Perinatal Marijuana Use and the Developing Child

Cannabis for morning sickness: areas for intervention to decrease cannabis consumption during pregnancy

BACKGROUND

Cannabis use during pregnancy is increasing, with 19-22% of patients testing positive at delivery in Colorado and California. Patients report using cannabis to alleviate their nausea and vomiting, anxiety, and pain. However, preclinical and clinical data highlight harmful effects to offspring physiology and behavior following fetal cannabis exposure. This narrative review identifies potential areas for intervention to decrease cannabis consumption during pregnancy.

METHODS

A combination of keywords, including "cannabis", "cannabis", "weed", "pregnancy", "morning sickness", "child protective services", and "budtender" were searched in databases such as PubMed and Google Scholar, as well as in social media forums, governmental webpages, and other publicly available sources.

RESULTS

The literature search identified several areas for intervention to reduce cannabis use during pregnancy, including physician and pharmacist training, engagement with pregnant patients, regulation of dispensary workers, and the role of child protective services.

DISCUSSION

This comprehensive review identifies multiple areas for improvement to benefit pregnant patients. Recommendations are independent and can be implemented simultaneously by the identified groups. Limitations of this research includes the relatively limited availability of data focused specifically on cannabis consumption during pregnancy and the complexity of the sociopolitical field of substance use during pregnancy.

CONCLUSIONS

Cannabis consumption during pregnancy is increasing and causes harm to the developing fetus. To educate pregnant patients about these risks, we must address the gaps in education from multiple contact points.

Prenatal exposure to Cannabis smoke induces early and lasting damage to the brain

Cannabis is the most widely used illegal drug during pregnancy, however, the effects of gestational exposure to Cannabis smoke (CS) on the central nervous system development remain uncharacterised. This study investigates the effects of maternal CS inhalation on brain function in the offspring. Pregnant mice were exposed daily to 5 min of CS during gestational days (GD) 5.5-17.5. On GD 18.5 half of the dams were euthanized for foetus removal. The offspring from the remaining dams were euthanized on postnatal days (PND) 20 and 60 for evaluation. Brain volume, cortex cell number, SOX2, histone-H3, parvalbumin, NeuN, and BDNF immunoreactivity were assessed in all groups. In addition, levels of NeuN, CB1 receptor, and BDNF expression were assessed and cortical primary neurons from rats were treated with Cannabis smoke extract (CSE) for assessment of cell viability. We found that male foetuses from the CS exposed group had decreased brain volume, whereas mice at PND 60 from the exposed group presented with increased brain volume. Olfactory bulb and diencephalon volume were found lower in foetuses exposed to CS. Mice at PND 60 from the exposed group had a smaller volume in the thalamus and hypothalamus while the cerebellum presented with a greater volume. Also, there was an increase in cortical BDNF immunoreactivity in CS exposed mice at PND 60. Protein expression analysis showed an increase in pro-BDNF in foetus brains exposed to CS. Mice at PND 60 presented an increase in mature BDNF in the prefrontal cortex (PFC) in the exposed group and a higher CB1 receptor expression in the PFC. Moreover, hippocampal NeuN expression was higher in adult animals from the exposed group. Lastly, treatment of cortical primary neurons with doses of CSE resulted in decreased cell viability. These findings highlight the potential negative neurodevelopmental outcomes induced by gestational CS exposure.

Child Abuse Prevention and Treatment Act, family care plans and infants with prenatal substance exposure: Theoretical framework and directions for future research

In May 2021, a reauthorization of the Child Abuse Prevention and Treatment Act (CAPTA) was introduced in the U.S. Senate. This reauthorization substantially amends provisions concerning infants affected by prenatal substance exposure and decidedly shifts the policy from a child safety- to a public health-focused approach to achieve the larger goals of healthy and safe child development and caregiver recovery from substance use disorder. Despite its honorable aspirations, no research has tested whether CAPTA "works". To advance scholarship on this policy, we summarize the service needs for this population and clarify how the CAPTA reauthorization aims to address these needs. We then apply a health utilization theory to understanding the mechanisms of effect on maternal-child outcomes. Based on this theoretical analysis, we discuss directions for future research.

