Cannabis (Marijuana) Use in Pregnancy and Breast Feeding Maureen Shogan, MN, RNC Weed to Know: Need to Know • Disclosure statement: Mead Johnson Nutrition, a Reckitt Benckiser Cannabis (Marijuana) Company (“MJN”) sponsors programs such as this to Pregnancy &Lactation give healthcare professionals access to scientific and educational information provided by experts. • The presenter has complete and independent control over the planning and content of the presentation. Voters Legalized Recreational • The presenter’s comments and opinions are not 2012 $395M 2019 tax necessarily those of MJN. In the event that the revenue presentation contains statements about use of drugs Maureen Shogan, MN, RNC that are not within the drugs’ approved indications, Clinical Director for National Institute on Drug Abuse Project MJN does not promote the use of any drug for (NIH) GOVERNMENT Contract NO. HHSN‐271‐201700021C Phase 2 Spokane, WA indications outside the FDA‐approved product label. [email protected] Maureen Shogan, MN, RNC Not to be Maureen Shogan, MN, RNC Not to be reproduced in any electronic or paper from without permission in writing from author reproduced in any electronic or paper from without permission in writing from author 12 Objectives Aug 2020 • Participants should be able to: • Relate the US Surgeon General, FDA, AAP, ACOG, AWHONN Breast Feeding Medicine, and AHA recommendations CBD CBD regarding marijuana/cannabis use in pregnancy and yes yes breastfeeding. NJ vote • Describe usage and prevalence of TetraHydroCannabinol 2020 (THC). • Describe potential outcomes for children exposed prenatally CBD CBD to cannabis. yes yes Hemp Farming Act 12/2018 Hemp no longer schedule 1 CBD <0.3%THC Legal Maureen Shogan, MN, RNC Not to be reproduced in any electronic or paper from without permission in writing from author Maureen Shogan, MN, RNC Not to be reproduced in any electronic or paper from without permission in writing from author 34 Copyright 2019 Maureen Shogan, MN, RNC Spokane, WA Not to be reproduced electronically in any form or copied on paper without permission in writing from above. [email protected] Cannabis (Marijuana) Use in Pregnancy and Breast Feeding Maureen Shogan, MN, RNC Prevalence Marijuana Use before, during and after pregnancy Pregnancy Risk Assessment Monitoring System (PRAMS) 2017 All Use legal All Use legal Adult Adult Medical Use 9 Medical % Use O r e g o n Ko, JY……Grant, AM (2020). 2017 PRAMS, MMWR, 69 (32), 1058, Aug 14.2020 Maureen Shogan, MN, RNC Not to be Volkow,ND et al (2019) JAMA Maureen Shogan, MN, RNC Not to be reproduced in any electronic or paper from without reproduced in any electronic or paper from permission in writing from author without permission in writing from author 56 Reasons for marijuana use during pregnancy 8 states ‐ PRAMS What do the experts say? Ko, JY……Grant, AM (2020). 2017 PRAMS, MMWR, 69 (32), 1058, Aug 14. Maureen Shogan, MN, RNC Not to be reproduced in any electronic or paper from Calgary, AB without permission in writing from author 78 Copyright 2019 Maureen Shogan, MN, RNC Spokane, WA Not to be reproduced electronically in any form or copied on paper without permission in writing from above. [email protected] Cannabis (Marijuana) Use in Pregnancy and Breast Feeding Maureen Shogan, MN, RNC ACOG Women who are pregnant or contemplating American College of pregnancy should be encouraged to discontinue Obstetrics and Gynecology marijuana use. Marijuana use during lactation 10.2017 and breast feeding is discouraged.” August 28, 2019 AAP Marijuana should not be used during pregnancy. American Academy of Maternal marijuana use while breastfeeding is Pediatrics 9.2018 discouraged. Because of potential risks unknown to the infant and potential risk during lactation, ..encouraged to abstain from using any marijuana while breast feeding Academy of Avoid further use or reduce their use as much as Breastfeeding possible while breast feeding, advise them as to No amount of marijuana use during pregnancy or adolescence is Medicine its possible long‐term neurobehavioral effects. known to be safe. ……the safest choice for pregnant women and 2015 Instruct them to avoid direct exposure of the adolescents is not to use marijuana.Maureen Shogan, MN, Surgeon RNC Not Generalto be Jerome Adams Advisory: Marijuana infant to marijuana and its smoke reproduced in any electronic or paper from Maureen Shogan, MN, RNC Not to be reproduced in any electronic or paper from without permission in writing from author withoutUse and permission the developing in writing from brain. author 910 Cannabis in Pregnancy Professional Organization Statements Health Care Providers AWHONN “Support of implementation legislation, policies, Key Educators Association of and public health initiatives that help raise Women’s Health, • Know as much AND more than those who receive Obstetric, and awareness, remove stigma, discourage use, and Neonatal Nursing facilitate access to prenatal and maternity care of your counsel 9.2018 women who use marijuana during pregnancy