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Cannabis Use During Pregnancy and Postpartum CLINICAL REVIEW Editor’s key points Cannabis use during } In utero exposure to cannabis has been associated with long-term pregnancy and postpartum neurodevelopmental outcomes Sophia Badowski MD Graeme Smith MD PhD FRCSC that persist into young adulthood. Pregnant women should be counseled regarding these risks and encouraged to abstain from use. Abstract Objective To help obstetric care providers, including family physicians, nurse } Maternal risks of cannabis use are practitioners, midwives, and obstetricians, educate patients on the risks of related to the mode of ingestion cannabis use in pregnancy and postpartum and its relationship to nausea and and its addictive potential. Harm vomiting in pregnancy. reduction options should be offered to those not able to quit completely. Sources of information The Ovid MEDLINE database was searched using the } The relationship between cannabis MeSH terms pregnancy, cannabis, lactation, and cannabinoid hyperemesis in and nausea in pregnancy is complex various combinations. The relevant articles were reviewed and further sources and remains poorly defined. While were found within the references of these articles. women using it in pregnancy often find it effective, chronic use might be associated with cannabinoid Main message In utero exposure to cannabis has been associated with long- hyperemesis syndrome, a condition term neurodevelopmental outcomes that persist into young adulthood. Cannabis characterized by episodes of acute should not be used to treat nausea and vomiting in pregnancy and its chronic abdominal pain, nausea, and vomiting. use might lead to the development of cannabinoid hyperemesis syndrome. There are other safe and effective treatments for nausea and vomiting Conclusion There is no known safe level of cannabis use during pregnancy or that should be used first line. lactation. Pregnant women should be counseled regarding the risks of in utero } Tetrahydrocannabinol is excreted exposure and encouraged to abstain from use in pregnancy and while breastfeeding. in human breast milk. Human data have suggested possible impaired s cannabis has been legalized in Canada, and increasingly is being infant motor development at 1 year legalized worldwide, our lack of information regarding its safety in the in children exposed to cannabis pregnant and lactating population has become apparent. while breastfeeding; however, these ACannabis is the most commonly used illicit drug during pregnancy.1 Self- data are limited. reported rates of use in pregnancy are 2% to 5%; however, these likely rep- resent an underestimate. In one study exploring the outcomes of prenatal cannabis and alcohol exposure on academic achievement, Goldschmidt et al2 reported on the frequency of concurrent cannabis and alcohol use dur- ing pregnancy. In their study, 14% of women reported heavy use of cannabis (ie, smoking 1 or more joints per day) during the first trimester of preg- nancy, compared with 5.3% and 5.0% during the second and third trimes- ters of pregnancy, respectively. Risk factors for continued use include single or unmarried status, lower income, less education, or a partner who also uses cannabis.1,3 Women using cannabis in pregnancy are more likely to use alcohol, tobacco, and illicit drugs, which might have additive or synergistic effects.1,4 At the same time, studies have demonstrated that cannabinoids readily cross the placenta5 and appear in human breast milk,6 resulting in fetal and neonatal exposure. Case description Julie is a 23-year-old nulliparous woman who is currently at 18 weeks’ ges- tation. Her pregnancy has been uncomplicated to date. She presents to your office with an urgent concern of diffuse abdominal pain and intractable nau- sea and vomiting. Findings of investigations, including bloodwork and imag- ing, are unremarkable. On history she admits to increasing cannabis use during the past week to mediate worsening symptoms of “morning sickness.” Nausea and vomiting were not an issue in her first trimester. You wonder whether her cannabis use is contributing to the overall clinical picture. 