Cannabis Use in Pregnancy: A State of the Science Review

With a growing number of states legalizing recreational use, cannabis consumption during pregnancy is increasing. Population-based data and rigorous studies examining the association of cannabis use in pregnancy with perinatal outcomes are limited, but trends include preterm prelabor rupture of membranes, placenta previa, and an increased length of hospital stay. Neonates of pregnant persons who used cannabis during their pregnancy can be at increased risk of low birth weight, preterm birth, neonatal intensive care unit admission, neurocognitive deficits, and infectious and neurologic morbidity and mortality. This state of the science review examines the prevalence of cannabis use in pregnancy, its pharmacodynamics and how that is influenced by pregnancy, and associated adverse perinatal and neonatal outcomes. Implications for health care providers caring for pregnant persons using cannabis, especially in legalized states, are discussed.

Marijuana use in opioid exposed pregnancy increases risk of preterm birth

BACKGROUND

The prevalence of opioid use disorder has increased across the United States, but the rural population of Appalachia has been disproportionately impacted. Concurrently, the slow, but steady progress in the legalization of marijuana may be affecting perception of marijuana use in pregnancy. However, marijuana use in pregnancy has been associated with adverse perinatal outcomes. Concomitant use of opioids and marijuana in pregnancy has not been evaluated.

OBJECTIVE

The primary aim of the study was to evaluate the association between confirmed marijuana use in late pregnancy and preterm birth in opioid-exposed pregnancies.

METHODOLOGY

A retrospective chart review was conducted that included all births from July 2011 to June 2016 from 6 delivery hospitals in South-Central Appalachia. Out of 18,732 births, 2368 singleton pregnancies indicated opioid use and met remaining inclusion criteria, with 108 of these mothers testing positive for marijuana at delivery. Independent sample t-test and Chi-Square analyses compared marijuana and non-marijuana exposed groups on maternal and neonatal outcomes. Regression analyses controlled for confounding variables in predicting neonatal abstinence syndrome (NAS), NICU admission, preterm birth, small for gestational age, and low birth weight outcomes as shown in Table 1.

RESULTS

Neonates born to marijuana-positive women in opioid-exposed pregnancy were more likely to be born preterm, small for gestational age, have low birth weight, and be admitted to NICU. After statistically controlling for parity, marital status, tobacco and benzodiazepine use, preterm birth and low birth weight remained statistically significant with aOR of 2.35 (1.30-4.24) and 2.01 (1.18-3.44), respectively.

CONCLUSIONS

Maternal use of marijuana in any opioid-exposed pregnancy may increase risk of preterm birth and low-birth weight infants. Prospective studies need to examine the dose and timing of marijuana and opioid use in pregnancy to better delineate perinatal effects. Nonetheless, pregnant women using opioids, including recommended medication assisted treatment for opioid use disorder, should be educated about the risks of concurrent marijuana use during pregnancy and may need to be counseled to abstain from marijuana use during pregnancy for an optimal outcome.

A randomized controlled trial testing the efficacy of a Nurse Home Visiting Program for Pregnant Adolescents

To test the efficacy of a nurse home visiting program (HVP) on child development, maternal and environmental outcomes in the first years of life. We conducted a randomized controlled trial to test the efficacy of Primeiros Laços, a nurse HVP for adolescent mothers living in a poor urban area of São Paulo, Brazil. Eighty adolescent mothers were included and randomized to receive either Primeiros Laços (intervention group, n = 40) or healthcare as usual (control group, n = 40). Primeiros Laços is a home visiting intervention delivered by trained nurses that starts during the first 16 weeks of pregnancy and continues to the child's age of 24 months. Participants were assessed by blind interviewers at 8-16 weeks of pregnancy (baseline), 30 weeks of pregnancy, and 3, 6, 12, and 24 months of child's age. We assessed oscillatory power in the mid-range alpha frequency via electroencephalography when the children were aged 6 months. Child development was measured by the Bayley Scales of Infant Development Third Edition (BSID-III). Weight and length were measured by trained professionals and anthropometric indexes were calculated. The home environment and maternal interaction with the child was measured by the Home Observation and Measurement of the Environment. Generalized estimating equation models were used to examine intervention effects on the trajectories of outcomes. Standardized effect sizes (Cohen's d) were calculated using marginal means from endpoint assessments of all outcomes. The trial was registered at clinicaltrial.gov: NCT02807818. Our analyses showed significant positive effects of the intervention on child expressive language development (coefficient = 0.89, 95% CI [0.18, 1.61], p = 0.014), maternal emotional/verbal responsivity (coefficient = 0.97, 95% CI [0.37, 1.58], p = 0.002), and opportunities for variety in daily stimulation (coefficient = 0.37, 95% CI [0.09, 0.66], p = 0.009). Standardized effect sizes of the intervention were small to moderate. Primeiros Laços is a promising intervention to promote child development and to improve the home environment of low-income adolescent mothers. However, considering the limitations of our study, future studies should be conducted to assess Primeiros Laços potential to benefit this population.Clinical Trial Registration: The study was registered at clinicaltrial.gov (Registration date: 21/06/2016 and Registration number: NCT02807818).

