By Sonia Alvarado, Senior Teratogen Information Specialist, MotherToBaby CA

Unless you don’t own a television and never listen to the radio, you know that marijuana has been in the news a lot lately and for marijuana users who have had to smoke in illegally, it appears societal attitudes about pot smoking may be changing. Twenty states have laws legalizing some form of marijuana use. Two states, Colorado and Washington, have legalized its recreational use. In an interview, the NFL Commissioner seemed to leave open the possibility that medicinal use could be considered for NFL players if there was scientific evidence that it was helpful to treat injuries and pain. Even President Obama has said that he doesn’t believe marijuana is any more dangerous than alcohol. Marijuana is currently listed as a Schedule I drug. Other Schedule I drugs include heroin, lysergic acid diethylamide (LSD), 3,4-methylenedioxymethamphetamine (ecstasy).

What The Research Shows Us

According to studies, pregnant women who use illicit substances are more likely to use marijuana compared to other drugs. This is often due to the belief that marijuana is less harmful to the developing embryo and fetus, compared to other drugs such as cocaine or heroin.

Marijuana is Cannabis. The delta-9-tetrahydrocannabinol (THC) in the Cannabis plant produces the psychoactive effect or “high.” Marijuana can be smoked in a joint, inhaled through a bong or vaporizer, eaten in food and teas/beverages, used in tinctures, and topical balms. Smoking and ingestion exposes the user to THC, producing the high. When smoked in a joint, the user is exposed to carbon monoxide from the burning of the leaf as well as tar, which can stay behind in the lungs.

Marijuana use during pregnancy has been studied since the 1960’s. Like all studies, there are weaknesses that have been pointed out. For example, asking women about past drug use may not be the most accurate way to make a connection between the dose of the drug and the adverse effects because the women may have forgotten. Also asking women to volunteer information about drug use, which they may fear disclosing even in a confidential setting, may make it difficult to know how frequently pregnant women use drugs overall. Still, a number of experts have reviewed hundreds of reports in humans and animals. At least to this point, the studies do not support an association between marijuana smoking and birth defects. One large study of 12,825 interviews done after delivery, did not find a statistical association between marijuana use and birth defects.

However, the studies also show that marijuana is not risk free. Studies have reported associations between marijuana smoking and growth restriction and lower birth weight, particularly in women who keep smoking through delivery or late in pregnancy. An Australian study of almost 420,000 live births reported a higher risk for neonatal intensive care admission for newborns exposed prenatally to pot. Also, there are reports of abnormal responses or behaviors in the newborn period and this suggests a toxicity or withdrawal. The symptoms include exaggerated and prolonged startle reflexes (sleep cycle disturbances with high-pitched crying.) In a Brazilian study, exposed newborns were “more irritable and less responsive to calming, cried more during the examination, and exhibited more jitteriness and startles than the non-exposed neonates.” Pregnant women who smoke daily and/or through delivery, have a higher risk for complications in their pregnancy compared to women who quit in the first trimester.

Researchers have attempted to assess the long-term effects of prenatal marijuana exposure. Studies of 3, 10 and 14-year old prenatally exposed children suggest that the prenatal exposure to high doses of marijuana may make it harder for children to learn and may affect their emotions (increased aggression) and increase depression symptoms. Studies are needed to assess which prenatally exposed children are most at risk. Its important to note that the children in these studies often have had prenatal exposure to other drugs as well, struggles with poverty and other life challenges, making it difficult to know that the findings are due to a single drug exposure.

So Where Does Marijuana Rank Compared To Other Drugs?

Alcohol: Specific to use during pregnancy, marijuana is not alcohol. Alcohol is still the drug with the highest risk and the widest range of birth defects, including physical, mental and behavioral. Alcohol is a drug with the highest use throughout the world, easy legal access, and social acceptance.

Cocaine: Cocaine, by comparison, is associated with a small risk for birth defects, and a higher risk for admission to newborn intensive care for withdrawal and toxicity. Additionally, cocaine is associated with prenatal growth retardation, lower birth weight, shorter length, and smaller head circumference. Studies suggest the effects on height extend into childhood.

