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Official websites use. Share sensitive information only on official, secure websites. Correspondence to Dr Abdulazeez Towobola a. As drug policies pertaining to cannabis use become more liberalised, the prevalence of cannabis use in pregnancy could increase. However, there is limited guidance available for clinicians. This paper presents a narrative review of literature published in the past 16 years — to a address the impact of legalisation and decriminalisation on the risks, ethics and support of women who use cannabis during pregnancy and b develop guidance for clinicians. Both national and international trends suggest increased use of cannabis over the past decade, while the risks of cannabis use for recreational or medicinal purposes in pregnancy remain unmitigated. This review confirmed that the recommendation of cannabinoid-based products for pregnant and breast-feeding women is currently premature. More research is needed to address safety concerns. We discussed navigating ethical concerns and suggest targeted management strategies for clinicians treating pregnant women who choose to use cannabis. The Crime Survey of England and Wales 1 showed that in the most common drugs taken by adults aged 16—59 were: cannabis 7. The prevalence of cannabis use in pregnancy varies widely and is largely affected by factors such as socioeconomic status, age and ethnicity. Self-reported rates of cannabis use are relatively low, whereas direct or objective measures of use often indicate higher rates. Although current evidence indicates increasing prevalence of cannabis use, particularly in young women, 1 this is an evolving field with limited guidance. This study is an up-to-date narrative review of literature to guide doctors and other clinicians who often find themselves in ethically, clinically and legally challenging situations in the management of pregnant women who use cannabis. Based on our findings, we recommend targeted interventions at different perinatal stages to contribute to policy discussions in local healthcare services and facilitate developing regional and national guidelines. Legalisation refers to an approach that would remove all legal sanctions and penalties for possession and use of a drug. In this scenario, the government may establish regulations to manage licensing and to control the manufacture, quality, purity and supply of the drug, leading to it being more freely available to the general public e. In comparison, decriminalisation refers to an approach that would remove any criminal penalties despite it still being illegal to possess and use the drug i. In light of the increasing evidence supporting the use of medicinal cannabis, there have been international calls for reform and review of drug policies on cannabis and cannabis-related products. However, findings from international research have highlighted that decriminalising or legalising cannabis could lead to an increase in use, both among adults who have previously used cannabis and among those who may not have ordinarily used it e. Thus, liberalising cannabis policies may lead to an increase in cannabis use in the preconception, prenatal and postpartum period, 26 , 27 but there is a clear lack of guidance available for clinicians working with women who may use cannabis during the perinatal period. It is critical to establish guidance, especially as recreational cannabis use in pregnancy can sometimes be associated with psychiatric comorbidity, disrupted parental care, and poor maternal and fetal outcomes 28 but see also 29 , Some use cannabis to manage nausea in pregnancy, albeit against medical advice, 31 while conversely chronic use of cannabis has been associated with hyperemesis syndrome. Clinicians may therefore find themselves in an ethically and clinically challenging position, balancing the health benefits of cannabis against the potential risks that may be incurred during pregnancy. All searches were limited by publication date — We identified articles that met the search criteria; these were then screened and assessed independently by the authors for quality of evidence e. We excluded articles with similar but no additional relevant information. There are over cannabinoids and other components in the cannabis plant, with tetrahydrocannabinol THC and cannabidiol CBD being the most studied. CB 1 receptors have psychoactive properties and are expressed in the central nervous system, gastrointestinal system, adipocytes, liver tissue and skeletal muscle. CB 2 receptors, which are more restricted, are expressed in immune cells located in the tonsils, thymus, spleen and bone marrow, as well as in the enteric nervous system within the gastrointestinal tract. The earliest recorded date for cannabis use as a medicine is bce in China, and in the 19th and 20th centuries it has been used to treat migraine, neuropathic and musculoskeletal pain, and in childbirth. Recent guidance from the UK's Food Standards Agency FSA on the increasingly popular oral non-medicinal CBD-containing products such as beverages beer, spirits, wine, coffee and soda style drinks , oils tinctures, drops, syrup, olive oils and confectionary gum drops, chocolate limited their use to no more than 70 mg daily. It recommended that non-medicinal CBD products should not be used by pregnant or breastfeeding individuals, extrapolating from data on animal research which showed fetal harm. Although guidance from official sources is relatively clear, there is a risk that information from other sources may provide conflicting advice to consumers. A mystery caller from the study team contacted dispensaries stating that she was 8 weeks pregnant and was looking for advice regarding cannabis-based products for morning sickness. It was found that Many people with psychological or mental disorders self-medicate with cannabis; 37 however, the evidence on treatment efficacy is limited and often mixed. Advocates of medicinal cannabis suggest that it could reduce the rates of opioid dependence and deaths from overdose if patients switch from opioid-based pain relief to cannabis, as the risk of dependence is much lower and there are no reports of death from cannabis overdose. Factors associated with the continued use of cannabis