Effect of prenatal marijuana exposure on sleep wake cycles and amplitude-integrated electroencephalogram (aEEG)

OBJECTIVE

To assess whether prenatal exposure to marijuana (THC) results in abnormal amplitude integrated encephalograms (aEEG).

DESIGN

This was a (2018-2020) prospective cohort study of prenatally THC-exposed newborns. Maternal and Infant demographics, urine (UDS) and umbilical cord drug screening (UCDS) were recorded. A limited channel continuous aEEG was obtained within 48 h of birth. Statistical analysis included univariate, multivariate, and logistical regression.

RESULTS

A total of 30 mother/infant dyads were enrolled. 60% (18/30) of neonates had abnormal aEEGs with sleep wake cycle (SWC) disturbances (p < 0.001). UCDS Carboxy-THC pg/g levels were similar in infants with abnormal [1758 (296,2838)] and normal aEEG [1589 (332,2794)], p = 0.82.

CONCLUSIONS

Absence of SWCs on aEEG is associated with prenatal THC exposure. While THC UCDS levels did not correlate to aEEG results future longitudinal studies are necessary to obtain detailed history of THC use and to evaluate its association with abnormal aEEG and the neurodevelopmental outcomes.

Mesolimbic dopamine dysregulation as a signature of information processing deficits imposed by prenatal THC exposure

Cannabis is the illicit drug most widely used by pregnant women worldwide. Its growing acceptance and legalization have markedly increased the risks of child psychopathology, including psychotic-like experiences, which lowers the age of onset for a first psychotic episode. As the majority of patients with schizophrenia go through a premorbid condition long before this occurs, understanding neurobiological underpinnings of the prodromal stage of the disease is critical to improving illness trajectories and therapeutic outcomes. We have previously shown that male rat offspring prenatally exposed to Δ⁹-tetrahydrocannabinol (THC), a rat model of prenatal cannabinoid exposure (PCE), exhibit extensive molecular and synaptic changes in dopaminergic neurons of the ventral tegmental area (VTA), converging on a hyperdopaminergic state. This leads to a silent psychotic-like endophenotype that is unmasked by a single exposure to THC. Here, we further characterized the VTA dopamine neuron and sensorimotor gating functions of PCE rats exposed to acute stress or a challenge of the D2 receptor agonist apomorphine, by using in vivo single-unit extracellular recordings and Prepulse Inhibition (PPI) analyses. At pre-puberty, PCE male rat offspring display a reduced population activity of VTA dopamine neurons in vivo, the majority of which are tonically active. PCE male progeny also exhibit enhanced sensitivity to dopamine D2 (DAD2) receptor activation and a vulnerability to acute stress, which is associated with compromised sensorimotor gating functions. This data extends our knowledge of the multifaceted sequelae imposed by PCE in the mesolimbic dopamine system of male pre-adolescent rats, which renders a neural substrate highly susceptible to subsequent challenges that may trigger psychotic-like outcomes.

Cannabis Use During the Pre-Conception Period and Pregnancy After Legalization

OBJECTIVE

There is limited evidence of the impact of cannabis legalization on the prevalence of cannabis use and use of other substances. The aim of this exploratory observational study was to compare rates of cannabis use, cigarette smoking, alcohol consumption, and the use of any street drugs during the preconception period and in pregnancy in two convenience samples of pregnant persons in British Columbia, Canada, before and after the legalization of cannabis.

