MARIJUANA IN PREGNANCY: Now that it is legal

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1 MARIJUANA IN PREGNANCY: Now that it is legal June 7, nd Annual Antepartum and Intrapartum Management No financial disclosures DISCLOSURES Lena H. Kim, MD MFM, Sutter Health, California Pacific Medical Center LEARNING OBJECTIVES Current trends in marijuana use Marijuana history Marijuana legalization Medicinal use Risks in pregnancy & lactation Patient counseling AUDIENCE RESPONSE QUESTION #1 What percentage of your pregnant patient population uses marijuana? A. 0% B. <10% C % D. >20% E. I don t know 2% 19% 44% 26% 10% 0% <10% 10-20% >20% I don t know

2 MARIJUANA FACTS Cannabis plant Tetrahydrocannabinol (THC) 482 other compounds ~65 other cannabinoids Also known as cannabis, pot, weed Most commonly used illicit drug Smoke, vape, edible, extract Self-reported prevalence of use in pregnancy 2-5% 15-28% in young, urban, low SES women 34-60% of users continue in pregnancy Van Gelder et al. Drug Alcohol Depend 2010 Beatty et al. J Addict Res Ther 2012 MARIJUANA USE INCREASING WITH LEGALIZATION National Survey on Drug use and Health Trends in marijuana use Cross-sectional, nationally representative survey In-person audio computer-assisted self-interviews 200,510 reproductive age women 5.3% pregnant (n=10,587) Adjusted prevalence past-month use in pregnancy Increased 62% % % Brown et al. JAMA 2017 PATIENT VIEWS OF MARIJUANA USE IN PREGNANCY Cross-sectional convenience sample survey Women presenting for prenatal care 306 women 35% current use 96% reported use for nausea 34% planned to continue use in pregnancy 70% acknowledged risks 62% cited risk as reason to cut back or quit 10% more likely to use in pregnancy if legalized Mark et al. J Addict Med 2017 AUDIENCE RESPONSE QUESTION #2 Do you think that marijuana use in pregnancy is harmful? 58% A. YES B. NO C. MAYBE D. I don t know that s why I am here YES NO 6% 23% MAYBE I don t know that s why I... 14%

3 MARIJUANA EFFECTS CNS effects via cannabinoid receptor type 1 Euphoria high Anxiety, paranoia, fear or panic High potency (THC content) increasing % % (some as high as 37%) Heightened sensory perception Impaired motor skills (MVA) Decreased short term memory Increased appetite ORIGINS OF MARIJUANA Cannabis plant Central Asia Africa Europe The Americas 500 BC herbal medicine Asia 800 AD hashish Middle East & Asia LEGAL STATUS OF MARIJUANA IN THE UNITED STATES 16 th century cannabis cultivation in America Hemp fibers: textiles & rope VA, MA, CT required farmers to grow hemp Early 1900s recreational use introduced 1931 cannabis outlawed in 29 states Prohibition Evil weed CRIMINALIZATION OF MARIJUANA 1937 Marijuana Tax Act 1 st Federal U.S. law to criminalize marijuana Excise tax on sale, possession, transfer of all hemp products Criminalization of all but industrial uses of marijuana 1 st American jailed was a farmer Hemp needed throughout WWII 1957 last hemp fields planted in Wisconsin

4 WAR ON DRUGS Controlled Substances Act of 1970 Marijuana grouped with heroin & LSD Schedule I drug High potential for abuse 1972 The Shafer Commission ignored Marijuana: A Signal of Misunderstanding Partial prohibition Lower penalties for small amounts of marijuana MEDICAL MARIJUANA LEGALIZATION The Compassionate Use Act of 1996 California 1 st state to legalize medical marijuana Current count of legal medical use 29 states District of Columbia U.S. territories Guam Puerto Rico RECREATIONAL MARIJUANA 2012 Colorado & Washington 1 st states to legalize recreational marijuana As of January states AK, CA, ME, MA NV, VT, OR District of Columbia U.S. federal law Still illegal MEDICINAL MARIJUANA HISTORY 1830s cannabis extracts in India Decrease abdominal pain/vomiting of cholera Late 1800s in Europe & U.S. Stomach problems & other ailments 1985 FDA approved Marinol Cancer: chemotherapy related nausea 2016 FDA approved Syndros AIDS: appetite loss