Heroin: Heroin has not been associated with an increased risk for birth defects, however, is associated with a higher risk for withdrawal and admission to newborn intensive care and sudden infant death syndrome.

Bottomline: Snuff Out Smoking It

Clearly, marijuana use in pregnancy is not preferable, nor less risky, compared to most other drugs when a side-by-side comparison is made. Changing societal attitudes doesn’t change the fact that the developing embryo (and fetus) is dependent on the mother for oxygen, nutrients and a balance of hormones, chemicals and other substances to grow normally. Disrupting the normal fetal environment, through the introduction of marijuana or other recreational drugs, puts the pregnancy at risk in the short-term and possibly the long term as well.

Sonia Alvarado is a bilingual (Spanish/English) Senior Teratogen Information Specialist with MotherToBaby California, a non-profit that aims to educate women about medications and more during pregnancy and breastfeeding. Along with answering women’s and health professionals’ questions regarding exposures during pregnancy/breastfeeding via MotherToBaby’s toll-free hotline, email and private chat counseling service, she’s provided educational talks regarding pregnancy health in community clinics and high schools over the past decade.

MotherToBaby is a service of the international Organization of Teratology Information Specialists (OTIS), a suggested resource by many agencies including the Centers for Disease Control and Prevention (CDC). If you have questions about beauty products, medications or other exposures, call MotherToBaby toll-FREE at 866-626-6847 or visit MotherToBaby.org to browse a library of fact sheets and find your nearest affiliate.

In this session, Christina Chambers, PhD, MPH, a perinatal epidemiologist from UC San Diego and Principal Investigator of MotherToBaby Pregnancy Studies, reviews what is known and what still requires further study on the use of alcohol, cannabis and other substances by breastfeeding women, and how this translates to clinical practice. Participants should leave this session with a better understanding of the potential effects of substance use on infant growth and development, how knowledge gaps in this area are being addressed, and how to translate current knowledge into clinical situations in midwife practice.

Participants will gain a clearer understanding of the potential short- and long-term impacts of maternal substance use on infants and learn how ongoing research is addressing current knowledge gaps. The session will also focus on translating this evidence into practical clinical guidance, including strategies for counseling breastfeeding women, supporting informed decision-making, and integrating risk assessment into midwifery care.

This webinar is designed to enhance the knowledge and clinical skills of midwives and other healthcare providers involved in maternal-child health.

Continuing Education (CE) credits are available for ACNM members and non-members who view this session via the ACNM Online Learning Center.

If you have listened to the news lately, you have probably heard of the outbreak of lung injuries and related deaths associated with e-cigarettes and vaping products. Breaking news by health experts have reported that tetrahydrocannabinol (THC) was present in most of the samples of the products and lung tissue collected from the injured individuals, but Vitamin E acetate was present in all of the samples that have been tested to date. While this is a major breakthrough, the experts are not ready to draw any conclusion as of yet, for it is possible that there are other ingredients involved. Here at MotherToBaby we strive to prepare for the questions that may arise from hot topics such as this for the women and providers we serve. Therefore, this seems as good a time as any to ask, “What do we know about vaping and pregnancy?” For the purpose of this blog, I’m going to focus on nicotine vaping.

What are ENDS?

Electronic nicotine delivery systems (ENDS) describe a variety of products that includes vaporizers, vape pens, hookah pens, tank systems, mods and electronic cigarettes (e-cigarettes). Although ENDS were originally developed as an alternative way to inhale tobacco products (like nicotine), the devices are now also used to vape other substances, like cannabis. Each of these devices work by heating a liquid to produce an aerosol that a person inhales into their lungs producing a mist (vape). The liquid in ENDS can contain: nicotine, tetrahydrocannabinol (THC), cannabidiol (CBD) oils, propylene glycol and glycerol.

Are ENDS a safer alternative than cigarette smoking in pregnancy?