METHODS

Any pregnant person residing in British Columbia, aged >19 years, at any gestational age was eligible to participate. Pre- and post-legalization study participants were recruited between May and October 2018 and July 2019 and May 2020, respectively. Multivariate models were constructed to examine the effect of legalization on cigarette smoking and the use of cannabis, alcohol, and street drugs, adjusting for demographic, pre-pregnancy, and pregnancy confounders.

RESULTS

From pre- to post-legalization, the prevalence of self-reported cannabis use during the preconception period increased significantly, from 11.74% (95% CI 9.19%-14.88%) to 19.38% (95% CI 15.45%-24.03%). Rates of cannabis use during pregnancy also increased from 3.64% (95% CI 2.32%-5.69%) before legalization to 4.62% (95% CI 2.82%-7.47%) after; however, this difference was not statistically significant. Adjusting for potential confounders, the post-legalization group had significantly higher odds of cannabis use during the preconception period (adjusted odds ratio 1.71; 95% CI 1.14-2.58) but not during pregnancy (adjusted odds ratio 1.66; 95% CI 0.75-3.65). Legalization was also not associated with significant changes in cigarette smoking, alcohol consumption, or the use of street drugs during the preconception period and pregnancy, after adjusting for potential confounders.

CONCLUSION

The preliminary evidence presented in this study shows that the legalization of cannabis was associated with 71% higher odds of cannabis use during the preconception period. Studies examining the effects of cannabis use on perinatal outcomes, as well as public health interventions and educational programs related to cannabis use, should include the preconception period as an area of focus.

Associations Between Prenatal Cannabis Exposure and Childhood Outcomes: Results From the ABCD Study

IMPORTANCE

In light of increasing cannabis use among pregnant women, the US Surgeon General recently issued an advisory against the use of marijuana during pregnancy.

OBJECTIVE

To evaluate whether cannabis use during pregnancy is associated with adverse outcomes among offspring.

DESIGN, SETTING, AND PARTICIPANTS

In this cross-sectional study, data were obtained from the baseline session of the ongoing longitudinal Adolescent Brain and Cognitive Development Study, which recruited 11 875 children aged 9 to 11 years, as well as a parent or caregiver, from 22 sites across the United States between June 1, 2016, and October 15, 2018.

EXPOSURE

Prenatal cannabis exposure prior to and after maternal knowledge of pregnancy.

MAIN OUTCOMES AND MEASURES

Symptoms of psychopathology in children (ie, psychotic-like experiences [PLEs] and internalizing, externalizing, attention, thought, and social problems), cognition, sleep, birth weight, gestational age at birth, body mass index, and brain structure (ie, total intracranial volume, white matter volume, and gray matter volume). Covariates included familial (eg, income and familial psychopathology), pregnancy (eg, prenatal exposure to alcohol and tobacco), and child (eg, substance use) variables.

RESULTS

Among 11 489 children (5997 boys [52.2%]; mean [SD] age, 9.9 [0.6] years) with nonmissing prenatal cannabis exposure data, 655 (5.7%) were exposed to cannabis prenatally. Relative to no exposure, cannabis exposure only before (413 [3.6%]) and after (242 [2.1%]) maternal knowledge of pregnancy were associated with greater offspring psychopathology characteristics (ie, PLEs and internalizing, externalizing, attention, thought and, social problems), sleep problems, and body mass index, as well as lower cognition and gray matter volume (all |β| > 0.02; all false discovery rate [FDR]-corrected P < .03). Only exposure after knowledge of pregnancy was associated with lower birth weight as well as total intracranial volume and white matter volumes relative to no exposure and exposure only before knowledge (all |β| > 0.02; all FDR-corrected P < .04). When including potentially confounding covariates, exposure after maternal knowledge of pregnancy remained associated with greater PLEs and externalizing, attention, thought, and social problems (all β > 0.02; FDR-corrected P < .02). Exposure only prior to maternal knowledge of pregnancy did not differ from no exposure on any outcomes when considering potentially confounding variables (all |β| < 0.02; FDR-corrected P > .70).

CONCLUSIONS AND RELEVANCE

This study suggests that prenatal cannabis exposure and its correlated factors are associated with greater risk for psychopathology during middle childhood. Cannabis use during pregnancy should be discouraged.

