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CMECNECPE

ACOG Recommendations on Marijuana Use During Pregnancy and Lactation

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Learning Objectives and CME/Disclosure Information

This activity is intended for healthcare providers delivering care to women and their families.

After completing this activity, the participant should be better able to:

1. Discuss the ACOG recommendations on the use of marijuana in pregnancy
2. Describe the associations between marijuana use in pregnancy and adverse perinatal outcomes

Estimated time to complete activity: 0.25 hours

Faculty:

Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires faculty, planners, and others in control of educational content to disclose all their financial relationships with ineligible companies. All identified conflicts of interest (COI) are thoroughly vetted and mitigated according to PIM policy. PIM is committed to providing its learners with high quality accredited continuing education activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of an ineligible company.

The PIM planners and others have nothing to disclose. The OBG Project planners and others have nothing to disclose.

Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.

Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.

Method of Participation and Request for Credit

Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from Oct 29 1018 through Jan 25 2023, participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education

Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Pharmacy Education

Postgraduate Institute for Medicine designates this continuing education activity for 0.25 contact hour(s) (0.25 CEUs) of the Accreditation Council for Pharmacy Education. (Universal Activity Number – JA4008162-9999-18-413-H01-P)

Type of Activity: Knowledge

Continuing Nursing Education

The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.

Designated for 0.2 contact hours of pharmacotherapy credit for Advance Practice Registered Nurses.

Read Disclaimer & Fine Print

SUMMARY:

The US Surgeon General released an advisory regarding marijuana use during pregnancy and the potential for adverse outcomes. This advisory echoes concerns of ACOG and AAP regarding potency and potential harms during pregnancy and adolescence. Use in pregnancy has doubled (3.4 to 7%) and appears to be associated with adverse outcomes including LBW. ACOG’s updated committee opinion on marijuana use in pregnancy and lactation, due to reported association between marijuana use and impaired neurodevelopment in the offspring, recommends that the use of marijuana in the pre-conception, pregnancy, or lactation periods should be discouraged.

KEY POINTS:

Background 

  • Prevalence of marijuana use (self-reported) during pregnancy: 2-5% 
    • May be as high as 28% in young, urban and disadvantaged populations 
  •  Up to 60% of women using marijuana may continue use during pregnancy  
    • Data suggests that women are not aware of risks and consider marijuana to be cheaper and safer than tobacco

Pharmacology 

  • Tetrahydrocannabinol (THC) is the active substance  
    • Distributed rapidly to the brain and fat 
    • Metabolized by the liver 
    • Half-life:  20-36 hours in occasional users and may be up to 4 to 5 days in heavy users 
    • Excretion: Up to 30 days 
  • Fetal THC levels are
    • Approximately 10% of maternal levels (animal models)
    • Found in breast milk (human studies)

Perinatal Risks and Outcomes  

CNS Effects Including Visual and Behavioral Outcomes 

  • Cannabinoid receptors have been detected in humans as early as 14 weeks gestation and endocannabinoids may be important for neurodevelopment
  • Animal models suggest that exogenous cannabinoids may interfere with normal brain development
  • Children exposed to prenatal marijuana may have
    • Lower scores on tests of visual problem solving
    • Visual-motor coordination
    • Decreased attention span
    • Behavioral problems 

Structural malformations 

  • Available evidence does not suggest increased risk for fetal structural malformations 

Perinatal death 

  • Marijuana use does not increase risk of perinatal death
    • Relative risk (RR) 1.09; 95% CI, 0.62 to 1.91
  • Some studies have shown higher risk of stillbirth but may be confounded by cigarette smoking and other factors
    • RR 1.74; 95% CI, 1.03 to 2.93

Birth weight 

  • Some studies have shown an association between marijuana use and lower birth weight (<10th percentile) even after adjusting for tobacco use
  • A meta-analysis with primary outcome of birth weight <2,500 did not show a difference when adjusted for other factors, such as tobacco use, but did identify possible effects when data was stratified by
    • Weekly users
    • Use in the 1st and 2nd trimesters 

Preterm birth

  • A meta-analysis with primary outcome of preterm delivery <37 weeks did not a show a relationship when adjusted for tobacco use
    • Possibility exists that tobacco “may be an important mediator for some “adverse pregnancy outcomes”

Note: For perinatal death/stillbirth, birthweight and preterm birth, data derived from meta-analysis (see ‘Learn More – Primary Sources below) and other more recent studies

Breastfeeding 

  • There are insufficient data on the effects of marijuana use on breastfeeding infants 
  • Bertrand et al. (Pediatrics, 2018) identified significant transfer of cannabinoids into breast milk following marijuana us (see ‘Related ObG Topics’, below)
  • At this time, both ACOG and AAP recommend that marijuana use during lactation should be discouraged

Medical Marijuana Use 

  • The FDA does not evaluate nor regulate medical marijuana use 
  • There are currently no indications for use in pregnancy 
  • ACOG recommends the following
    • Encourage women to discontinue marijuana use
    • Avoid prescribing or suggesting the use of marijuana for medicinal purposes during pre-conception, pregnancy, or lactation periods 
    • Identify alternative therapies with better safety profiles

Other Counseling Notes

  • All pregnant women, or those planning to become pregnant should be asked about their use of alcohol, tobacco, and drugs including marijuana
  • Discuss potential adverse events
    • More research is necessary to determine whether marijuana is an isolated risk factor for adverse outcomes or whether findings are a result of confounding related to other factors (e.g., tobacco use, other substances, socioeconomic factors, nutrition) or recall bias
  • ACOG recommends that patients should be made aware that screening for substance use allows for the provision of treatment when necessary and not to punish
  • In addition, the ACOG guideline states

…patients should also be informed of the potential ramifications of a positive screen result, including any mandatory reporting requirements

Seeking obstetric–gynecologic care should not expose a woman to criminal or civil penalties for marijuana use, such as incarceration, involuntary commitment, loss of custody of her children, or loss of housing

Learn More – Primary Sources:

ACOG Committee Opinion 722: Marijuana use in pregnancy

ACOG Breastfeeding Page

AAP: Marijuana Use During Pregnancy and Breastfeeding – Implications for Neonatal and Childhood Outcomes

Maternal Marijuana Use and Adverse Neonatal Outcomes: A Systematic Review and Meta-analysis

U.S. Surgeon General’s Advisory: Marijuana Use and the Developing Brain

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Related ObG Topics:

Does Marijuana Affect Time to Pregnancy?
Marijuana Detection in Breast Milk: Does Route and Timing Make a Difference?

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OBG Project CME requires a modern web browser (Internet Explorer 10+, Mozilla Firefox, Apple Safari, Google Chrome, Microsoft Edge). Certain educational activities may require additional software to view multimedia, presentation, or printable versions of their content. These activities will be marked as such and will provide links to the required software. That software may be: Adobe Flash, Apple QuickTime, Adobe Acrobat, Microsoft PowerPoint, Windows Media Player, or Real Networks Real One Player.

Disclosure of Unlabeled Use

This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.

The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

Disclaimer

Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.

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