Prevalence and outcomes of prenatal recreational cannabis use in high-income countries: a scoping review

BACKGROUND

With expanding recreational cannabis legalisation, pregnant women and their offspring are at risk of potentially harmful consequences.

OBJECTIVES

To assess the prevalence of recreational cannabis use among pregnant women, health outcomes associated with prenatal recreational cannabis use, and the potential impact of recreational cannabis legalisation on this population.

SEARCH STRATEGY

Five databases and the grey literature were systematically searched (2000-2019).

SELECTION CRITERIA

Human studies published in English or French reporting on the prevalence of prenatal recreational cannabis use in high-income countries.

DATA COLLECTION AND ANALYSIS

Data on study characteristics, prenatal substance use, and health outcomes were extracted and qualitatively synthesised.

MAIN RESULTS

Forty-one publications met our inclusion criteria. The overall prevalence of prenatal cannabis use varied substantially (min-max: 0.24-22.6%), with the greatest use in the first trimester. In the three studies with temporal data available, rates of prenatal cannabis use increased across years. Only 7/41 and 5/41 studies provided information on gestational age of exposure and frequency of use, respectively. The concomitant use of alcohol, illicit drugs, and tobacco was higher among cannabis users than nonusers. Prenatal cannabis use was associated with select neonatal, but not maternal, health outcomes. There were insufficient data to compare prenatal cannabis use between the pre- and post-legalisation periods.

CONCLUSION

Cannabis use among pregnant women is prevalent and may be associated with adverse neonatal outcomes. Future studies should assess the gestational age and frequency of cannabis exposure, and usage patterns prior to and following legalisation.

TWEETABLE ABSTRACT

Women who consume cannabis during pregnancy could risk predisposing their newborns to poor birth outcomes.

The effect of smoking cessation counselling in pregnant women: a meta-analysis of randomised controlled trials

BACKGROUND

Pregnant smokers are often prescribed counselling as part of multicomponent cessation interventions. However, the isolated effect of counselling in this population remains unclear, and individual randomised controlled trials (RCTs) are inconclusive.

OBJECTIVE

To conduct a meta-analysis of RCTs examining counselling in pregnant smokers.

SEARCH STRATEGY

We searched the CDC Tobacco Information and Prevention, Cochrane Library, EMBASE, Medline and PsycINFO databases for RCTs evaluating smoking cessation counselling.

SELECTION CRITERIA

We included RCTs conducted in pregnant women in which the effect of counselling could be isolated and those that reported biochemically validated abstinence at 6 or 12 months after the target quit date.

DATA COLLECTION AND ANALYSIS

Overall estimates were derived using random effects meta-analysis models.

MAIN RESULTS

Our search identified eight RCTs (n = 3290 women), all of which examined abstinence at 6 months. The proportion of women that remained abstinent at the end of follow up was modest, ranging from 4 to 24% among those randomised to counselling and from 2 to 21% among control women. The absolute difference in abstinence reached a maximum of only 4%. Summary estimates are inconclusive because of wide confidence intervals, albeit with little evidence to suggest that counselling is efficacious at promoting abstinence (odds ratio 1.08, 95% confidence interval 0.84-1.40). There was no evidence to suggest that efficacy differed by counselling type.

CONCLUSIONS

Available data from RCTs examining the isolated effect of smoking cessation counselling in pregnant women are limited but sufficient to rule out large treatment effects. Future RCTs should examine pharmacological therapies in this population.

Pregnancy outcomes in women with osteogenesis imperfecta: a retrospective cohort study

OBJECTIVE

Osteogenesis imperfecta (OI) is a rare genetic disorder characterized by defects in type I collagen that can pose serious complications during pregnancy. The aim was to evaluate maternal and fetal outcomes in pregnant women with OI.

STUDY DESIGN

This was a retrospective cohort study, using the Healthcare Cost and Utilization Project Nationwide Inpatient Sample. We examined the records of pregnant women with OI during the period 2003 to 2011. We evaluated antenatal complications and method of delivery among 295 women with OI, using unconditional logistic regression.

