COLORADO PERINATAL CARE COUNCIL
A. MEETING
B. DATE
C. LOCATION
Colorado Perinatal Care Council, Meeting#: 216
July 25, 2014
Colorado Department of Public Health & Environment
Denver, Colorado
D. PARTICIPANTS:
MEMBERS, GUESTS AND EXECUTIVE COMMITTEE MEMBERS PRESENT:
Liz Whitley, CDPHE, CPCC Executive Committee Member
Cheryl Yesko, ELMC
Betsy Block, Consumer
Teresa Sanderlin, Littleton Adventist
Diane Flannery, ELMC
Abe Grinberg, MD, Retired Neonatologist
Mary Laird, MD, CHCO Memorial, Pediatrix Medical Group
Carol Wallman, CHCO, Poudre Valley Hospital System
Barb Wahl, Tri County Health Department
Shelly Posey, CNM
Pat Bohling-Smith, CPCC Executive Committee Member
Sue Ricketts, CDPHE
Briana Goodfellow, Center for Maternal Fetal Health / RMHC
Cindy Gaines, St. Mary’s Hospital Grand Junction
Angela Polson, Sky Ridge Medical Center
Kit Harden, CHCO/CSW
Kina Howard, Penrose St. Francis
Amy Speers, Tri County Health Department
Kathryn Ward, SFMC
Bonita Shviraga, CNM, Aurora Nurse-Midwives
Tiffany Glick, Children’s Hospital Colorado
Cyndy Krening, Saint Joseph Hospital
Marianne Neifert, MD, Dr. Mom Presentations
Scott Matthews, March of Dimes
Janet Milliman, Colorado Access, CHP+, SMCN
Stephanie Johnson St Dic, SFMC NICU
Jan Lapetino, Colorado Midwives Association
Laraine Guyette, CNM, Colorado ACNM
Pat Maass, Saint Joseph Hospital
Nina Huffer, North Suburban Medical Center
Patrick Smith, Valley Wide, La Junta
Sara McCoy, RN-C, Saint Joseph Hospital
Lee Morgan, MD, COPIC
Jackie Garrad, MD, San Luis Valley Health
Sharon Langendoerfer, MD, Denver Health
Kirtley Ceballos, VCH NICU
Mandy Bakulski, CHPHE
Anne Behring, UCH Central
Andrea Mitrorka, UCH Central
Eileen Meisner, Good Samaritan Medical Center
Lisbeth Gabrielski, CHC
Susan Clarke, CHCO
Glenda Beyers, Presbyterian/St. Luke’s
Amy Dempsey, Lutheran Medical Center
Aaron Miller, Colorado DEC
Laura Borgelt, University of Colorado
Chris Freeman, Centura
Neko Upson, CNM Saint Joseph Hospital Nurse-Midwives
Joanna Reeder, CHCO
Kim Wood, Lutheran
Annabelle Tashma, Student
Erin Ross, Rose Medical Center
Erica Eymore, MD, Children’s Hospital Colorado
Rachel Wright, MD, Denver Health and Hospital, CPCC Executive Committee Member
Suze Ketchem, Good Samaritan Medical Center
Stacy Kreil, MSN, Littleton Adventist
Marcia Teague, Lutheran Medical Center
Deb Bopp, Memorial, Colorado Springs, CPCC Executive Committee Member
Rainy Tieman, Montrose Memorial
Ellen Duran, North Suburban Medical Center
April McPike, Penrose/St. Francis
Christie Salvi, Platte Valley Medical Center
Tracy Heaberlin, Poudre Valley Medical Center, CPCC Executive Committee Member
Glenda Beyers, Presbyterian/St. Luke’s
Steve Holt, MD, CPCC Chairman
Sally Garcia, St. Anthony North
Jamie Martin, Sky Ridge Medical Center
Kathy Anderson, University of Colorado Hospital
Sherrie Williams, Univeristy of Colorado Hospital
Lesa Nesbit, March of Dimes
Mary McMahon, CPCC Executive Committee Member
Kirk Bol, CDPHE
Krista Beckwith, CDPHE
E. HANDOUTS (Available Upon Request)
1. Agenda
2. Conference Calendar
3. CPCC Meeting Dates & Locations - 2014
4. Self-Assessment Survey Summary
5. Meeting Minutes
6. Community Program Handouts
F. SUMMARY OF THE MEETING
1. Procedural Items
a. The Council thanked CDPHE, Dr. Tista Ghosh and Joni Reynolds for hosting the meeting.
