ACOG Recommendations on Marijuana Use During Pregnancy and Lactation
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
Susan J. Gross, MD, FRCSC, FACOG, FACMG President and CEO, The ObG Project
Disclosure of Conflicts of Interest
Postgraduate Institute for Medicine (PIM) requires instructors, planners, managers and other individuals who are in a position to control the content of this activity to disclose any real or apparent conflict of interest (COI) they may have as related to the content of this activity. All identified COI are thoroughly vetted and resolved according to PIM policy. PIM is committed to providing its learners with high quality CME activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of a commercial interest.
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 Oct 29 2021, 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.
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.
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
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
Decreased attention span
Available evidence does not suggest increased risk for fetal structural malformations
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
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
Use in the 1st and 2nd trimesters
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
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
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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.
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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