RESULTS

Of the total 7 287 994 births in our cohort, we encountered 295 deliveries among women with OI. The prevalence was 4 per 1 00 000 deliveries per year over the study period. Births to women with OI were more likely to be complicated by antepartum hemorrhage (odds ratio (OR) 2.01, 95% confidence interval (CI) 1.04 to 3.91), placenta abruption (OR 2.50, 95% CI 1.24 to 5.03), intrauterine growth restriction and small-for-gestational-age infants (OR 2.42, 95% CI 1.42 to 4.14), congenital malformation (OR 7.33, 95% CI 4.20 to 12.78) and preterm birth (OR 2.24, 95% CI 1.63 to 3.06). Seventy-five percent of women with OI delivered by cesarean section, and they had an increased rate of tubal sterilization at delivery (OR 1.67, 95% CI 1.18 to 2.36). No differences in rates of stress fracture and maternal death were found.

CONCLUSION

These findings suggest that there are increased risks to both mother and fetus in pregnancies complicated by OI.

Influence of ultrasound-to-delivery interval and maternal-fetal characteristics on validity of estimated fetal weight

OBJECTIVES

To explore the effects of ultrasound-to-delivery interval and maternal-fetal characteristics on the distribution of measurement error in estimated fetal weights (EFWs), and to determine the predictive ability of EFW for diagnosis of small-for-gestational age (SGA) and large-for-gestational age (LGA) among infants delivered within 1 day of an ultrasound examination.

METHODS

Percentage differences between EFW and birth weights were calculated in 3697 pregnancies. Linear regression was used to compare the accuracy of EFW for births on each of the 6 days after an ultrasound scan with the accuracy observed among births on the same day. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value for diagnosis of SGA and LGA according to EFW was assessed.

RESULTS

The mean +/- SD percentage difference among deliveries within 1 day of the last ultrasound scan was 0.2 +/- 9.0%. Mean percentage differences were not significantly different from day 0 on days 1, 2 and 3; however, combining the data from these 4 days obscured a slight bias towards an overestimation of weight evident on day 0 and day 1. Among deliveries within 1 day of an ultrasound scan, the PPV was 61% for SGA diagnosis and 54% for LGA diagnosis.

CONCLUSION

Combining data from births > 1 day after the last ultrasound examination may lead to a false conclusion that there is systematic underestimation of weight. EFW tended to underestimate the weight of macrosomic fetuses and overestimate that of small fetuses which limited sensitivity and PPV. Maternal-fetal characteristics are weak predictors of individual errors in EFW.

Maternal and neonatal outcomes of pregnancies in women with Addison's disease: a population-based cohort study on 7.7 million births

OBJECTIVE

To assess if pregnancies among women with Addison's disease (AD) are at higher risk of adverse maternal and neonatal outcomes.

DESIGN

Population-based retrospective cohort study.

SETTING/POPULATION

All births in the United States' Healthcare Cost and Utilization Project-Nationwide Inpatient Sample from 2003 to 2011.

METHODS

Baseline characteristics were compared between women with AD and those without, and prevalence over time was measured. Logistic regression was used to estimate the effect of AD on maternal and neonatal outcomes by calculating the crude and adjusted odds ratios (OR) and corresponding 95% confidence intervals (95% CI).

RESULTS

We calculated a prevalence of AD in pregnancy of 5.5/100 000, increasing from 5.6 to 9.6/100 000 (P = 0.0001) over the 9-year study period. Compared with women without AD, women with AD were more likely to deliver preterm (OR 1.50, 95% CI 1.16-1.95), deliver by caesarean section (OR 1.32, 95% CI 1.08-1.61), have impaired wound healing (OR 4.28, 95% CI 2.55-7.18), develop infections (OR 2.44, 95% CI 1.66-3.58) and develop thromboembolism (OR 5.21, 95% CI 2.15-12.63), require transfusions (OR 6.69, 95% CI 4.69-9.54), and have prolonged postpartum hospital admissions (OR 5.71, 95% CI 4.37-7.47). Maternal mortality was significantly higher than in the comparison group (OR 22.30, 95% CI 6.82-72.96). Congenital anomalies (OR 3.62, 95% CI 2.05-6.39) and small-for-gestational age infants (OR 1.78, 95% CI 1.15-2.75) were more likely in these pregnancies.