b. Introduction of Council members and guests.
c. The Minutes from the May 16, 2014 meeting were reviewed and approved
d. The Treasurer’s Report was provided by Sandra Gardner, CPCC Treasurer.
e. Additional conferences were noted at the meeting: For a list of upcoming conferences, please
refer to the Council’s website at: www.coloradoperinatalcarecouncil.com.
f. Executive Committee Report:
CPCC Executive Committee is looking at our current structure and continuing to define the
visions and goals of CPCC for the future. We would like to focus on more state collaborative
efforts and establish more key partnerships. CPCC Executive Committee is working on the
upcoming agenda for the September meeting. Topics will include: Outreach Update to
Level I hospitals, Follow up Marijuana Discussion and a Conference Update. If you have
any agenda topics you would like Exec Committee to consider for future meetings, please
email Heather. CPCC Exec Committee is still looking for a new Chairman Elect. Dr. Liz
Whitley (CDPHE) and Dr. Rachel Wright (Neonatologist, Denver Health) have now joined
the Executive Committee. Welcome Deb Bobb as our newest Executive Committee
Member. We are still recruiting for a Chairman elect for 2015.
CPCC Executive Committee has begun to reach out to our Colorado Level I hospitals as part
of our state collaborative efforts. CPCC has defined the first wave of hospitals to reach out
to. The meetings will be scheduled for southeast Colorado between Sept. 29-Oct. 1:
o Saint Thomas More – Canon City
o San Luis Valley MC – Alamosa
o Arkansas Valley MC – La Junta
o Prowers Medical Center – Lamar
o Evans Army Hospital – Ft Carson
We have received a grant through CDPHE to visit their sites. The purpose of the CPCC
visit is to introduce the work of the council, become acquainted with their regional
providers, and to share data specific to their regions with comparative data from regions
throughout the state. Representatives from the council, which include Maternal-Fetal
Medicine, Obstetrics, Nurse-Midwifery, Neonatology and a Maternal Health
Specialist from the CDPHE, would like to visit their facility. CDPHE Maternal Mortality
Review Committee Members who are interested in joining CPCC on these site visits are
Kent Heyborne, MD, Amy Nacht, MSN, CNM, Jessica Anderson, MSN, CNM, WHNPBC, and Torri Metz, MD. It will be a 2-3 hour site visit that will cover MMR info, OB
and neonatal topics, discussions around what their needs are, and our outreach and
collaborative efforts. CPCC has also requested an additional grant from March of Dimes
to provide formal outreach initiatives. For example, when Level I hospitals come to a
CPCC meeting, CPCC will reimburse their expenses from the grant money. We are also
exploring opportunities with CHA regarding quality outcomes in areas of common
interest and possible grant opportunities.
g. Conference Calendar: Please send Heather any 2014 conferences from your organization or
in your community
The following summaries are from the presentations from the May 16, 2014 meeting:
I. Colorado Department of Public Health & Environment Update
Presented by: Tista Ghosh, MD, MPH, Deputy Chief Medical Officer and Director, Disease Control &
Environmental Epidemiology Division (DCEED)
Dr. Ghosh began her presentation discussing the history of medical marijuana in Colorado. In
November 2000, Amendment 20 was passed and a registry was established in July 2001. The Ogden
Memorandum was published in October 2009 and the commercial production and distribution began in
2010 under HB 10-1284 and SB 10-109. Dr. Ghosh reviewed the medical marijuana registry and shared
some data regarding the active patients on the Colorado Medical Marijuana Registry from 2009-2014.
