Marijuana in the Obstetric Population Brittany MacGregor PGY 1 on behalf of Sophia Lenson PGY 3, Queens OB/Gyn Objectives 1. Review the status of legalization of cannabis products in Canada and the potential impact on the obstetric population. 2. Assess the literature to date on the safety of in-utero exposure to cannabis to the fetus and mother. 3. Discuss management considerations and propose treatment options throughout the antenatal and postpartum period in mothers who use cannabis products. 4. Present a review of the cannabinoid hyperemesis syndrome vs cyclic vomiting syndrome. 5. Compare the current guidelines on marijuana use while breastfeeding 6. Review limitations of urine drug screening for assessment of marijuana use Disclosures In the News I have nothing to disclose But surely not... A Lack of High Quality Research - Cannabis is the most commonly used illicit drug in pregnancy - Self reports of use are 2.3% - Prospective cohort studies: - 10-15% in middle-class - 23-30% in inner-city - Highest use during first trimester ( 10.7%) The Reproductive Health Working Group 2006 Day, Leech & Goldschmidt, 2011; Fried, 2002 1
a. Say okay and move on because you do not have solid evidence it s bad? b. b. Tell her to stop smoking marijuana immediately because it is harmful to her growing baby? c. c. Discuss harm reduction options? What do our guidelines say? ACOG COMMITTEE OPINION - Screen all women for tobacco, alcohol and other drug abuse - Women reporting marijuana use should be counseled about concerns regarding potential adverse health consequences of continued use during pregnancy. - Women who are pregnant or contemplating pregnancy should be encouraged to discontinue marijuana use. - Pregnant women or women contemplating pregnancy should be encouraged to discontinue use of marijuana for medicinal purposes in favor of an alternative therapy for which there are better pregnancy-specific safety data. - 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. SOGC GUIDELINE ON SUBSTANCE ABUSE - All pregnant women should be asked periodically about alcohol, tobacco, prescription and illicit drug use (III-A) - Women should be counselled about the risks of periconception, antepartum, and postpartum substance use. (III-B) - Health care providers should advise pregnant women to abstain from or reduce cannabis use during pregnancy to prevent negative long-term cognitive and behavior outcomes for exposed children (II-1A) - Health care providers should employ a flexible and harm reduction approach to the care of pregnant women who use alcohol, tobacco or drugs. They should be offered brief interventions and referral to community resources for further psychosocial interventions - When testing for substance use is clinically indicated, urine drug screening is the preferred method. (II-2A) Informed consent should be obtained from the woman before maternal drug toxicology testing is ordered. (III-B) - Policies and legal requirements with respect to drug testing of newborns may vary by jurisdiction, and caregivers should be familiar with the regulations in their region. (III-A) What good quality studies can we turn to? OPPs ( Ottawa Prenatal Prospective Study) - Started in 1978 - Mostly caucasian middle-class families MHPCD ( Maternal Health Practices and Child Development) - Pittsburgh in 1982 - Mostly african-american women from low SES background Generation R - Started in 2001. - Multi-ethnic with higher SES from the Netherlands. Maternal Outcomes - No association with gestational diabetes, anemia, gestational hypertension,postpartum hemorrhage or maternal weight gain has been reliably reproduced. CCSA: Clearing the smoke on Cannabis, 2015 2
Neonatal Outcomes - Preterm Birth - Low Birth weight Yes in Gen R, No in OPPs?Potency effect. Meta-analysis have not shown a strong association. - 5 fold increase in FASD features - Neurological Sequelae ( OPPS, MHPCD, Gen R) - decreased self-quieting ability - increased fine tremors and startles - increased hand-to-mouth activity - sleep pattern changes CCSA: Clearing the smoke on Cannabis, 2015 CCSA: Clearing the smoke on Cannabis, 2015 Recommended Resources - Is she addicted? - Could she go into withdrawal? - If she can t quit cold turkey are there ways to make it safer while she cuts down slowly? ( harm reduction) Cannabis Use Disorder - DSM 5 Same criteria as for other substance use disorders: Involves a pathological set of behaviors related to the use of a cannabis that fall into 4 main categories: 1. Impaired control ( using more than intended, not able to stop etc) 2. Social impairment ( use despite interference with work, relationships etc) 3. Risky use ( use while driving etc) 4. Tolerance and withdrawal Need to meet 2 of these criteria for diagnosis Cannabis withdrawal (DSM 5) - Criteria A: Cessation of cannabis use that has been heavy and prolonged - Criteria B: > 3 of the following 7 symptoms: - Anger, irritability or feelings of aggression - Depressed mood - Feelings of restlessness - A loss of appetite (or weight loss) - Insomnia or other sleeping problems - Feelings of anxiety or nervousness - Physical symptoms of withdrawal, such as headache, stomach pains, increased sweating, fever, chills or shakiness (enough to cause significant discomfort) - Criteria C: The symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning - Criteria D. The symptoms are not due to a general medical condition and are not better accounted for by another disorder 3