CONCLUSIONS

Addison's disease significantly increases the risk of severe adverse maternal and neonatal outcomes, so pregnant women with AD are best managed in tertiary-care centres.

TWEETABLE ABSTRACT

Pregnancies complicated by Addison's disease have an increased risk of adverse maternal and neonatal outcomes.

Arterial stiffness for the early prediction of pre-eclampsia compared with blood pressure, uterine artery Doppler and angiogenic biomarkers: a prospective cohort study

OBJECTIVE

Our aim was to evaluate the ability of arterial stiffness parameters to predict pre-eclampsia early compared with peripheral blood pressure, uterine artery Doppler and established angiogenic biomarkers.

DESIGN

Prospective cohort study.

SETTING

Tertiary care antenatal clinics in Montreal, Canada.

POPULATION

Women with singleton high-risk pregnancies.

METHODS

In the first trimester, arterial stiffness was measured by applanation tonometry, along with peripheral blood pressure and serum/plasma angiogenic biomarkers; uterine artery Doppler was measured in the second trimester. The predictive ability of different metrics was assessed through multivariate logistic regression.

MAIN OUTCOME MEASURES

Arterial stiffness (carotid-femoral pulse wave velocity, carotid-radial pulse wave velocity) and wave reflection (augmentation index, reflected wave start time), peripheral blood pressure, ultrasound indices of velocimetry and circulating angiogenic biomarker concentrations.

RESULTS

In this prospective study, among 191 high-risk pregnant women, 14 (7.3%) developed pre-eclampsia. A first-trimester 1 m/s increase in carotid-femoral pulse wave velocity was associated with 64% increased odds (P < 0.05), and a 1-millisecond increase in time to wave reflection with 11% decreased odds for pre-eclampsia (P < 0.01). The area under the curve of arterial stiffness, blood pressure, ultrasound indices and angiogenic biomarkers was 0.83 (95% confidence interval [CI] 0.74-0.92), 0.71 (95% CI 0.57-0.86), 0.58 (95% CI 0.39-0.77), and 0.64 (95% CI 0.44-0.83), respectively. With a 5% false-positive rate, blood pressure had a sensitivity of 14% for pre-eclampsia and arterial stiffness a sensitivity of 36%.

CONCLUSIONS

Arterial stiffness predicted pre-eclampsia earlier and with greater ability than blood pressure, ultrasound indices or angiogenic biomarkers.

A cluster-randomized trial to reduce major perinatal morbidity among women with one prior cesarean delivery in Québec (PRISMA trial): study protocol for a randomized controlled trial

Background

Rates of cesarean delivery are continuously increasing in industrialized countries, with repeated cesarean accounting for about a third of all cesareans. Women who have undergone a first cesarean are facing a difficult choice for their next pregnancy, i.e.: (1) to plan for a second cesarean delivery, associated with higher risk of maternal complications than vaginal delivery; or (b) to have a trial of labor (TOL) with the aim to achieve a vaginal birth after cesarean (VBAC) and to accept a significant, but rare, risk of uterine rupture and its related maternal and neonatal complications. The objective of this trial is to assess whether a multifaceted intervention would reduce the rate of major perinatal morbidity among women with one prior cesarean.

Methods/design

The study is a stratified, non-blinded, cluster-randomized, parallel-group trial of a multifaceted intervention. Hospitals in Quebec are the units of randomization and women are the units of analysis. As depicted in Figure 1, the study includes a 1-year pre-intervention period (baseline), a 5-month implementation period, and a 2-year intervention period. At the end of the baseline period, 20 hospitals will be allocated to the intervention group and 20 to the control group, using a randomization stratified by level of care. Medical records will be used to collect data before and during the intervention period. Primary outcome is the rate of a composite of major perinatal morbidities measured during the intervention period. Secondary outcomes include major and minor maternal morbidity; minor perinatal morbidity; and TOL and VBAC rate. The effect of the intervention will be assessed using the multivariable generalized-estimating-equations extension of logistic regression. The evaluation will include subgroup analyses for preterm and term birth, and a cost-effectiveness analysis.