ENDS products came on the market in the U.S. in 2007, and their popularity quickly grew. One of the reasons they grew in popularity was due to the belief that they were a safer alternative to cigarettes, and could help smokers quit or reduce the amount of cigarettes they smoke. Cigarettes contain nicotine and many other agents as well as carbon monoxide. Cigarette smoking during pregnancy has been associated with an increased chance of miscarriage, cleft lip or palate, premature birth (before 37 weeks) and SIDS (sudden infant death syndrome). Smoking has also been associated with an increase chance of infertility, ectopic pregnancy (a pregnancy that occurs outside of the uterus) and complications with the placenta (i.e., placental abruption and placenta previa). The issues with cigarette smoking are not only limited to pregnancy but continue after the birth of the child as well. Smoking has been associated with a higher chance for asthma, childhood obesity and behavioral problems.

While pregnancy is a big motivation for women to quit smoking, many struggle and look for a solution during pregnancy. Complicating the issue is the fact that many nicotine replacement therapies have not been well studied, and their effectiveness in helping smokers to quit has been questioned. Therefore, there is a hesitancy to use them. Also, medications to help stop smoking, like bupropion (Wellbutrin) and varenicline (Chantix), while not considered to pose a significant chance of birth defects, have limited data regarding their use in pregnancy. Recently the Food and Drug Administration (FDA) added warnings to the label regarding an increased chance of psychiatric effects including suicidal thoughts. This does not mean these medications should not be used by pregnant women who medically need them, but it shows how complex the issue of choosing an appropriate medication can be when you need to weigh the risks versus benefits. This leads pregnant women to find an alternative that might solve their problem and for some, ENDS seemed like the solution when they came on the market.

The effects of inhaling the substances contained in ENDS are not known, especially when it comes to pregnancy. One study has shown that users of e-cigarettes can obtain a substantial amount of nicotine from e-cigarettes that is comparable to regular cigarettes, and we do know that nicotine can cross the placenta. Animal data shows that exposure to the chemicals found in e-cigarettes can cause various effects on offspring that include impact to the immune system, lung and heart function, and neuro-development (related to the function of brains and nerves); unfortunately, so far there is no data to suggest what the impact in human pregnancy might be. In addition, while ENDS products may reduce exposure to many of the toxins in cigarettes, there is still exposure to nicotine and other toxic chemicals, which can pose an increased chance of harm to pregnancies. Also, some ENDS products that have stated they were free of nicotine have been tested and were actually found to contain nicotine.

There is no evidence to support ENDS as an effective way to stop smoking.

A recent review of the use of ENDS products among non-pregnant patients found no strong evidence that they help in the effort to quit smoking. Regardless of the lung injuries that are currently in the news, health experts recommend that pregnant women avoid all ENDS use. Instead, any pregnant woman who is struggling to quit smoking should talk with their health care provider to discuss a plan that is suitable to them and contact resources such as the National Quitline Network (1-800-QUIT NOW). Quitting is best for you and your child so go ahead and clear the air. Trust me; your baby will thank you.

References:

Whittington J. et al. 2018. The Use of Electronic Cigarettes in Pregnancy: A Review of the Literature. Obstetrical and Gynecological Survey. 73(9): 544-549

Committee on Underserved Women et al. 2017. Smoking Cessation During Pregnancy. 130(4): e200-e204.

Kuehn B. 2019. Vaping and Pregnancy. JAMA. 321(14)

Steenhuysen J. “UPDATE 1-U.S. CDC reports ‘breakthrough’ in vaping lung injury probe as cases top 2,000.” Reuters: Yahoo finance. 8 November 2019. Web 11 November 2019.