FDA FDA strongly advises against the use of CBD and 10.2019 THC and marijuana in any form during pregnancy Dr. Linda Balneaves, PhD, RN or while breastfeeding. Assoc. Prof –University of Manitoba 27.6.17 American “Doubling down on the AHA commitment to • https://www.youtube.com/watch?v=2b7NLa0V7 Heart limiting the smoking and vaping of any products Q8&t=4480s Association and banning cannabis use for youth. All clinicians need greater exposure to and education on the 8.2020 various cannabis products and their health implications” Maureen Shogan, MN, RNC Not to be Maureen Shogan, MN, RNC Not to be reproduced in any electronic or paper from reproduced in any electronic or paper from without permission in writing from author .https://www.ahajournals.org/doi/pdf/without10.1161permission/CIR.00000000000in writing from author 11 12 Copyright 2019 Maureen Shogan, MN, RNC Spokane, WA Not to be reproduced electronically in any form or copied on paper without permission in writing from above. [email protected] Cannabis (Marijuana) Use in Pregnancy and Breast Feeding Maureen Shogan, MN, RNC Prenatal Cannabis exposure Potential FETAL What about Dads who use? Higher level of CB1 receptors in fetal brain • Dads ≥ 1 times/week before conception Specific role for endocannabinoid system • No use in 83% male partner (axonal elongation + synaptogenesis) • 8% 1 or more times/week NeuroProtector • Female partner more likely to use marij • Use 1 or more times/week = poor semen quality • Cannabinoid receptors testicular tissue and Nerve cell proliferation and migration sperm Synaptogenesis Disruption: Neurotransmitter development • Harlow, A et al. (2019). Male marijuana use and spontaneous abortion, presented ASRM, 10.14.19. Abstract O‐4 Eur J Neurosci. 2003;17:1747‐54. Neurotox Res. 2000;23:14‐20.41 Psychopharmacology. 2011;214:5‐15. J Perinatol. 2014;34(6):417‐24. EMBO J. 2014;33(7):668‐85. Prog NeuropsychopharmacolMaureen Biol Shogan, MN, RNC Not Maureen Shogan, MN, RNC 13 Psychiatry. 2014;52:45‐52 to be reproduced in any electronic or paper from without 13 14 Amygdala –regulation of mood and emotional development 50% size of control Potential propensity towards inattention and impulsivity Maureen Shogan, MN, RNC Not to be Maureen Shogan, MN, RNC Not to be reproduced in any electronic or paper from reproduced in any electronic or paper from without permission in writing from author ACOG 5.18 without permission in writing from author 15 16 Copyright 2019 Maureen Shogan, MN, RNC Spokane, WA Not to be reproduced electronically in any form or copied on paper without permission in writing from above. [email protected] Cannabis (Marijuana) Use in Pregnancy and Breast Feeding Maureen Shogan, MN, RNC Cannabis in Pregnancy Drug Molecular Weight Pos UA at Delivery Newborn Outcomes ‐ 2019 Hydrocodone 299 Non Marijuana THC 314 Marijuana Exposed p CBD N=330 N=330 Oxycodone 315 LBW 6.8% 14.7% 0.002 GA 39.0 38.7 0.007 Insulin 6,000 Preterm delivery <37 wks 6.0 % 11.3% 0.17 NICU admit 4.1% 7.3% 0.86 Bailey, Wood, & Shah (2020). J. Perinatology, O’Neill, MJ. (2018). The Merck Index, An Encyclopedia of chemicals, drugs, and biologicals. 16th Ed. Maureen Shogan, MN, RNC Not to be reproduced in any electronic or paper from without permission in writing from author 17 18 Cannabis in Pregnancy Retrospective Report (BORN ‐ Ontario) Newborn Outcomes – 2019 Cannabis exposure in Pregnancy Non Marijuana ONLY Marijuana Exposed N= N=9427 652190 • 3435 8.2% positive UA SGA ( 3rd percentile) 2.4% 6.3% • SGA 70% increased risk SGA (10th percentile) 9.3% 18.2% • Ages Stages (ASQ‐SE) screens 12mos Preterm delivery <37 wks 5.9 %9.1% – Self report by mom No effect on <28 wks 0.5% 1.0% – . Greatest effect 34‐36 6/7 4.7% 8.7 • Score >50 = abnormal screen Transfer to NICU 11.9% 25.1 % Prematurity (2007‐2012) 499,917 3148 (Corsi, 2020) Nature Medicine 6.1% 12.4% – Kharbanda, EO et al (2020). J. Perinatology, doi:10.1038/s41372‐019‐0576‐6 Corsi, DJ et al (7/2019) JAMA doi:10.1001/jama.2019.8734 Canada Better Outcomes Registry and Network (BORN) Maureen Shogan, MN, RNC Not to be reproduced in any electronic or paper from without permission in writing from author Maureen Shogan, MN, RNC 19 20 Copyright 2019 Maureen Shogan, MN, RNC Spokane, WA Not to be reproduced electronically in any form or copied on paper without permission in writing from above. [email protected] Cannabis (Marijuana) Use in Pregnancy and Breast Feeding Maureen Shogan, MN, RNC Case Report Cannabinoid Hyperemesis • 26 yr old female presents to Community Hospital • th 16 week gestation with N/V for past 24 hours • Resistant to anti emetics • PMH: hospitalization 4 months gastritis • Treatment to alleviate • Hyperemesis gravidarum assumed • Hospital course: • Thermoregulatory role – Day 1: Frequent and severe vomiting episodes (12 X/day) • Hot bathing may be result of CB1 receptor activation – Day 2: patient showered multiple times‐ mood seemed to considerably improve – Specific inquiry: • Symptoms improved with hot bathing • Ishaq, s, Ismail, S., Ghaus, S.