during pregnancy include history of cannabis use disorder 2. Studies have reported short-term risks for individuals who use CBD in pregnancy. This includes impaired short-term memory and motor coordination, altered judgement, paranoia, dependence disorder, psychosis, injuries, motor vehicle collisions and suicide. As THC is highly fat soluble it can be excreted into breast milk 65 , 66 and released slowly over days to weeks, depending on extent of use. This is a concern as evidence suggests that breastfeeding mothers sometimes increase their consumption of cannabis after childbirth. As studies the majority of which are animal rather than human 68 indicate conflicting outcomes, women who are unable to abstain are advised not to breastfeed within 1 h of inhaling or consuming cannabis, with the aim of reducing the infant's exposure to the highest concentration of cannabis in breast milk. The long-term effect of cannabis use should also be borne in mind as intrauterine exposure to cannabis has been found to increase the likelihood of initiation of cannabis and other substance use in adolescents. These children can suffer from behavioural, emotional and cognitive problems and experience long-term psychological effects from their experience of being raised in a chaotic household. One study found that women with a post-secondary education and lower scores of depression and anxiety were more likely to attain abstinence, whereas those aged 21 years and below and with a diagnosis of depression were more likely to relapse in the postpartum period. The use of medicinal cannabis for different conditions has gained in popularity despite evident risks. Claims that a fetus has full rights and that the right to life 83 or prenatal care 84 override the mother's right to autonomy or inviolability 85 have led to jailing of women in the USA who took drugs in pregnancy or after birth if found positive on drug screening. Furthermore, punitive measures place healthcare workers in difficult positions as they have also questioned the policy of drug screening in pregnancy without consent, their role in policing women who take cannabis in pregnancy and the disproportionate impact on women from minority ethnic groups. The principle of non-maleficence supports advising against cannabis use in pregnancy. Proponents of recreational drug use contend that the government should intervene only when there is a high risk of causing harm to others. Table 1 shows ethical considerations and recommended approaches to navigating ethical dilemmas of cannabis use in pregnancy. Ethical principles and recommended approaches in navigating ethical dilemmas concerning cannabis use in pregnancy. It is important for doctors and other healthcare practitioners involved in supporting women of childbearing age to be aware of the benefits of medicinal cannabis and potential risks of cannabis use in pregnancy. Some of these interventions are targeted at vulnerable women or at-risk groups, whereas others are indicated for public health. Provide psychoeducation, assess motivation to change and discuss risk—benefit analysis to enable patient to make an informed decision about cannabis use. Use opportunities to embed contraception and precontraception care discussions during health and non-health contacts for women of childbearing age. Identify and attempt to address social problems that may lead to low levels of happiness, which have been associated with drug use. Particular attention should be paid to identifying determinants of social inequalities so as to consider referral for social support. Public health interventions and multimedia campaigns to educate women of childbearing age-group regarding risks associated with cannabis use. The following factors should be noted in booking clinic and follow-up as they are associated with continued use of cannabis during pregnancy: history of cannabis use disorder, frequent cannabis use daily or weekly compared with monthly , level of education, having a psychiatric disorder, biological father's cannabis use, and marital status. History of oral consumption of non-medicinal CBD-containing foods or products should also be noted. Multiple urine screens should be offered throughout pregnancy owing to underreporting in clinical interviews; reassurance may need to be given that this is not punitive but meant to identify those requiring support. Look out for cannabis withdrawal syndrome CWS in regular and dependent users — symptoms from three of the following groups within 7 days of stopping cannabis: irritability, anger or aggression; nervousness or anxiety; sleep disturbance; appetite or weight disturbance; restlessness; depressed mood; somatic symptoms such as headaches, sweating, nausea, vomiting or abdominal pain. Use of evidence-based treatment such as motivational enhancement therapy and cognitive—behavioural therapy with abstinence-based incentives for the treatment of cannabis use disorders. A multidisciplinary approach involving the general practitioner, midwife, obstetrician, paediatrician and social worker is important, so clear communication between all healthcare professionals involved in the care of the patient is necessary. Cannabis use is not recommended while breastfeeding, based on current evidence, but if a nursing mother wants to use cannabis, support should be provided in line with the ethical principles discussed above regarding the use of cannabis-based products for medicinal or recreational use. We emphasise the importance of a multidisciplinary approach within health and social services because of the impact of substance misuse on the fetus, the mother and the newborn child. Accurate identification of cases, use of motivational interviewing techniques and access to cognitive—behavioural therapy CBT are vital. This should lead to a plan and care package involving well-coordinated, multidisciplinary care with a specialist drug service working collaboratively with the general practitioner GP , midwife, obstetrician, paediatrician and social worker. The World Health Organization WHO recommends the use of interventions that are brief, structured and require easy-to-administer tools. These interventions include information and motivational components that have been effective in primary care