She shared that 67% of them are male and the average age is 41. She shared that a medical marijuana
research program was authorized in 2014 and grants to fund research regarding the efficacy of marijuana
as part of the medical treatment were initiated. She then reviewed the history of retail marijuana in
Colorado since Amendment 64 was passed. C.R.S. Sec. 25-1.5-111 specifically designated a role for
CDPHE. It outlined specific duties which include "Monitor changes in drug use patterns, broken down
by county and race and ethnicity, and the emerging science and medical information relevant to the
health effects associated with marijuana use.” It also stated that "The Department shall appoint a panel
of health care professionals with expertise in cannabanoid physiology to monitor the relevant
information. The panel shall:
• Provide a report by 1/31/15 and every 2 years thereafter*
• Establish criteria for 1) studies to be reviewed, and 2) reviewing studies and other data*, and
•
Make recommendations, as appropriate, for policies intended to protect consumers of
marijuana or marijuana products and the general public*. (*no required duties until funding
is secured)
Dr. Ghosh then discussed legal marijuana and public health issues and provided an overview of the
Governance of Recreational Marijuana-Related Activities at CDPHE. She shared some specific
concerns for legal marijuana, including marijuana contamination literature reports, high potency
marijuana, increase in unintentional poisonings, prevention among youth and pregnancy/breastfeeding.
Dr. Ghosh shared several educational resources that can be found on their website at
www.colorado.gov/marijuana and reviewed the CDPHE monitoring activities. She discussed that the
PRAMS 2014 survey asks the question if a woman used marijuana or hashish during certain time
periods in her pregnancy. CDPHE is working with Denver Health to develop standard screening
questions on the frequency and method of use of marijuana and will match the data to the birth defects
registry. Dr. Ghosh identified the members of the Retail Marijuana Public Health Advisory Committee.
She reviewed their literature and evidence review strategies and summarized the findings. The
committee has determined some initial approved public health messages:
• There is no known safe amount of marijuana use during pregnancy.
• THC can pass from mother to the unborn child through the placenta.
• The unborn child is exposed to THC used by the mother.
• Maternal use of marijuana during pregnancy is linked with negative effects on exposed
children.
• There are negative effects of marijuana use during pregnancy regardless of when it is used
during pregnancy.
• THC can also be passed from the mother’s breast milk, potentially affecting the baby.
Dr. Ghosh concluded her presentation with a discussion of the next steps including developing
prevention messaging, continuing to collect and analyze surveillance data and reporting on data/trends
as they become available. A copy of Dr. Ghosh’s presentation can be found on the CPCC website.
II. Building a statewide, population-based, perinatal health improvement collaborative
Presented by: Ed Donovan. MD, Retired Neonatologist, CPCC Consultant
Dr. Donovan began his presentation by defining the principles that drive the vision/mission collaborative
efforts. These include:
• Primary focus on population health: denominator
• Relentless attention on short-term results
• “One cannot improve without measurement”
• Transparency
• Public – Private Partnership
• Trusted, respectful leadership
He then reviewed what it takes to build a successful, statewide, perinatal improvement collaborative and
reviewed each of the following points in detail:
• Population-based, rapid-response data system [CDPHE]
• Well-connected, committed, clinical leadership in both obstetrics and pediatrics
• Access to one or two years of baseline data [CDPHE]
• Involvement of key state agencies & professional organizations [CPCC, CDPHE, MOD]
• Centralized administrative infrastructure [CPCC]
• Access to rigorous, improvement science expertise [?]
• Integration of community and academic providers
• Open to idea of transparent sharing of results
Dr. Donovan concluded his presentation by discussing the next steps regarding where CPCC should
start, including the creation of mission and vision statements, an organizational structure that represents
key stakeholders and key responsibilities, identification and communication with key stakeholders,
publicize widely and share examples. He challenged the group to choose a first project that is popular
and doable so that the group can stay focused. He stressed the importance of identifying QI expert
partners and developing a timeline and budget. Dr. Donovan emphasized the importance of sharing
early, small successes! A copy of Dr. Donovan’s presentation can be found on the CPCC website.