Maternal cannabis use in pregnancy and child neurodevelopmental outcomes

Cannabis use in pregnancy has increased^1,2, and many women continue to use it throughout pregnancy³. With the legalization of recreational cannabis in many jurisdictions, there is concern about potentially adverse childhood outcomes related to prenatal exposure⁴. Using the provincial birth registry containing information on cannabis use during pregnancy, we perform a retrospective analysis of all live births in Ontario, Canada, between 1 April 2007 and 31 March 2012. We link pregnancy and birth data to provincial health administrative databases to ascertain child neurodevelopmental outcomes. We use matching techniques to control for confounding and Cox proportional hazards regression models to examine associations between prenatal cannabis use and child neurodevelopment. We find an association between maternal cannabis use in pregnancy and the incidence of autism spectrum disorder in the offspring. The incidence of autism spectrum disorder diagnosis was 4.00 per 1,000 person-years among children with exposure compared to 2.42 among unexposed children, and the fully adjusted hazard ratio was 1.51 (95% confidence interval: 1.17-1.96) in the matched cohort. The incidence of intellectual disability and learning disorders was higher among offspring of mothers who use cannabis in pregnancy, although less statistically robust. We emphasize a cautious interpretation of these findings given the likelihood of residual confounding.

The impact of state legalization on rates of marijuana use in pregnancy in a universal drug screening population

Objective: To evaluate the effect of state legalization of rate on marijuana use in pregnancy in a population with universal drug screening.Methods: This is a retrospective cohort study from July 2016 to December 2018 of pregnant women who had universal drug screening of marijuana use before and after legalization of recreational marijuana in California on 1 January 2018. Maternal medical conditions and neonatal outcomes associated with usage were also evaluated. Student's t-test, Wilcoxon rank-sum test, and multiple linear regression were used for statistical analyses.Results: Of 466 women, initial marijuana usage in pregnancy confirmed by urine drug test increased after legalization from 6 to 11% (p = .05). Factors associated with marijuana usage included younger age, white or black race, single marital status, psychiatric disorders, intimate partner violence and concomitant tobacco and alcohol use. 73% of users in this study had cessation of marijuana use with subsequent negative UDT. There was no statistical difference in rates of preterm birth, small for gestational age, NICU admission, or Apgar scores, when adjusted for other risk factors. Conclusion: Rates of marijuana usage in pregnant women who underwent universal drug screening increased after legalization. There were no differences in neonatal outcomes between users and non-users.

Effects of cannabis exposure in the prenatal and adolescent periods: Preclinical and clinical studies in both sexes

Cannabis is the most commonly used illicit drug among adolescents and young adults, including pregnant women. There is substantial evidence for a significant association between prenatal cannabis exposure and lower birth weight in offspring, and mixed results regarding later behavioural outcomes in the offspring. Adolescent cannabis use, especially heavy use, has been associated with altered executive function, depression, psychosis and use of other drugs later in life. Human studies have limitations due to several confounding factors and have provided scarce information about sex differences. In general, animal studies support behavioural alterations reported in humans and have revealed diverse sex differences and potential underlying mechanisms (altered mesolimbic dopaminergic and hippocampal glutamatergic systems and interference with prefrontal cortex maturation). More studies are needed that analyse sex and gender influences on cannabis-induced effects with great clinical relevance such as psychosis, cannabis use disorder and associated comorbidities, to achieve more personalized and accurate treatments.

Recreational Cannabis Legalization in the US and Maternal Use during the Preconception, Prenatal, and Postpartum Periods

In the United States (US), recreational cannabis use is on the rise. Since 2011, 11 states and the District of Columbia have legalized cannabis for adult recreational use. As additional states consider legalizing, there is an urgent need to assess associations between recreational cannabis legalization and maternal use in the preconception, prenatal, and postpartum periods—all critical windows for maternal and child health. Using cross-sectional data from the 2016 Pregnancy Risk Assessment Monitoring System, we assessed associations between state cannabis legalization and self-reported maternal cannabis use. Using logistic regression, we estimated the adjusted prevalence ratio (PR) of cannabis use during the preconception, prenatal, and postpartum period for women delivering a live-born infant in three states that had legalized recreational cannabis (Alaska, Colorado, and Washington) and three states that had not legalized (Maine, Michigan, and New Hampshire) by 2016. Our final sample size was 7258 women. We utilized 95% confidence intervals (CI) and a significance level of alpha = 0.05. After adjustment for potential confounders, women who resided in states with legalized recreational cannabis were significantly more likely to use cannabis during the preconception (PR 1.52; 95%CI ranging from 1.28–1.80; p < 0.001), prenatal (PR 2.21; 95% CI ranging from 1.67–2.94; p < 0.001), and postpartum (PR 1.73; 95%CI ranging from 1.30–2.30; p < 0.001) periods, compared to women who resided in states without legalized recreational cannabis. Although evidence about the effect of marijuana use during these periods is nascent, these findings show potential for increased incidence of child exposure to cannabis. Longitudinal research is needed to assess immediate and sustained impacts of maternal use before and after state legalization of recreational cannabis.