By Lorrie Harris-Sagaribay, MPH, Teratogen Information Specialist and
Coordinator, MotherToBaby North Carolina

Back in the early 1970s, pregnant women and their health care providers didn’t talk about alcohol and drugs in pregnancy. Birth defects caused by alcohol? Unheard of! Then, along came two pediatric specialists at the University of Washington who changed everything: Drs. David W. Smith and Kenneth Lyons Jones noticed that a group of babies who had been exposed to high amounts of alcohol during pregnancy were all born with a similar pattern of unusual facial features and developmental delay. Their astute observations, along with further research and collaboration, led them to coin the term Fetal Alcohol Syndrome (FAS) in 1973.

The discovery that alcohol was a teratogen (an exposure that can cause birth defects) fueled the research on other exposures and opened up a world of questions. What about other drugs? What about medications? In order to share findings from the limited but ongoing research, Dr. Jones established the first teratogen information service in 1979, housed in a small apartment in San Diego and run by a dedicated staff of three. This service was the beginning of what would later become MotherToBaby.

Fast forward to June 2017, when experts from MotherToBaby and other teratogen information services around the world gathered in Denver, Colorado for the 30th Annual Meeting of the Organization of Teratology Information Specialists (OTIS). There, dozens of experts presented the latest research on exposures during pregnancy. Speakers summarized what we’ve learned, pointed out what we still don’t know, and suggested priorities for future research. Here are a few highlights from the meeting:

Prescription Opioids
At one time, opiates were peddled as remedies for fatigue, menstrual cramps, and even teething in children (search Mrs. Winslow’s Soothing Syrup as an example). Now, more than a century later, we are in the middle of an epidemic of substance use disorders from opioid pain relievers. And according to a 2014 study, more than 14% of pregnant women in the U.S. are prescribed opioids at least once during pregnancy for reasons such as back pain and migraines. Pregnant women who develop opioid use disorders (either before or during the pregnancy) are encouraged to undergo maintenance therapy such as methadone treatment, which is less risky to the baby and more likely to result in successful recovery than sudden withdrawal would be.

Infants with ongoing exposure to opioids during pregnancy can experience withdrawal symptoms at birth, commonly called neonatal abstinence syndrome (NAS). Like Fetal Alcohol Syndrome, NAS was first described in the literature in the 1970s, by Dr. Loretta Finnegan. The syndrome has gotten renewed attention during the current opioid epidemic as providers and researchers consider the best ways to prevent and manage NAS. Studies have shown that hospitalized infants with NAS have better outcomes–less severe symptoms, less need for medication, and shorter hospital stays–when they are breastfed, even if the mothers are still on opioid maintenance therapy. But some health care providers hesitate to encourage breastfeeding in these cases out of concern about baby’s ongoing exposure to the mother’s medication through the milk. Continued funding can help address these concerns by developing consistent standards of care for infants with NAS. If you are using opioids for any reason, be sure to talk to your health care provider as soon as you find out you are pregnant. Together, you can work on a plan for the best possible care for you and baby during and after the pregnancy.

Cocaine
To study the effects of cocaine in pregnancy, researchers have followed a group of young adults, now in their early 20s, since they were born. About half the group was exposed to cocaine before birth. Early on, the researchers observed that those with cocaine exposure had challenges with attention and remembering what they saw when compared to the children who had not been exposed to cocaine. In older years, exposed children had more difficulty with language skills, more behavior problems at school and at home, reported more substance use and risk-taking behavior, and had more difficulty with everyday skills such as staying organized, thinking ahead, and controlling their own behavior. Some dropped out of school. Interestingly, having a positive home environment seemed to help with some, but not all, of these challenges. For example, children in foster or adoptive homes had better language and reasoning skills than children who still lived with their birth mothers who used cocaine, but there was no difference in their behaviors. As the study continues, researchers hope to learn more about how prenatal cocaine exposure affects these individuals into adulthood.

E-cigarettes
E-cigarettes are marketed and often seen as a “safer” option to cigarettes. In fact, the most common users are current and former cigarette smokers who are using e-cigarettes to replace or reduce the number of cigarettes they smoke. In a study of over 1,300 pregnant women, those using e-cigarettes reported doing so because they felt they were less harmful than cigarettes, or to help with smoking cessation. They also preferred the sweeter flavors, and thought they were even less harmful than the tobacco-flavored liquids.

