As I’m writing this, I’m nearly halfway through my second pregnancy (not counting two anembryonic pregnancies). I’ve been lucky, having experienced hardly any nausea compared to some women. Up to 85% of pregnant women suffer from some degree of nausea and vomiting (NVP), while up to 2.3% suffer from a severe and debilitating condition called hyperemesis gravidarum (HG) – approximately 100,000 or more each year in the US alone. Although symptoms often subside by 20 weeks, some women experience the symptoms of HG throughout their entire pregnancy, with many requiring hospitalization.
Women suffering from HG vomit multiple times each day and are often incapable of even keeping down water. The condition leads to dehydration, extreme weight loss, electrolyte and acid-base imbalances, can cause ulcers, bleeding, and a host of other possible complications, not to mention death of the mother and/or fetus. The constant vomiting emaciates her body and destroys her teeth along with her mental and emotional well-being. Many women find themselves unable to care for themselves or their families. Many have to quit their jobs or school. The fetus is also affected, as HG has “a tremendous detrimental effect on the weight of newborns” and has been associated with a number of other abnormalities, including “CNS malformation.”
Still, it surprised me to learn recently that many women are being counseled by their physicians to have abortions in order to “cure” their HG. Additionally, many women who feel neglected by their obstetricians, who treat them as if their condition is purely psychological and fail to provide adequate treatment, reluctantly seek out abortion themselves due to desperation. As the British Daily Mail reported in 2010, Cheryl Harrison chose to abort at 9 weeks after vomiting up to 40 times a day. She commented that it was “the most horrendous decision” she’d ever made.
One study through the University of Southern California found that of all women surveyed across 23 countries, 15.2% elected to terminate their pregnancies due to HG. Of those, 87% chose abortion because they felt they had no hope of relief, 36.6% said they received no help from their healthcare provider, and 25.2% reported that they received no relief from treatment. A striking trend in the data revealed that women who terminated were more than twice as likely to feel that their providers were uncaring, unknowledgeable regarding HG, or otherwise didn’t provide adequate treatment.
Treatment for HG typically consists of modifications in diet (“Have you tried crackers and ginger ale?”), lifestyle changes, IV fluids and electrolytes, medication, meditation, hypnosis, acupuncture, nasogastric feeding tubes, G-tubes (inserted into the stomach through the abdominal wall), and total parenteral nutrition (carbohydrates, protein, and fat provided intravenously).
Of all the medications prescribed to treat NVP and HG, only one of them is is a Category A drug (in 2015 the FDA changed its pregnancy category system, but many people still find the old system useful). A medication achieves Category A status when well-controlled human studies have failed to demonstrate risk to the fetus during the first trimester and have shown no adverse effects in the second and third trimesters. Unfortunately, a well-controlled clinical trial of the only Category A drug used to treat NVP and HG, Diclegis, showed that it actually doesn’t work. Three of the drugs (dimenhydrinate, ondansetron, and metoclopramide) are Category B, which means that there are no well-controlled studies on pregnant woman and no proven risk. The rest (promethazine, prochlorperazine, steroids, etc.) are Category C, which indicates that animal studies have shown an adverse effect on the fetus, but no well-controlled studies on human have been done.
Nevertheless, the FDA allows for such drugs to be prescribed for pregnant women so long as potential benefits outweigh potential risks. This is despite the fact that ondansetron (Zofran) has potentially been linked to birth defects, while the HER Foundation reports that “the 3 most commonly prescribed antiemetics (phenergan, compazine, and tigan) are more strongly correlated with second trimester fetal demise than with having any positive therapeutic effect.”
Many women report no relief from accepted treatment regimens, and hospitalization is a costly intervention that further disrupts women’s lives and possesses additional risks of its own. Being hospitalized and having tubes inserted through the nose or abdominal wall, or having central venous catheters with their increased risk of infection and clot formation, are preferably avoided unless absolutely necessary.
Many women, finding no relief from any of the traditional options offered by their healthcare providers, have turned to cannabis in order to ease their symptoms. Reasoning that since it works well for patients receiving chemotherapy, women with unrelenting HG have tried cannabis and found it to be the only effective treatment option that both eliminated their nausea and vomiting and restored their appetite, allowing them to gain weight and continue with healthy pregnancies. Unfortunately, these women often face resistance and disapproval from their physicians, family, or communities, and so are forced to use cannabis secretly and, frequently, illegally. Thus, they live with increased fear and anxiety over the possibility of becoming victims of the War on Drugs by being arrested and/or reported to CPS.
My friend Shawnee is one such woman. Her HG left her unable to function and made caring for her other daughter extremely difficult, despite taking ondansetron (Zofran). She credits cannabis with keeping her from being hospitalized by allowing her to eat and drink small amounts. She was fortunate enough to receive support from her obstetrician but still lived with the anxiety of possibly being reported to CPS. As another friend who has experience working for the Indiana Department of Child Services told me, it all depends on which county you live in whether your fitness as a parent will be challenged over cannabis. A positive test requires that the umbilical cord be sent to a lab to screen for all drug use during the course of the pregnancy. Meanwhile, women whose children are born addicted to nicotine never even receive a social work consult, and women whose children are born with Fetal Alcohol Syndrome don’t have to worry about a visit from CPS. Those drugs are legal, after all.