98 Canadian Family Physician | Le Médecin de famille canadien } Vol 66: FEBRUARY | FÉVRIER 2020 CLINICAL REVIEW Sources of information effect. Others have proposed that with increasing THC The Ovid MEDLINE database was searched using the potency over time, we might see a greater magnitude of MeSH words pregnancy, cannabis, lactation, and cannabi- difference between users and nonusers.11 noid hyperemesis in various combinations. The relevant Neurodevelopment: Probably the greatest contri- articles were reviewed and further sources were found bution that the OPPS, MHPCD, and GenR studies have within the references of these articles. This is not a com- provided is information on the effects of cannabis on plete systematic review of the literature; instead, this is neurodevelopment and mental health. In utero expo- meant to be a clinical review of relevant articles to date. sure to marijuana has been linked to a “withdrawal”-like syndrome in newborns, demonstrated by an increase in Main message startles and tremors and reduced habituation to light.15 Within the literature there is an overall lack of good- In the GenR population, increased aggressive behav- quality research on cannabis use in pregnancy and post- iour and attention deficits were seen as early as at 18 partum. For obvious reasons, there are no randomized months.15,16 By preschool age, difficulties with verbal controlled trials on cannabis use in pregnancy, and and visual reasoning, hyperactivity, attention deficits, many studies do not exclude or control for polysub- and impulsivity became apparent in both the OPPS and stance use. A reliance on self-reported measures might the MHPCD populations and persisted throughout the underestimate the prevalence of drug use in pregnancy, school years.15,17 At age 10, depressive and anxious and the rising tetrahydrocannabinol (THC) potency in symptoms became apparent and were found to predict cannabis products during the past decade might act as a earlier cannabis use and poorer adolescent and early confounder. Finally, pregnant women who use cannabis adult achievement.2,10,18-22 are more likely to be underweight, have less education, While these findings suggest that marijuana is not and have a lower household income, and are less likely without potential harm, these studies are limited in to take folic acid, compared with nonusers.7,8 terms of their ability to control for several environmen- Worthy of note, there are 3 important prospective lon- tal and socioeconomic factors. Furthermore, some find- gitudinal cohort studies that are ongoing and have pro- ings were not reliably reproduced between the cohort vided some insight into both short-term and long-term studies, suggesting a complex relationship between the effects of in utero exposure to cannabis products (Table effects of marijuana on neurodevelopment. For example, 11,2,9-11): the Ottawa Prenatal Prospective Study (OPPS),9 in the OPPS and MHPCD studies, the preschool pop- the Maternal Health Practices and Child Development ulation was found to have lower scores on memory (MHPCD) study,2,10 and Generation R (GenR).1,11 These and verbal reasoning testing, a finding not reproduced studies all recruited women who were pregnant and have by the GenR study.15,17 Further information and clarity followed their children into early childhood (GenR), ado- on the effects of cannabis on the developing brain will lescence (MHPCD), and early adulthood (OPPS). They all require future study, but at this time, it does not appear controlled for sex, ethnicity, home environment, mater- that cannabis use in pregnancy portends a specific phe- nal socioeconomic status, prenatal alcohol and tobacco notype that can be reliably reproduced. exposure, and current maternal substance use. A sum- mary of their findings can be found inTable 2.1,2,9-11 Maternal risks. Maternal risks of marijuana use are related to the mode of ingestion and its addictive poten- Neonatal outcomes. Proposed neonatal outcomes of in tial. Approximately 8% of people who try marijuana will utero cannabis exposure include lower birth weight and develop cannabis dependence.13 Cannabis use disor- long-term neurologic sequelae.12 der, like other substance use disorders, is character- Birth weight: A large number of studies on canna- ized by impaired control, social difficulties, risky use, bis use in pregnancy focus on fetal growth. Results are tolerance, and withdrawal as defined by theDiagnostic mixed, with some studies showing lower birth weights and Statistical Manual of Mental Disorders, 5th edition. and others showing no effect. Of the large prospective Treatment programs are limited and no single method studies, GenR alone showed a statistically significant has been proven superior. That being said, any treat- decrease in birth weight associated with cannabis use ment appears to be better than none, and where out- while controlling for tobacco smoking. This result was patient treatment programs are available, they should dose dependent, with those continuing to use cannabis be used.23 No pharmacotherapy has been shown to throughout pregnancy showing a mean reduction in birth be effective at mitigating withdrawal symptoms other weight of 277 g compared with 156 g in those who only than THC replacement.13 Harm reduction options used it in early pregnancy.11,13 A recent meta-analysis by include using vaporizers or edibles instead of smoking Gunn et al showed a pooled mean difference
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