A comparison of common practices for identifying substance use during pregnancy in obstetric clinics

BACKGROUND

Substance use during pregnancy has been linked to adverse birth and other outcomes. Screening and intervention in the prenatal clinic are recommended, and reliance on patient reports or selective urine drug screening is inadequate. The aim of this prospective project was to determine substance use identification rates associated with common screening practices, compared to universal screening, among pregnant women seeking care at an urban, academic obstetric clinic.

METHODS

Women attending their first prenatal visit (N = 275) completed a self-report questionnaire on lifetime and current substance use. A urine drug screening was also conducted, the results of which were not reported to providers. Participants' charts were reviewed to obtain the results of provider-ordered screens.

RESULTS

The sample was primarily African-American and Latino, with Medicaid insurance. Ten women (4.6%) reported current marijuana use, while more than double that number (n = 27; 11.6%) screened positive for marijuana via universal screening. The majority of women who screened positive via universal screening did not have a provider-ordered urine drug screening, and less than one-third (29.3%) of clinician-ordered screens were positive for at least one substance. Finally, 90% of women who reported they were using marijuana were not selected by providers for a screen.

DISCUSSION

Data demonstrate the high proportion of women using marijuana and the limitations of patient self-report and selective, nonroutine screening to identify substance use during pregnancy. Effective, standardized, clinic-wide strategies are needed to support providers in identifying pregnant women who use substances in order to increase the frequency of education and intervention.

Prenatal THC exposure produces a hyperdopaminergic phenotype rescued by pregnenolone

Increased legal availability of cannabis has led to a common misconception that it is a safe natural remedy for, amongst others, pregnancy-related ailments like morning sickness. Emerging clinical evidence, however, indicates that prenatal cannabis exposure (PCE) predisposes offspring to various neuropsychiatric disorders linked to aberrant dopaminergic function. Yet, our knowledge of how cannabis exposure affects the maturation of this neuromodulatory system remains limited. Here, we show that male, but not female, offspring of Δ⁹-tetrahydrocannabinol (THC)-exposed dams, a rat PCE model, exhibit extensive molecular and synaptic changes in dopaminergic neurons of the ventral tegmental area, including altered excitatory-to-inhibitory balance and switched polarity of long-term synaptic plasticity. The resulting hyperdopaminergic state leads to increased behavioral sensitivity to acute THC during pre-adolescence. The FDA-approved neurosteroid pregnenolone rescues synaptic defects and normalizes dopaminergic activity and behavior in PCE offspring, suggesting a therapeutic approach for offspring exposed to cannabis during pregnancy.

Consequences of Perinatal Cannabis Exposure

Cannabis exposure during the perinatal period results in varied and significant consequences in affected offspring. The prevalence of detrimental outcomes of perinatal cannabis exposure is likely to increase in tandem with the broadening of legalization and acceptance of the drug. As such, it is crucial to highlight the immediate and protracted consequences of cannabis exposure on pre- and postnatal development. Here, we identify lasting changes in neurons' learning flexibility (synaptic plasticity) and epigenetic misregulation in animal models of perinatal cannabinoid exposure (using synthetic cannabinoids or active components of the cannabis plant), in addition to significant alterations in social behavior and executive functions. These findings are supported by epidemiological data indicating similar behavioral outcomes throughout life in human offspring exposed to cannabis during pregnancy. Further, we indicate important lingering questions regarding accurate modeling of perinatal cannabis exposure as well as the need for sex- and age-dependent outcome measures in future studies.