Cannabis use during pregnancy:
Controversy surrounds the use of cannabis during pregnancy as risks and long-term effects are largely unknown. The American College of Obstetricians and Gynecologists (ACOG) cites research indicating a risk of low birthweight or stillbirth, as well as developmental deficits, of children born to mothers who used cannabis while pregnant. The research cited, however, is poor and did not control for other confounding factors such as use of other substances such as tobacco, opiates, or cocaine, socioeconomic and nutritional status, education level, form and amount of cannabis consumed, and so on.
A comparison of the effects of prenatal exposure to tobacco, alcohol, cannabis, and caffeine noted that while nicotine had the largest adverse effect on fetal growth, “Neither cannabis nor caffeine use had a significant negative effect on any growth parameter.” Another study similarly concluded: “After adjustment for confounding factors, the association between cannabis use and birthweight failed to be statistically significant.” (And here’s another.) As a systematic review and meta-analysis confirmed,
“Maternal marijuana use during pregnancy is not an independent risk factor for adverse neonatal outcomes after adjusting for confounding factors. Thus, the association between maternal marijuana use and adverse outcomes appears attributable to concomitant tobacco use and other confounding factors.”
While ACOG’s warnings regarding the possible effects of cannabis on cognitive development are based partially on a study of fetal mice, other studies evaluating the effects of cannabis on human fetuses challenge their conclusions. One study investigating the effect of prenatal drug exposure on motor and cognitive development found that only those children whose mothers used cannabis alone possessed greater global motion perception than that of children whose mothers did not use recreational drugs. A study of prenatal marijuana use on neonatal outcomes in Jamaica concluded:
“Exposed and nonexposed neonates were compared at 3 days and 1 month old, using the Brazelton Neonatal Assessment Scale, including supplementary items to capture possible subtle effects. There were no significant differences between exposed and nonexposed neonates on day 3. At 1 month, the exposed neonates showed better physiological stability and required less examiner facilitation to reach organized states. The neonates of heavy-marijuana-using mothers had better scores on autonomic stability, quality of alertness, irritability, and self-regulation and were judged to be more rewarding for caregivers.”
A five-year follow-up study on the same children found “no significant differences in developmental testing outcomes between children of marijuana-using and non-using mothers.”
ACOG states, also, that there is “no evidence that marijuana is helpful in managing morning sickness,” while failing to mention that the lack of evidence is due to the fact that there have been no well-controlled trials of marijuana use to treat morning sickness. However, a survey of women who used cannabis during pregnancy revealed that 68% of respondents used cannabis to treat NVP, and of those, 92% rated cannabis as either “extremely effective” or “effective.”
Considering the fact that most drugs prescribed to treat NVP and HG are in categories B and C, indicating that no controlled human trials have been done and that risk cannot be ruled out, it is difficult to understand ACOG’s automatic dismissal of cannabis based on poor research that has been repeatedly contradicted by other studies that adjust for confounding factors. Were cannabis not a schedule I controlled substance, it would likely be, at worst, a Category C medication. It is clear that, as with the FDA-approved drugs currently prescribed, the potential benefits of cannabis use for HG far outweigh its risks or the risks of poorly-treated HG. HG is certainly associated with low birthweight; marijuana is clearly not.
To date, there are no controlled human trials of the effects of cannabis as a treatment for NVP or HG, and that is because cannabis is classified as a Schedule I controlled substance. In order for researchers to be able to conduct such a trial, special permission must be granted by the federal government – namely, the FDA, DEA, and the National Institute for Drug Abuse (NIDA). Furthermore, those who wish to study cannabis must obtain the cannabis directly from NIDA or the University of Mississippi, which limits researchers’ abilities to use a specific, quality-controlled cannabis strain in a variety of forms (such as flower, vape, or tincture) with a specified THC to CBD ratio.
If that weren’t bad enough, NIDA is known for only granting permission and funding to studies that focus on the negative effects of drugs. Researchers thus feel compelled to emphasize the adverse effects of drugs in order to get their research funded in the first place. It almost seems as if the system is rigged.
The current situation is one in which millions of women in the US suffer from NVP each year, and perhaps 100,000 of those or more are afflicted with HG. Their treatment options are often ineffective, leading many to be hospitalized or counseled to abort much-wanted children. Others are living in fear while illegally using cannabis to treat their HG. In order to provide these women additional relief and hope, to perhaps save both them and their unborn children, and in order to open the doors to an expanded body of research comprised of well-controlled human trials that would enhance our understanding of how best to use cannabis (or not) to treat NVP/HG as well as other conditions, cannabis must be legalized. If nicotine and alcohol are recognized as harmful yet nevertheless “the mother’s choice,” then surely given all of the research cited above, women ought to be granted the same liberty when it comes to cannabis, their health, and the health of their children.
LCI is not a medical organization and is not advocating that any individual use cannabis as a treatment. The above article should not be considered medical advice by any means. Consult with your doctor before making any crucial medical decision.