E-cigarettes don’t expose users to the combustion by-products of traditional cigarettes, but even those labeled “nicotine-free” do contain nicotine, and vaporization creates its own potentially harmful by-products. Since e-cigarettes are liquid-filled and can be smoked longer, it’s more difficult to monitor actual exposure to nicotine than it is with traditional cigarettes. Plus, because e-cigarettes are not regulated by the FDA, there is no way of knowing exactly what they contain and what your pregnancy is exposed to when you use them.

Past studies have observed that prenatal exposure to nicotine affects baby’s brain development and increases the chance of later behavior problems and depression in adolescence. It even predicts baby’s own cigarette use in his/her teen years. And recent studies have shown that those adolescents who use cigarettes are more likely to also use e-cigarettes as teens and adults than their peers who don’t use cigarettes. We will learn more about the possible long-term effects of prenatal e-cigarette use as the first generation of children who were exposed to them in pregnancy gets older.

Marijuana
Marijuana is the most common “illicit” drug used in pregnancy. Some health care providers in Colorado, where marijuana is now legal, are seeing more pregnant women who believe that using it is not harmful and might even be beneficial. For example, pregnant women in one survey reported using marijuana to help manage depression or anxiety, help with pain, or ease nausea and vomiting, among other reasons. Without crucial data about exactly how marijuana might be harmful to a pregnancy, some health care providers are hesitant to talk to women about it, even if they know they are using it in pregnancy.

There is little doubt that marijuana can be harmful in pregnancy: THC crosses the placenta and, even in very early pregnancy, can affect the cells that form the baby’s brain. But studies on its effects on overall brain development and pregnancy outcomes have had mixed results so far, and they face challenges such as co-exposures (women using other substances along with marijuana) and, in some cases, relying on self-reporting to know how much of the drug a pregnancy is exposed to (this can skew the data if users do not accurately reveal how much and how often they use.) As researchers forge ahead to provide better answers, the best advice is still to avoid marijuana altogether in pregnancy.

Alcohol
Since those early years, we have discovered that the facial features and developmental delay often seen with FAS are not the only possible effects of prenatal exposure to alcohol. In some children, subtle changes to the brain might not be noticed until the child is older and begins to struggle with learning and behavior problems that can follow them into adulthood. This range of possible effects has been more recently named Fetal Alcohol Spectrum Disorder (FASD). According to Dr. Jones, FASD affects about 2% of babies born in the U.S. each year–more common than autism–despite the fact that it is 100% preventable.

Looking ahead.
The decades ahead require not only continued research, but also increased awareness of what we already know. To that end, each September we observe FASD Awareness Month. MotherToBaby is happy to answer your questions about alcohol and other exposures in pregnancy—in fact, check out our brief YouTube video here. Together, we can continue the work towards the best possible outcomes for future generations.

Lorrie Harris-Sagaribay, MPH is the Coordinator of MotherToBaby North Carolina and a bilingual Teratogen Information Specialist. After working with midwives as a community health educator with the Peace Corps in Honduras, she earned her Master of Public Health at the University of North Carolina at Chapel Hill. She has worked in the field of maternal and child health for over 25 years.

About MotherToBaby

MotherToBaby is a service of the Organization of Teratology Information Specialists (OTIS), suggested resources by many agencies including the Centers for Disease Control and Prevention (CDC). If you have questions about exposures during pregnancy and breastfeeding, please call MotherToBaby toll-FREE at 866-626-6847 or try out MotherToBaby’s new text information service by texting questions to (855) 999-3525. You can also visit MotherToBaby.org to browse a library of fact sheets about dozens of viruses, medications, vaccines, alcohol, diseases, or other exposures during pregnancy and breastfeeding or connect with all of our resources by downloading the new MotherToBaby free app, available on Android and iOS markets.

References:

Bateman BT et al. Patterns of Opioid Utilization in Pregnancy in a Large Cohort of Commercial Insurance Beneficiaries in the United States. Anesthes 2014;120(5):1216-1224.