III. Marijuana in Pregnancy and Lactation: Weeding Out the Myths
Presented by: Laura Borgelt, PharmD, FCCP, BCPS, NCMP, Professor, University of Colorado,
Department of Clinical Pharmacy and Family Medicine
Dr. Borgelt began her presentation by polling the audience as to whether they knew someone who is
pregnant or breastfeeding and using marijuana for medical or recreational purposes. She then shared a
patient case and outlined how complicated the issues can be. She then provided an overview of the
pharmacology and the effects of cannabis exposure during pregnancy. Dr. Borgelt reviewed some of the
relevant literature and statistics, and reviewed how marijuana should be studied. She then reviewed 3
prospective longitudinal studies regarding the fetal development and birth outcomes. The studies
specifically looked at neonatal development, infant behavior, child behavior and cognitive development
and young adults through functional magnetic resonance imaging. She discussed that there are 3 routes
of administration: the lungs (vaporized or smoked), the gut (oral ingestion) and the skin (topical
application). Dr. Borgelt shared data that demonstrated the potency of seized marijuana in the US has
shown a 121% increase from 1998 – 2010. She then provided a summary of prenatal marijuana
exposure and reviewed the short term and long term effects of marijuana exposure as it relates to birth
outcomes. She then further reviewed a summary of human and animal studies. Dr. Borgelt also
summarized marijuana and breastfeeding studies. She reviewed that there also needs to be proper retail
marijuana labels. She reviewed CDPHE’s statement regarding “Is Marijuana Safe for Pregnant or
Breastfeeding Women?” The official statement is as follows:
“As with alcohol and cigarettes, there likely is no “safe” amount of marijuana use during
pregnancy. THC, the chemical in marijuana that makes a person “high,” can pass from mother to
the unborn child through the placenta. This means the unborn child is exposed to THC used by
the mother. Smoking also passes carbon monoxide to the unborn child, which disrupts the oxygen
supply and can result in growth issues, possible premature birth, miscarriage or stillbirth. There
is some evidence marijuana use during pregnancy can result in babies with low birth weight,
certain birth defects and symptoms similar to fetal alcohol syndrome. THC can also be passed
from the mother’s breast milk, potentially affecting the baby.”
Additional information can be found in the following link:
https://www.colorado.gov/pacific/sites/default/files/M_RM_Marijuana-Health-Effects-FAQs.pdf
Dr. Borgelt then provided some general recommendations:
1. Ask about the use of marijuana and consider screening in high-risk patients
2. Educate women about impact of cannabis during pregnancy and lactation and strongly advise
discontinuation or use harm-reduction approach
3. Offer drug services/counseling and/or cognitive behavioral therapy
4. Perform appropriate developmental milestones
5. Counsel about patient safety issues including keeping out of the reach of children and using
proper packaging and labeling of marijuana
6. Avoid second hand/passive exposure
7. Follow hospital policies and procedures
She finished her presentation by offering the following conclusions:
•
•
•
•
Marijuana most likely used more frequently than reported in pregnancy and lactation
No evidence of teratogenicity (birth defects)
Although inconsistent, clinical studies indicate prenatal exposure to heavy marijuana use may
have:
Little/no effect in early infancy
•
•
•
Some specific cognitive or behavioral outcomes in childhood
Altered executive function in adolescence
Marijuana should be regarded as harmful to the developing fetus and breastfeeding infant
A copy of Dr. Borgelt’s presentation can be found on the CPCC website.
IV. Community Experts: A panel discussion regarding the issues of marijuana
Moderated by: Steve Holt, MD, CPCC Chairman
Hot topics were discussed and questions were invited and answered from the panel. Dr. Holt reiterated
that this will be the first of many discussions that will be occurring within CPCC, and that CPCC is
considering forming a Marijuana Task Force or Sub-Committee that will continue to address these
ongoing issues in partnership with other hospitals and organizations.
Panel Experts:
Laura Borgelt, PharmD, FCCP, BCPS, NCMP
Professor, University of Colorado, Department of Clinical Pharmacy and Family Medicine
Tista Ghosh, MD, MPH
Deputy Chief Medical Officer and Director, Disease Control & Environmental Epidemiology Division (DCEED),
Colorado Department of Public Health and Environment (CDPHE)
Sarah Rasche, MSW
Social Work Care Manager, Center for Women & Infants, Saint Joseph Hospital
Carol Wallman, NNP-BC
Poudre Valley Hospital – University North
Kathryn Wells, MD, FAAP
Medical Director, Denver Health Clinic at the Family Crisis Center
President, Colorado Chapter of the American Academy of Pediatric
Jade Woodard
Executive Director, Colorado Alliance for Drug Endangered Children
Rachel Wright, MD
Interim Director of Newborn Services, Denver Health Medical Center Instructor, Department of Pediatrics,
Section of Neonatology University of Colorado School of Medicine
The meeting was adjourned. The next CPCC meeting is scheduled for September 26, 2014 at Estes
Park Medical Center in Estes Park, CO from 1pm – 4pm.
Respectfully Submitted,
Heather Hagenson, CPCC Coordinator