Miscarriage among women in the United States Women's Interagency HIV Study, 1994-2017

BACKGROUND

Relatively little is known about the frequency and factors associated with miscarriage among women living with HIV.

OBJECTIVE

The objective of the study was to evaluate factors associated with miscarriage among women enrolled in the Women's Interagency HIV Study.

STUDY DESIGN

We conducted an analysis of longitudinal data collected from Oct. 1, 1994, to Sept. 30, 2017. Women who attended at least 2 Women's Interagency HIV Study visits and reported pregnancy during follow-up were included. Miscarriage was defined as spontaneous loss of pregnancy before 20 weeks of gestation based on self-report assessed at biannual visits. We modeled the association between demographic, behavioral, and clinical covariates and miscarriage (vs live birth) for women overall and stratified by HIV status using mixed-model logistic regression.

RESULTS

Similar proportions of women living with and without HIV experienced miscarriage (37% and 39%, respectively, P = .638). In adjusted analyses, smoking tobacco (adjusted odds ratio, 2.0), alcohol use (adjusted odds ratio, 4.0), and marijuana use (adjusted odds ratio, 2.0) were associated with miscarriage. Among women living with HIV, low HIV viral load (<4 log10 copies/mL) (adjusted odds ratio, 0.5) and protease inhibitor (adjusted odds ratio, 0.4) vs the nonuse of combination antiretroviral therapy use were protective against miscarriage.

CONCLUSION

We did not find an increased odds of miscarriage among women living with HIV compared with uninfected women; however, poorly controlled HIV infection was associated with increased miscarriage risk. Higher miscarriage risk among women exposed to tobacco, alcohol, and marijuana highlight potentially modifiable behaviors. Given previous concern about antiretroviral therapy and adverse pregnancy outcomes, the novel protective association between protease inhibitors compared with non-combination antiretroviral therapy and miscarriage in this study is reassuring.

Feasibility and Acceptability of e-Screening and Brief Intervention and Tailored Text Messaging for Marijuana Use in Pregnancy

Background: There are at present no evidence-based interventions for marijuana use during pregnancy, despite it being by far the most commonly used illicit drug during pregnancy. Lack of treatment-seeking, combined with implementation challenges, has limited the extent to which at-risk women receive interventions of any kind. This study sought to evaluate the feasibility and acceptability of two high-reach technology-based interventions: electronic screening and brief intervention (e-SBI) and tailored text messaging, delivered either alone or in combination. Materials and Methods: In this exploratory feasibility trial, pregnant women seeking prenatal care services and scoring positive for marijuana use risk (n = 45) were randomly assigned to e-SBI, text messaging, or e-SBI plus text messaging. We examined completion rates and acceptability ratings as a function of intervention condition and participant characteristics. Results: All participants assigned to receive the e-SBI (n = 30) were able to complete it during the in-clinic baseline session. Participants assigned to text messaging (n = 30) received a median of 24 text messages before giving birth; 6 of 30 (20%) chose to end text messages before giving birth. Acceptability ratings for the e-SBI were high, with most being above 4.4 on a 5-point scale (e.g., for ease of use, respectfulness, and helpfulness). Acceptability ratings for some aspects of the texting intervention were also high (e.g., for ease of understanding and respectfulness). Participants in the combined e-SBI plus texting condition chose to stop messages at a rate of 13.3% (2 of 15), versus 26.7% (4 of 15) in the texting-only condition (p = 0.37). Conclusions: These two high-reach intervention elements showed strong feasibility and modest to high acceptability. Future efforts evaluating efficacy are warranted, and should specifically examine the possibility that combining text messaging with a brief intervention may promote retention.

[Current State of Family-Based Prevention and Therapy of Substance-Use Disorders in Children and Adolescents: A Review]

Current State of Family-Based Prevention and Therapy of Substance-Use Disorders in Children and Adolescents: A Review Adolescence is a vulnerable period for substance use disorders (SUD) as indicated by epidemiological studies. Research demonstrates the family's role for the etiology of SUD and provides a rationale for interventions based on family-associated risk and resilience factors. In this article, we summarize published results for family-based interventions from 2008-2018. Taken together, prevention programs can be effective when they focus on the promotion of broader developmental competencies and familial resources, rather than narrowly addressing substance use. Moreover, programs could benefit from targeting youth and parents as done in the "Strengthening Families Program 10-14"; most existing programs however target parents and do not include the adolescents. Family-based treatment programs with an evidence base are Multisystemic Therapy, Functional Family Therapy, Multidimensional Family Therapy and Brief Strategic Family Therapy. Overall, the effects of family-based interventions are small-to-middle sized but vary significantly across populations. Across the field of family-based interventions, there is a need for more knowledge on effective components and differential effects. The results could be improved by translational research such as on the emerging concept of mindfulness. Moreover, there is a need for implementation research and the effectiveness of service delivery programs on the community level in Germany.