McQueen K and Murphy-Oikonen J. Neonatal Abstinence Syndrome. N Engl J Med 2016; 375:2468-2479.

Presented at the (joint) Annual Meetings of OTIS (Organization of Teratogen Information Specialists), DNTS (Developmental Neurotoxicology Society), RSA (Research Society on Alcoholism) and the Teratology Society in Denver, Colorado on June 25-27, 2017:

• From the FAS to OTIS – A Long Strange Trip. Buzz Chernoff, California Environmental Protection Agency (Retired).
• The Opioid Epidemic and Impact of Prenatal Exposure on Child Development. Lynn Singer, Case Western Reserve University.
• Project Newborn: What We Have Learned from 20 Years of Research on Prenatal Cocaine Exposure. Sonia Minnes, Case Western Reserve University.
• Epigenetic Changes Induced by Prenatal Nicotine and Cocaine Exposure. Pradeep Bhide, Florida State University.
• Effects of Prenatal Nicotine Exposure on Adolescent Dopamine Systems. Frances Leslie, University of California at Irvine School of Medicine.
• Electronic Cigarette Use in Pregnancy: Patient and Provider Perspectives. Katrina Mark, University of Maryland School of Medicine.
• Pathways from Prenatal Tobacco Exposure to Electronic Cigarette Use. Natacha M. DeGenna, University of Pittsburgh School of Medicine.
• Perceptions and Use of Electronic Cigarettes during Pregnancy: Implications for Infant Outcomes. Laura Stroud, Brown Medical School.
• Pathways from Prenatal Exposures to Tobacco and Cannabis to Adult Electronic Cigarette Use. Natacha De Genna, University of Pittsburgh Medical School.
• Counseling Women about Prenatal Marijuana Use: Weeding through the Data. Torri D. Metz, University of Colorado-Denver.
• Introduction: Marijuana and Child Development Symposium. Diana Dow-Edwards, SUNY/Downstate Medical Center.

Multi-lingual health educational materials on exposures during pregnancy and breastfeeding

MotherToBaby is proud to offer a variety of free resources in multiple languages to help you stay informed about exposures during pregnancy and breastfeeding. We are the nation’s most trusted source of evidence-based information based on evidence. We provide important resources on medications, health conditions, chemicals, and other exposures for families and healthcare professionals. Our goal is to make sure expecting and new mothers have reliable information, so they can make good choices for their health and their babies’ health.

Our resources are available not only on our bilingual (English and Spanish) website but also in several other languages. We know how important it is for all mothers to have clear and accurate information, no matter what language they speak.

Below is a list of our materials in different languages. These resources are easy to read and cover some of the most common questions about exposures during pregnancy and breastfeeding, such as:

1. Cannabis/Marijuana: Information about the effects of cannabis use during pregnancy and breastfeeding.
2. Vaccines: Information on preventable diseases and getting vaccines during pregnancy and breastfeeding.
3. Mental Health: Information about mental health and treatments during pregnancy and breastfeeding.

To learn more about our program, you can check out the MotherToBaby Rack Card. This card provides detailed information about our exposure information counseling service and observational pregnancy studies. It’s a great starting point to understand the full range of services and support we offer.

All the resources listed below are available for free download. If you prefer a printed version of any material, you can request one while supplies last by contacting us at MTBorder@health.ucsd.edu.

Besides these multi-lingual resources, we also have additional print and digital materials in English and Spanish on our Request Materials page.

We are dedicated to providing high-quality information to help mothers and families during this important time. By offering materials in many languages, we aim to reach and support even more people. Thank you for choosing MotherToBaby for trusted information on exposures during pregnancy and breastfeeding. We are here to help you make informed decisions for a healthy pregnancy and beyond. Please explore the resources below and contact us if you need more help or have any questions.

Thank you for becoming our partner in pregnancy and breastfeeding health. Please let us know how we can better serve and educate your community at experts@mothertobaby.org.