FAQ: What does ACOG's cannabis guidance mean for your patients?

ACOG issued Clinical Consensus No. 10, Cannabis Use During Pregnancy and Lactation, published online September 18, 2025, and in the October 2025 issue of Obstetrics & Gynecology, replacing Committee Opinion No. 722 from October 2017. The guidance recommends universal screening for cannabis use during the prepregnancy, pregnancy, and postpartum periods and states that there are no medical indications for cannabis use during pregnancy and the postpartum period. Every recommendation statement met or exceeded the 75% approval threshold required for consensus.¹ ACOG described the document as new and significantly updated clinical guidance.²

The guidance notes that cannabis is the most commonly used illicit drug under US federal law and that prevalence among pregnant and lactating individuals ranges from 3.9% to 16.0%.¹ ACOG said cannabis use in pregnancy has been associated with spontaneous preterm birth, low birth weight, NICU admissions, and postnatal neurocognitive and behavioral dysfunction, yet a misperception persists that cannabis is safe during pregnancy because of its increasing availability, legalization, and social acceptability.² The document gives ob-gyns and other obstetric health care professionals evidence-based direction on counseling, screening, and strategies to reduce cannabis use before and during pregnancy and during lactation.¹ ²

1. What does ACOG recommend for screening for cannabis use?

ACOG recommends that ob-gyns and other obstetric health care professionals perform universal screening by interview, self-report, or validated screening tools for cannabis use during the prepregnancy, pregnancy, and postpartum periods.¹ The guidance states that universal screening helps eliminate bias because it is required for all patients.² For adults, the guidance cites the TAPS (Tobacco, Alcohol, Prescription medication, and other Substance use) tool as an example, and for adolescents, it cites S2BI (Screening to Brief Intervention), CRAFFT (Car, Relax, Alone, Forget, Friends, Trouble), and 5Ps (Parents, Peers, Partner, Past, and Pregnancy).¹

The guidance applies the ethical principle of justice to universal screening because it supports equitable and nondiscriminatory health practices, and it notes that substance use disorders affect individuals of all ages from diverse racial and ethnic backgrounds, economic strata, and rural and urban communities. Early screening also offers an opportunity to repeat screening across gestation, and serial screening has demonstrated a several-fold decrease in pregnant individuals screening positive for substance use.¹

2. Should biologic testing be used to screen for cannabis use?

No. ACOG states that biologic testing should not be used as a screening assessment for cannabis use, and it describes routine use of biological materials such as urine and hair as controversial and strongly discouraged.¹ The guidance also cautions that testing is not a definitive way to accurately diagnose a substance use disorder because of limitations in assessing severity of use and the wide detection window.² Drug tests on biological materials are not used to detect alcohol or tobacco, which are used more prevalently and associated with adverse fetal effects, and they do not rule out sporadic use of illicit substances. The detection window for carboxy-THC is 1 to 30 days in urine, up to 90 days in hair, up to 24 hours in oral fluid, and 7 to 14 days in sweat, and clearance time in pregnancy has not been studied extensively.¹

A positive presumptive or definitive test result does not diagnose a substance use disorder or detect the severity of use, and all positive presumptive results should be validated by definitive gas or liquid chromatography combined with mass spectrometry, as indicated.¹

3. Is there a medical indication for cannabis use in pregnancy, and why do patients use it?

ACOG recommends that clinicians educate patients that there are no medical indications for cannabis use during pregnancy and the postpartum period.¹

Patients have reported that cannabis helps with symptom management of pre-existing conditions such as anxiety, depression, insomnia, and chronic pain, as well as pregnancy-related symptoms such as nausea and vomiting, weight gain, pain, and stress.¹ ² Clinicians should work with patients to identify alternative methods to address health concerns, especially if cannabis is being used to cope with unmet physical or mental health needs.² The guidance advises inquiring about reasons for use in a nonjudgmental manner.¹

Some patients may hesitate to disclose use because of concerns about judgment, stigma, guilt, or potential legal or child welfare implications, and the guidance describes limiting the discussion of cannabis risks to patients who disclose use as a missed opportunity. In an ancillary study of 9,250 nulliparous pregnancies, higher THC metabolite levels were associated with greater odds of moderate to severe nausea than no THC metabolite detection (adjusted odds ratio 1.6, 95% CI, 1.1 to 2.2 for a 500 ng/mg Cr THC-COOH increment). Cannabis hyperemesis syndrome, a recognized complication characterized by cyclic episodes of nausea, vomiting, and abdominal pain, is associated with high potency or regular use of cannabis, and more than 95% of individuals can achieve complete resolution of symptoms with cessation.¹

