ACOG Releases New Recommendations on Cannabis Use in Pregnancy and Lactation

Washington, D.C. - Universal screening for cannabis use during the prepregnancy, pregnancy, and postpartum periods is now recommended by the American College of Obstetricians and Gynecologists, according to new and significantly updated clinical guidance released today.

Despite the fact that cannabis use in pregnancy has been associated with spontaneous preterm birth, low birth weight, NICU admissions, and postnatal neurocognitive and behavioral dysfunction, there is a misperception in the general public that cannabis is safe for use during pregnancy due to its increasing availability, legalization, and social acceptability. The Clinical Consensus Cannabis Use in Pregnancy and Lactation provides ob-gyns with evidence-based guidelines for counseling, screening, and strategies to reduce the use of cannabis in prepregnancy and pregnancy and during lactation.

"The largest consumers of cannabis are reproductive-aged people, so we need to have these conversations with our patients and make sure that we educate them on the risks of cannabis use," said Melissa Russo, MD, FACOG, coauthor of the guidance. "While people do use cannabis for medicinal purposes, there is a lack of data on its safety and efficacy in pregnant and lactating people, and research now shows there are potential adverse effects on the pregnancy from cannabis use. We still have a lot learn about the effects of cannabis on placental function, fetal growth and development, and long-term physical and mental health in the child."

Cannabis is most frequently used during the first trimester. According to the guidance, pregnant women who use it often report that cannabis helps with "symptom management of pre-existing conditions such as anxiety, depression, insomnia, and chronic pain, and pregnancy-related symptoms such as nausea and vomiting, weight gain, pain, and stress."

However, ACOG recommendations state that there is no medical indication for cannabis use during pregnancy and the postpartum period. Clinicians should work with patients to identify alternative methods to address health concerns, especially if cannabis is being used to cope with unmet physical or mental health needs.
ACOG recommends universal screening-such as interviews, self-reporting, or validated screening tools-as it helps to eliminate bias because it is required for all patients. However, the guidance cautions ob-gyns against using biologic testing, such as urine and hair, as a screening assessment for cannabis use. Testing is not a definitive way to accurately diagnose a substance use disorder, due to limitations with assessing severity of use and the wide detection window.

Ob-gyns should be aware of the disproportionate rates of drug testing and mandatory reporting to child protective services among Black and minority women that have led to racial health inequities and should be aware of those inequities when engaged in patient counseling regarding risks of cannabis use during pregnancy.

"Structural racism and bias have led to increased testing and reporting of Black patients when the data indicate that white patients screen positive for substance use at the same rate," said Amy Valent, DO, FACOG, coauthor of the guidance. "A person with a substance use disorder does not have a specific age, a specific racial and ethnic background, or fall into a specific socioeconomic status category. Institutional and state policies can vary, so we as clinicians need to familiarize ourselves with those policies and the potential legal ramifications and effects testing will have on our patients and their families."

Pregnant women should always be counseled about the risks and benefits of drug testing, and informed consent should be obtained before drug testing of themself or their newborn, according to the guidance.

While more evidence-based treatment strategies are needed, ob-gyns are encouraged to motivate behavioral change by discussing cannabis use and the individualized risks with their patients in addition to their personal values, priorities, and any barriers to cessation and treatment.
The new guidance also clarifies approaches to breastfeeding for those who use cannabis.

"One personal value a patient may hold is to breastfeed their child," said Dr. Valent. "We want to discourage use of cannabis during lactation, but continued use is not a contraindication to breastfeeding. So, patients who want to breastfeed should be encouraged to do so because of the numerous health benefits it provides the newborn. Overall, we cannot be rigid in our approach. Ob-gyns need to work with patients on risk-reducing strategies that will work best for them and their lives while lowering adverse outcomes."

Cannabis Use in Pregnancy and Lactation is now available.