Prenatal cannabinoid exposure and altered neurotransmission

Marijuana is one of the most commonly used illicit drugs worldwide. In addition, use of synthetic cannabinoids is increasing, especially among adolescents and young adults. Although human studies have shown that the use of marijuana during pregnancy leads to adverse behavioral effects, such as deficiencies in attention and executive function in affected offspring, the rate of marijuana use among pregnant women is steadily increasing. Various aspects of human behavior including emotion, learning, and memory are dependent on complex interactions between multiple neurotransmitter systems that are especially vulnerable to alterations during the developmental period. Thus, exploration of neurotransmitter changes in response to prenatal cannabinoid exposure is crucial to develop an understanding of how homeostatic imbalance and various long-term neurobehavioral deficits manifest following the abuse of marijuana or other synthetic cannabinoids during pregnancy. Current literature confirms that vast alterations to neurotransmitter systems are present following prenatal cannabinoid exposure, and many of these alterations within the brain are region specific, time-dependent, and sexually dimorphic. In this review, we aim to provide a summary of observed changes to various neurotransmitter systems following cannabinoid exposure during pregnancy and to draw possible correlations to reported behavioral alterations in affected offspring.

Women's perspectives about cannabis use during pregnancy and the postpartum period: An integrative review

Cannabis is the most commonly used illicit drug among general and pregnant populations. Despite recommendations to abstain from cannabis use, its use is increasing during the perinatal period. In this integrative review, we aim to understand women's perspectives about the health aspects of perinatal cannabis use. The following databases were searched: MEDLINE, PsycInfo, EMBASE, and CINAHL. We included quantitative and qualitative studies with a primary focus on perinatal cannabis use. The methodological quality of the included studies was appraised using appropriate checklists. Extracted data were integrated into a single data matrix and iteratively compared across studies to summarize and synthesize the data. Full text of 33 citations was retrieved and reviewed of which 6 studies met the inclusion criteria. Women who continued to use cannabis during pregnancy often perceived no general or pregnancy-specific risk compared to nonusers. The uncertainty regarding adverse perinatal consequences, its perceived therapeutic effects, and lower costs of cannabis compared to that of cigarettes contributed to cannabis use. A lack of communication with health care providers regarding the health aspects of cannabis was evident. Women perceived this lack of counseling as an indication that adverse outcomes associated with cannabis use are not significant. Women's perceptions of health risks associated with cannabis use are important factors in the decision-making process regarding use or cessation, particularly as legal concerns are fading away. A discussion about health concerns surrounding cannabis use may influence women's perceptions of risk and help them to make informed choices.

[Prevention of substance use disorders]

Prevention of substance use disorders Abstract. Introduction: Adolescence is a vulnerable period for the development of Substance Use Disorders and preventive intervention is a public health priority. In this article, we summarize the available evidence for behavioral preventive action for Substance Use Disorders and related dysregulated behaviors during adolescence in various settings. Results: Current meta-analytic evidence is available mainly for the school and family settings and increasingly also for internet-based prevention. The literature is dominated by US-studies that focus on universal school-based approaches for legal substances in middle adolescence. Only few German studies are published. Taken together the results indicate that developmentally sensitive substance use prevention is effective across different settings with consistent small-to-middle sized effects. Differential effectiveness analyses for schoolbased prevention suggest that younger adolescents benefit most from universal prevention, while for older adolescents targeted approaches are more effective. Conclusions: Across the relevant settings, effective preventive measures are available. However, the results could be improved. There is a need for translational research on effective and more individualized approaches to prevention and differential effects of intervention modules. Moreover, there is a need for research on the implementation of evidence-based programs and especially in Germany, coordinated approaches on community levels are lacking.