Not Just Cannabis Quitting Cannabis 8% of people who try marijuana will develop cannabis dependence Outpatient treatment programs provide modest benefit - Any treatment program is better than none - no modality or duration of treatment has been proven superior No pharmacotherapy has been shown to be effective in mitigating withdrawal symptoms other than THC replacement therapies. Nordstrom and Levin, 2007 Tapering Nabilone - Start at 0.5mg qhs and ask the patient to try to taper down her consumption of cannabis products. - Titrate up to 0.5mg BID to target nausea and increase appetite - Increase by 0.5mg at a time with titration qweekly until able to abstain completely from cannabis products. Harm Reduction options - Use vaporizer - Avoid deep inhalation and breath holding - Avoid smoking with tobacco and higher potency cannabis - Wait 4 hours after smoking before driving - Only the 0.5mg nabilone capsule is covered by ODB - Can marijuana really make me retch and vomit so much? - I thought marijuana made nausea and vomiting better. Cannabinoid Hyperemesis Syndrome 3 Features: - Chronic Cannabis use - Cyclic episodes of Nausea and Vomiting - Frequent hot bathing Often confused with Cyclic Vomiting Syndrome Galli JA, Sawaya RA, Friedenberg FK., 2011 4
Cyclic Vomiting Syndrome - Episodes of nausea/vomiting and diffuse abdominal pain with acute onset lasting <1 week - Absence of nausea and vomiting between episodes - > 3 episodes per year, may be triggered by psychological stressors. - Cannabis may be used to self medicate, no improvement in episode frequency if stopped - Family or personal history of migraines - Hot showers not helpful - Acute treatment :anti-migraine meds, supportive care, psych support. - Prophylaxis: avoid triggers, TCA Cannabinoid Hyperemesis Syndrome - Episodes of nausea/vomiting and diffuse abdominal pain with acute onset lasting typically 24-48 hrs - Absence of nausea and vomiting between episodes - History of chronic cannabinoid use - Recurrence likely if continue to use cannabinoids. - Hot showers helpful - Acute treatment: supportive, abstain from cannabinoids. - Prophylaxis: no cannabis Galli JA, Sawaya RA, Friedenberg FK., 2011 - Now that I ve delivered can I have a joint every once in awhile? - Will you call family and children s services if I do? Marijuana and Breastfeeding - THC is fat soluble and is excreted in human breast milk in moderate amounts - In heavy users milk:plasma ratio can be as high as 8:1 Breastfeeding Recommendations - Motherisk, AAP, ABM, ACOG recommend avoidance of cannabis products while breastfeeding - Decreased motor development at 1 year - Probable increased risk of SIDS -?Compromise ability to care for child - No long term data beyond 1 year - Only the ABM has made a position statement regarding abstinence from breastfeeding in the setting of continued use. MOTHERISK, Academy of Breastfeeding Medicine Child Protection - Marijuana use is a gray zone - Independently not necessarily an indication to contact family and children s services, but may contribute to the whole picture - Both woman and child should receive additional supports - Discuss ability to parent while impaired: who is the designated parent? Urine Drug Testing - Urine drug testing for marijuana can stay positive for up to 30 days - Urine testing can be positive from second-hand exposure but only with exposure in unventilated areas, and likely only positive shortly after exposure Cone and Bigelow, 2015 5
I m still smoking marijuana every night before bed, it s safe cause it s natural right? - Counsel regarding the risks of marijuana use in pregnancy including lower birth weight, possible increase in FASD features, long term neurodevelopmental concerns - Advise to abstain in pregnancy - If not able to abstain advise re: harm reduction Am I addicted? Will I go into withdrawal? - It is possible to be addicted to marijuana and the features of addiction are the same as for other addictions including tolerance and withdrawal, - Withdrawal is characterised by shakes, anxiety, depression, N/V, diarrhea, insomnia. - A potential strategy to mitigate these symptoms is a tapering dose of nabilone while weaning off of cannabis products. Can marijuana really make me retch and vomit so much? - Yes, chronic use can cause cannabis hyperemesis syndrome characterised by cyclical vomiting and abdominal pain and frequent hot bathing. - The only cure is to stop using cannabis products and recurrence is common with resumption of use. Now that I ve delivered can I have a joint every once in awhile? - Marijuana is secreted in breastmilk at up to 8x maternal serum levels - Recommendation is to abstain from marijuana while breastfeeding though evidence is limited regarding the risks. Will you call family and children s services if I do? - Cannabis use itself is not an indication to contact Children s Aid when used responsibly. Thank you Any Questions? - Discuss the importance of the sober parent, avoiding secondhand smoke exposure and offer supports. - Urine drug screens can stay positive for up to 30 days and it is possible to have a positive UDS after significant second hand exposure. 6