settings. Identifying cannabis withdrawal syndrome CWS 97 in regular and dependent users is important as it can confound mental illness or early signs and symptoms of pregnancy such as nausea, headache and fatigue, which is why some patients present late for treatment of mental illness or for antenatal care. Women may hesitate to disclose cannabis use owing to fear of judgement and concerns that their parenting ability may be questioned. Asking about type, quantity and impact of substance use by a trained professional is vital in evaluating risk. Wilson and colleagues have suggested questions to consider pertaining to substance misuse in the preconception or perinatal period. These should focus on empathic enquiry to assess the type and number of substances used, care and support available, impact on daily life and potential motivators for change. Meconium cannabinoid testing is more expensive and is limited by the narrow collection window of 72 h. It is also important to ask patients about their consumption of non-medicinal CBD-containing foods or products, because of potential adverse effects. As stated earlier, there is limited research on the effects of CBD on embryonic development; however, several animal studies suggest that CBD can cause fetal harm. Cannabis use during breastfeeding is a key dilemma for clinicians as the benefits of breastfeeding are very well known but early evidence indicates that CBD and THC can be transferred to the infant via breast milk. Although there may be an increasing trend in the use of medicinal cannabis both among those prescribed it for medical conditions and those self-medicating because of perceived efficacy in managing their emotional and mental symptoms, more research is needed in human rather than animal studies to determine the safety of different strains and components, dosage and routes of administration, effect sizes for clinical outcomes and comparisons with existing treatments. Legalisation or decriminalisation may lead to the increased use of cannabis in pregnancy despite persisting risks. Clinicians should adopt a harm minimisation strategy when navigating the dilemma of the rights of the fetus versus those of the mother. Doctors treating pregnant women need to keep their knowledge up to date and be aware of the impact of cannabis use in the perinatal period, especially as studies show that cannabis use is underreported. This will enable the provision of targeted intervention and support, including adequate information for pregnant women to make an informed decision about cannabis use. The findings of this review should be seen in light of some limitations. This paper is a narrative review aiming to offer an objective analysis in the current context of decriminalisation and licensing of cannabis for medical use and its ethical considerations during pregnancy. A systematic review with rigorous methodological approaches, considering new and emerging evidence assessing the impact of licensing of medicinal cannabis in the UK, may be able to draw more robust conclusions on this topic of significant public health interest. The authors confirm that the data supporting the findings of this study are available within the article, and supplementary materials methods, literature search are available from the corresponding author, A. Each author has substantially contributed to researching and drafting this manuscript. He was involved in researching, collating ideas and writing up. This research received no specific grant from any funding agency, commercial or not-for-profit sectors. This section collects any data citations, data availability statements, or supplementary materials included in this article. As a library, NLM provides access to scientific literature. BJPsych Bull. Find articles by Abdulazeez Towobola. Find articles by Basirat Towobola. Find articles by Bosky Nair. Find articles by Arti Makwana. Ethical principle Considered approach Beneficence Discuss benefits and recommend cannabis-based medicinal products when indicated based on evidence Non-maleficence Discuss short-term and long-term risks to the mother, fetus and infant or child Respect for autonomy Assess whether the patient has capacity; obtain informed consent for procedures; demonstrate weighing of costs and benefits in collaboration with the patient- and patient-centred decision-making Justice Ensure adequate access to treatment and care irrespective of decision to take cannabis-based medicinal products. Open in a new tab. Indicated or targeted interventions by healthcare professional at different perinatal stages. Perinatal stage Indicated or targeted intervention Prenatal Provide psychoeducation, assess motivation to change and discuss risk—benefit analysis to enable patient to make an informed decision about cannabis use. Help women to maximise health and well-being before pregnancy by improving lifestyle and diet. Antenatal The following factors should be noted in booking clinic and follow-up as they are associated with continued use of cannabis during pregnancy: history of cannabis use disorder, frequent cannabis use daily or weekly compared with monthly , level of education, having a psychiatric disorder, biological father's cannabis use, and marital status. Postnatal A multidisciplinary approach involving the general practitioner, midwife, obstetrician, paediatrician and social worker is important, so clear communication between all healthcare professionals involved in the care of the patient is necessary. Monitoring of withdrawal symptoms in newborn by paediatrician. Similar articles. Add to Collections. Create a new collection. Add to an existing collection. Choose a collection Unable to load your collection due to an error Please try again. Add Cancel. Discuss benefits and recommend cannabis-based medicinal products when indicated based on evidence. Discuss short-term and long-term risks to the mother, fetus and infant or child. Assess whether the patient has capacity; obtain informed consent for procedures; demonstrate weighing of costs and benefits in collaboration with the patient- and patient-centred decision-making. Ensure adequate access to treatment and care irrespective of decision to take cannabis-based medicinal products.

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