women delivering prior to legalization, between legalization and accessibility, and following accessibility, the UDS completion rate and screening demographic characteristics were assessed using Chi-squared tests and multivariate logistic regression.

RESULTS

25,514 deliveries occurred between March 2011 and March 2016. A significantly higher percentage of women underwent UDS post-accessibility (24.5%) compared to pre-legalization (20.0%, p < 0.001). A corresponding increase was not observed in the percentage of marijuana-positive UDS in tested patients (22.7% vs. 23.3%, p = 0.86). African American women had 2.8 times higher odds than Latinas of being tested, 2.1 times higher odds than Asian women, 1.7 times higher odds than White women, and 1.4 times higher odds than women of other races (all p < 0.001). Subsidized insurance status was also strongly associated with increased likelihood of testing (aOR = 3.5, p < 0.001).

CONCLUSIONS FOR PRACTICE

Prenatal UDS testing patterns changed as recreational marijuana possession and accessibility became legal. Demographic discrepancies in testing reveal biases related to race and insurance status, which may be a proxy for socioeconomic status. As such discrepancies are potential contributors to health outcome disparities, it is important for providers and health care systems to examine their practices and ensure they are being appropriately, equally, and justly applied.

Update on the developmental consequences of cannabis use during pregnancy and lactation

There is a strong increase in prevalence trends for cannabis use during pregnancy and lactation as more states legalize use of this drug. Information on the teratogenic risk of cannabis is limited but some important themes can be gleaned. Studies have not found a unique phenotypic signature of prenatal exposure but an increased risk of congenital anomalies, particularly gastroschisis, has been reported. Changes in fetal growth have been described in some epidemiological studies but long-term patterns of physical growth appear unaffected. Prenatal exposure to cannabis is not generally associated with reductions in global IQ but specific cognitive skills, especially attention and memory, can be negatively impacted. Long-term impacts on psychological health include increased rates of depressive symptoms and anxiety as well as delinquency. Relatively little is known about the risk of maternal cannabis use during lactation but data suggest that infant exposure is relatively low compared to maternal exposure. As delta-9-tetrahydrocannabinol (THC) levels increase to meet consumer demand and routes of exposure diversify, there is a strong need for prospective birth-cohort studies that collect biological samples to quantify exposure. Data from such studies will be critical to overcoming the weaknesses of past cannabis research and are essential to establishing reliable information on the risks of maternal use. Until that time, health care providers should be encouraged to talk about the risks and benefits associated with cannabis use during pregnancy and lactation with their patients, emphasizing that fetal and neonatal risks cannot be excluded at this time.

Marijuana use and pregnancy outcomes among women with hypertension in pregnancy

Background: Marijuana has vasoconstrictive properties and its use has been associated with increased blood pressure in the general population. Yet, there are limited data on marijuana use and adverse outcomes among women with hypertension in pregnancy, even though these disorders are associated with severe maternal and fetal morbidity and mortality. Since marijuana is currently the most commonly used illicit drug in pregnancy, there is an urgent need to better understand the potential association between marijuana use and hypertension in pregnancy.Objective: To determine the adverse prenatal effects of marijuana use in women with hypertension in pregnancy.Study design: We conducted a retrospective cohort study among individuals with hypertension in pregnancy that delivered ≥23 weeks' gestation at Oregon Health & Science University (October 2013-September 2018). The primary exposure assessed was marijuana use, identified by chart review of documented patient self-report or positive urine toxicology screen. Individuals were stratified into two groups by marijuana use: use during pregnancy versus never used. Primary outcomes included composite adverse maternal and neonatal outcomes. Secondary outcomes included individual maternal outcomes, rarer neonatal outcomes and severe features of preeclampsia. Differences were analyzed by Fisher's exact, t-test, and logistic regression. Significance was determined by alpha = 0.05 for primary outcomes and alpha = 0.01 for secondary outcomes.Results: From 11,825 deliveries, 1,613 (13.6%) were classified with hypertension in pregnancy. A total of 117 individuals (7.3%) used marijuana during pregnancy, 1,110 (68.2%) had never used marijuana and 396 (24.6%) had unknown marijuana use and were excluded, leaving 1,217 individuals in this analysis. Women using marijuana in pregnancy were more likely to be younger, non-Hispanic White, publicly insured and using other substances compared to women who did not use marijuana. There were no differences in the overall distribution of hypertensive disorders, including preeclampsia with severe features, in women who used marijuana versus those who did not (p = .80). In multivariable analyses, after adjusting for maternal factors and other substance use, marijuana use was not associated with adverse maternal (aOR 1.23, 95% CI 0.43-3.50, p = .69) or neonatal (aOR 0.90, 95% CI 0.28-2.89, p = .86) outcomes.Conclusions: Marijuana use in pregnancy was not associated with maternal or neonatal outcomes or worsened hypertensive disease among women with hypertension in pregnancy after adjusting for maternal characteristics, including use of other substances. Our data highlight the need to consider use of other substances when evaluating the association between marijuana use in pregnancy and adverse pregnancy outcomes.