4. What perinatal and neonatal risks should clinicians discuss with patients?

Cannabis use in pregnancy has been associated with spontaneous preterm birth, low birth weight, NICU admissions, and postnatal neurocognitive and behavioral dysfunction.² The guidance also links cannabis exposure during pregnancy to small-for-gestational-age neonates and perinatal mortality. THC is lipid-soluble, crosses the placenta, and can transfer into breast milk, and cannabinoid receptors are present in the fetus as early as 5 weeks. Fetal concentration of THC has been reported to be approximately 10% of the maternal concentration, and the risk of adverse outcomes increases in a dose-dependent fashion.¹

Neonates exposed to cannabinoids in utero also demonstrate altered arousal patterns, regulation, and excitability in the first month of life. Prior studies suggest potential risk for postnatal neurocognitive and behavioral dysfunction, including attention deficit disorders, behavioral and short-term memory challenges, and intellectual disabilities, though varying doses, durations, delivery methods, gestational ages, and postnatal exposure make it difficult to rigorously quantify the risk of long-term neurocognitive dysfunction. Independent of tobacco and other drugs, cannabinoid use was associated with diminished cognitive functioning in verbal reasoning, language comprehension, and executive function, and adolescents and adults exposed prenatally are at increased risk of developing substance use disorder or psychiatric disorders.¹

5. How common is cannabis use in pregnancy, and what has changed in the products available?

Cannabis is the most commonly used illicit drug under U.S. federal law, with the highest proportion of users being of reproductive age. Use during pregnancy has increased over the past 20 years, with reported rates varying between 3.9% and 22.6% of pregnant individuals in high-income countries. The highest frequency is reported in the first trimester, when many patients report use to curb pregnancy-related nausea and vomiting, and use generally declines across gestation. Return to use or increased use within 6 to 12 months postpartum is common.¹

THC content in cannabis products has increased in markets by 0.29% to 0.57% annually, with nearly a fourfold increase since 1995. The guidance notes that cannabis is not regulated by FDA, and studies of products available online found that 23% to 60% contained underlabeled or overlabeled concentrations of cannabinoids and that 1 in 5 products labeled as CBD-only contained THC. Patients who use cannabis are also more likely to use alcohol, tobacco, or other substances during pregnancy than pregnant individuals who do not use cannabis.¹

6. What equity considerations should ob-gyns keep in mind when screening and counseling?

The guidance recommends that ob-gyns and other obstetric health care professionals be aware of the procedural, social, and legal consequences of positive screens in their institutions' local policies and jurisdictions, including involvement of child protective services and criminalization, and that they actively work to address inequities inherent in many existing systems.¹ ACOG also cautions that disproportionate rates of drug testing and mandatory reporting to child protective services among Black and minority women have led to racial health inequities, and ob-gyns should keep those inequities in mind when counseling patients on cannabis risks.²

Black patients screen positive for substance use disorders at the same rate as White patients yet are 4 to 10 times more likely to have a positive drug screen result reported to child protective services. At one institution, Black and Hispanic pregnant individuals were 4 to 5 times more likely to have drug testing for an indication other than reported substance use compared with their White counterparts, and a study of child protective services reporting found that Black women were reported almost 5 times more than White women despite similar levels of substance use across groups. A comparison of states with and without mandatory reporting requirements showed no difference in rates of neonatal abstinence syndrome.¹

"Structural racism and bias have led to increased testing and reporting of Black patients when the data indicate that white patients screen positive for substance use at the same rate," said Amy Valent, DO, FACOG, coauthor of the guidance. "A person with a substance use disorder does not have a specific age, a specific racial and ethnic background, or fall into a specific socioeconomic status category. Institutional and state policies can vary, so we as clinicians need to familiarize ourselves with those policies and the potential legal ramifications and effects testing will have on our patients and their families."²