5 OTHER MEDICAL USES Chronic pain management Decrease narcotic dependence Can t overdose Neuropathic pain Migraines Multiple sclerosis muscle spasms Childhood epilepsy (oil CBD >> THC) Traumatic brain injury? Bipolar disease? Alzheimer s disease? PREGNANCY & LACTATION THC small & highly lipophilic Animal models Crosses the placenta Fetal plasma levels 10% of maternal Found in breast milk 2.5% of maternal dose Long half-life 20-36hr (4-5d if chronic) Up to 30d to completely excrete Baker et al. Obstet Gynecol 2018 Moir et al. Chem Res Toxicol 2008 TERATOGEN? No clear association between marijuana and birth defects Timing of exposure in pregnancy not always known Marijuana exposure 1 st month of pregnancy Odds of anencephaly increased to 2.5 Possible confounding Less folic acid supplementation ADVERSE PERINATAL OUTCOMES Increased risk of low birth-weight Weekly use of marijuana increased risk 11.2% vs 6.7% RR 1.90 (95% CI ) Increased risk of IUFD RR 1.74 (95% CI ) Not adjusted for tobacco use Fergusson et al. BJOG 2002 Ostrea et al. Pediatrics 1997 Campolongo et al. Psychopharmacology (Berl) 2011 Warshak et al. J Perinatol 2015 Conner et al. Obstet Gynecol 2016

6 SPONTANEOUS PRETERM BIRTH Majority of studies no association Adverse effects of smoking tobacco Possibly synergistic or additive effect 1x Weekly use of marijuana increased risk 10.4% vs 5.7% RR 2.04 (95% CI ) Ko et al. Drug Alcohol Depend 2018 Warshak et al. J Perinatol 2015 Conner Obstet Gynecol 2016 Chabarria et al. Am J Obstet Gynecol 2016 EFFECTS OF FETAL EXPOSURE IN CHILDREN Impaired neurodevelopment Lower test scores Visual problem solving Visual-motor coordination Visual analysis Decreased attention span Behavioral problems Aggression Fried et al. Neurotoxicol Teratol 2003 Chandler et al. Alcohol Clin Exp Res 1996 Goldschmidt et al. Neurotoxicol Teratol 2000 OTHER LONGTERM EFFECTS PROBLEMS WITH THE DATA Predictor of marijuana use by age 14 Depression, anxiety Controversial effect on school performance Middle SES children age 5-12 No difference Urban, low SES Poorer reading & spelling scores Lower teacher-perceived school performance Fried et al. Neurotoxicol Teratol 1997 Goldschmidt et al. Neurotoxicol Teratol 2004 van Gelder et al. Epidemiology 2009 Limited data Difficult to study an illegal drug Many confounding exposures Polysubstance use Tobacco, alcohol, other drugs Low SES Malnutrition (folic acid) Intimate partner violence Reporting & recall bias Increasing potency over time Alhusen et al. J Pediatr 2013 Mehmedic et al. J Forensic Sci 2010

7 ACOG COMMITTEE OPINION #722 Because of concerns regarding impaired neurodevelopment, as well as maternal and fetal exposure to the adverse effects of smoking, women who are pregnant or contemplating pregnancy should be encouraged to discontinue marijuana use. PATIENT CASE 30yo weeks GA with a history of chronic pain seeing you for a new OB visit. There are insufficient data to evaluate the effects of marijuana use on infants during lactation and breastfeeding, and in the absence of such data, marijuana use is discouraged. Updated 9/22/17 (replaces #637, 7/2015) PRENATAL CARE Universal screening for tobacco, alcohol, & drug use including marijuana PATIENT CASE 30yo weeks GA with a history of chronic pain seeing you for a new OB visit. Uses medical marijuana daily to control her pain In the past, used narcotics Was not always prescription

8 PROVIDERS COUNSELING RESPONSES Content analysis of audio-recordings 468 patient-health care provider 1 st prenatal visits 90 (19%) of patients disclosed marijuana use 48% of the time, providers did not counsel 86% of tobacco use disclosure counseling 47 counseling results 33 punitive (urine tox screening, CPS) 34 supportive 26 medical counseling of risks Reassure your patient PATIENT COUNSELING Screening is NOT to punish or prosecute Screening IS to identify, educate, help Discuss with your patient Potential adverse health consequences Shared decision-making Marijuana less risk than illegal narcotics? Other medical options Holland et al. Obstet Gynecol 2016 KEY REFERENCES THANK YOU ACOG Committee Opinion #722 Updated 9/22/17, replaces #637 from 7/2015 Chabarria KC, Racusin DA, Antony KM, Kahr M, Suter MA, Mastrobattista JM, et al. Marijuana use and its effects on pregnancy. Am J Obstet Gynecol 2016;215:506.e1-7 Conner SN, Bedell V, Lipsey K, Macones GA, Cahill AG, Tuuli MG. Maternal marijuana use and adverse neonatal outcomes: a systematic review and meta-analysis. Obstet Gynecol 2016; 128: Metz TD, Stickrath EH. Marijuana use in pregnancy and lactation: a review of the evidence. Am J Obstet Gynecol Dec;213(6):