Discussion

The intervention is designed to facilitate: (1) women’s decision-making process, using a decision analysis tool (DAT), (2) an estimate of uterine rupture risk during TOL using ultrasound evaluation of low-uterine segment thickness, (3) an estimate of chance of TOL success, using a validated prediction tool, and (4) the implementation of best practices for intrapartum management.

Trial registration

Current Controlled Trials, ID: ISRCTN15346559. Registered on 20 August 2015.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-2150-x) contains supplementary material, which is available to authorized users.

Live births, cesarean sections and the development of menstrual abnormalities

OBJECTIVES

To examine the relationship between number of livebirths and cesarean sections on the development of menstrual abnormalities.

METHODS

The effect of number of livebirths and cesarean sections on menstrual abnormalities in the late reproductive period was evaluated using data from the Harvard Study of Moods and Cycles.

RESULTS

There were 298 women with no livebirths and 606 women with livebirths of which 184 had a history of cesarean section. Among all women, increasing number of livebirths was associated with an increasing trend in reported heavy menses, prolonged flow >6 days, and a decreasing trend in reported dysmenorrhea. This effect was amplified among women with a history of cesarean section.

CONCLUSIONS

Increasing number of livebirths is associated with heavy and prolonged menstrual flow during the late reproductive period. This association is particularly stronger in women with a history of cesarean section.

Gender differences in how physicians access and process information

There is an absence of information on how physicians make surgical decisions, and on the effect of gender on the processing of information. A novel web based decision-matrix software was designed to trace experimentally the process of decision making in medical situations. The scenarios included a crisis and non-crisis simulation for endometrial cancer surgery. Gynecologic oncologists, fellows, and residents (42 male and 42 female) in Canada participated in this experiment. Overall, male physicians used more heuristics, whereas female physicians were more comprehensive in accessing clinical information (p < 0.03), utilized alternative-based acquisition processes in the non-crisis scenario (p = 0.01), were less likely to consider procedure-related costs (p = 0.04), and overall allocated more time to evaluate the information (p < 0.01). Further experiments leading to a better understanding of the cognitive processes involved in medical decision making could influence education and training and impact on patient outcome.

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Novel software evaluating how physicians make decisions in clinical scenarios.

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Significant differences exist in how male and female surgeons access information and make decisions.

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Male physicians used more heuristics and made quicker decisions.

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Female physicians were more comprehensive, and took more time to evaluate information.

Program description: a hospitalist-run, medical short-stay unit in a teaching hospital

A hospitalist-run medical short-stay unit (MSSU) was created at a university-affiliated teaching hospital in Montreal in 1989. Its primary aim was to provide efficient and high-quality care to patients requiring a brief stay in hospital for short-lived medical conditions. After evaluation in the emergency department (ED), patients judged to have acute conditions requiring a short hospital stay are admitted directly to the MSSU. Conversely, patients with more complex conditions requiring a longer stay in hospital are admitted to a clinical teaching unit (CTU). Care in the MSSU is provided by a rotating group of hospitalists. Ensuring the admission of appropriate patients during non-daytime hours was the main difficulty identified. Preliminary evaluation of the MSSU suggested that ED consultants were effective at selecting suitable patients for admission to the MSSU, because only 1 in 5 patients later required transfer to other hospital wards. The 5 most common MSSU discharge diagnoses were asthma and chronic obstructive lung disease, pneumonia, congestive heart failure, urinary tract infection and cellulitis. MSSU patients had a shorter length of stay, lower rates of in-hospital complications and lower rates of readmission within 30 days of discharge compared with CTU patients. Our hospitalist-run MSSU appears to offer a workable system of health care delivery for patients with acute, self-limited illness requiring a brief stay in hospital. The MSSU appeared to promote the efficient use of hospital beds without compromising patient outcomes, however, further research is required to compare the efficiency and outcomes of care directly with that provided by the traditional CTU system.