7. What should clinicians know about informed consent and local reporting policies?

Pregnant patients should always be counseled about the risks and benefits of drug testing, and informed consent should be obtained before drug testing of the patient or their newborn.¹ ² Toxicology testing with biological materials may have significant social and legal consequences and should always be conducted with the patient's informed consent. The guidance notes inconsistent state and institutional policies on drug testing of pregnant individuals and their newborns and on notifying child protection agencies, and it states that clinicians should familiarize themselves with their own institutional and state policies on cannabis use in pregnancy, potential legal ramifications, and reporting duties to child protective services. Despite legalization in many states, there remains a lack of clarity for pregnant and lactating individuals about the legal and child protection implications of cannabis use.¹

8. Should patients who use cannabis be discouraged from breastfeeding?

No. ACOG advises cessation of cannabis use during pregnancy and lactation, but the guidance states that continued cannabis use is not a contraindication to breastfeeding and that breastfeeding should not be discouraged.¹ ² THC can transfer into breast milk, and literature on cannabis use and lactation is limited by study quality and sample size, so cannabis use during lactation is discouraged given the limited safety data. Breastfeeding has numerous health effects, including decreased rates of infection, asthma, and obesity and improved intellectual development. Cannabis use has also been shown to continue or increase during the postpartum period.¹

"One personal value a patient may hold is to breastfeed their child," said Amy Valent, DO, FACOG, coauthor of the guidance. "We want to discourage use of cannabis during lactation, but continued use is not a contraindication to breastfeeding. So, patients who want to breastfeed should be encouraged to do so because of the numerous health benefits it provides the newborn. Overall, we cannot be rigid in our approach. Ob-gyns need to work with patients on risk-reducing strategies that will work best for them and their lives while lowering adverse outcomes."²

9. What counseling and cessation strategies does ACOG suggest?

ACOG states that clinicians may use motivational interviewing, address social determinants of health, and assess barriers to cannabis cessation to guide cessation-intervention strategies.¹ While more evidence-based treatment strategies are needed, ob-gyns are encouraged to motivate behavioral change by discussing cannabis use and individualized risks alongside each patient's personal values, priorities, and barriers to cessation and treatment.²

The guidance also states that clinicians may use supportive home visits, psychobehavioral strategies, or brief electronic or text messaging interventions to reduce cannabis use in pregnancy and the postpartum period. Psychobehavioral interventions, including motivational enhancement therapy, cognitive behavioral therapy, or motivational interviewing with coping skills training, have been shown to be beneficial in reducing cannabis use, and integrated substance-use programs and paraprofessional home-visiting interventions have been shown to improve child developmental outcomes, particularly in populations that experience higher health disparities. There are no FDA-approved medications for the treatment of cannabis use disorder.¹

Clinicians should also consider cannabis withdrawal syndrome, which can occur within 24 to 72 hours after last cannabis use and continue for up to 2 weeks. The guidance states that clinicians should have a higher suspicion for withdrawal with cannabis consumption greater than 1.5 g/d (inhaled) or use of products more than 2 to 3 times per day, and it notes that recognizing withdrawal as a barrier to cessation may be key to relapse prevention.¹

10. What do clinicians still not know about cannabis use in pregnancy and lactation?

The guidance identifies a critical need for more robust human research on perinatal and postpartum cannabis use and adverse outcomes. It notes a paucity of data rigorously investigating the safety or efficacy of cannabis use in human pregnant or lactating individuals, even with medicinal use, and says that understanding the pathobiology of cannabis use on placental function, fetal growth and development, and the developmental programming of long-term health is critical. The health effects of legalization are difficult to quantify because of heterogeneity of laws, varying cannabis potencies and products, frequency of polysubstance use, and inconsistent adverse outcomes reported in the literature, and robust evidence-based treatment strategies are lacking.¹

"The largest consumers of cannabis are reproductive-aged people, so we need to have these conversations with our patients and make sure that we educate them on the risks of cannabis use," said Melissa Russo, MD, FACOG, coauthor of the guidance. "While people do use cannabis for medicinal purposes, there is a lack of data on its safety and efficacy in pregnant and lactating people, and research now shows there are potential adverse effects on the pregnancy from cannabis use. We still have a lot learn about the effects of cannabis on placental function, fetal growth and development, and long-term physical and mental health in the child."²

References:

1. American College of Obstetricians and Gynecologists. Cannabis use during pregnancy and lactation. Clinical Consensus No. 10. Obstet Gynecol. 2025;146(4):600-611. Published online September 18, 2025. doi:10.1097/AOG.0000000000006053

2. American College of Obstetricians and Gynecologists. [Press release title]. Press release. Published [date]. Accessed November 6, 2026.