Considerations and risks
Before initiating opioid therapy for women who can become pregnant, clinicians and their patients should discuss potential effects of long-term opioid use. For all women with reproductive potential, it is important to discuss future pregnancy intentions and engage in shared decision-making regarding contraception, if appropriate.
The American College of Obstetricians and Gynecologists (ACOG) recommends balancing a cautious approach to prescribing opioids with the need to address pain, and that pregnancy should not be a reason to avoid treating acute pain.1
Clinicians and patients together should carefully weigh benefits and risks when making decisions about whether to initiate opioid therapy for pain during pregnancy (see Recommendation 8 of the 2022 Clinical Practice Guideline).
Opioid use during pregnancy might be associated with risks to both the pregnant woman and the fetus. Certain observational studies have shown an association of opioid use in pregnancy with:
- Stillbirth
- Poor fetal growth
- Preterm delivery
- Maternal death
In some cases, opioid use during pregnancy leads to neonatal opioid withdrawal syndrome.
For more information about potential health outcomes, visit About Opioid Use During Pregnancy.
Pain management during pregnancy
Acute Pain
When opioids are needed for treatment of acute pain in pregnant woman:
- The treatment should not be longer than the expected duration of pain severe enough to require opioids (see also Recommendation 6).
Chronic Pain
For pregnant women with chronic pain, ACOG recommends avoiding or minimizing the use of opioids for pain management. It highlights pain therapies such as
- Nonpharmacologic treatments (e.g., exercise, physical therapy, behavioral approaches)
- Nonopioid pharmacologic treatments
Pain management during the postpartum period
For pain management in the postpartum period, ACOG recommends stepwise, multimodal, shared decision-making, incorporating pharmacologic treatments that might include opioids.2
- Vaginal delivery: ACOG recommends acetaminophen or non-steroidal anti-inflammatory drugs (NSAIDs), and if needed, adding an opioid.
- Cesarean delivery: ACOG recommends standard oral and parenteral medications. Options include acetaminophen, NSAIDs, or low-dose, low-potency, short-acting opioids with use limited to the shortest reasonable course expected for treating pain.
ACOG recommends counseling about the risk of central nervous system depression for the postpartum woman and in the breastfed infant. If pain treatment includes codeine-containing medication, duration of therapy and neonatal signs of toxicity should be reviewed with patients and families.
Tapering
Clinicians should consult with experts in pain management or addiction medicine if considering tapering opioids during pregnancy. There are possible risks to both the woman and the fetus if the patient goes into withdrawal (see Recommendation 5).
OUD treatment during pregnancy
Early universal screening, brief intervention (e.g., short conversation, feedback and advice), and referral for treatment for pregnant women with OUD improve both maternal and infant outcomes.
- For pregnant women with OUD, medication for opioid disorder (MOUD) is preferred over withdrawal management via tapering.
- MOUD (buprenorphine or methadone) is the recommended therapy. It should be offered as early as possible in pregnancy to prevent harms to both the woman and the fetus (see also Recommendation 12).
- Keep in mind, changes occur in a pregnant woman’s body that may require dose adjustments, especially in the third trimester.
For more information on OUD please see:
Treating OUD after pregnancy
According to SAMHSA and ACOG, MOUD should be continued postpartum for women with OUD. The postpartum period is a time of increased vulnerabilities, as the demands of caring for the new baby, sleep deprivation, and threat of loss of child custody are potential triggers for return to use.3 Women with OUD return to use far more often in the postpartum period compared with during pregnancy.
Depression, anxiety, bipolar disorder, and posttraumatic stress disorder are more common among women with OUD.
- Screening for postpartum depression should be routine, and assessing for other co-occurring mental health conditions should be considered if there is a prior history or if concern exists.
- Additional caution and increased monitoring might lessen the increased risk for overdose among patients with depression (see Recommendation 7).
Monitoring newborns
Clinicians caring for pregnant women taking any opioids should arrange for delivery (i.e., childbirth) at a facility prepared to monitor, evaluate for, and treat neonatal opioid withdrawal syndrome. When travel to such a facility would present an undue burden on the patient, it is appropriate for the clinician to arrange to deliver locally, monitor and evaluate the newborn for neonatal opioid withdrawal syndrome, and transfer the newborn for additional treatment as needed.
Comprehensive coordinated care including the pediatrician, mental health specialists, and other hospital supports (e.g., social work and home-nurse visitation programs) is important to appropriately assess and assist families for the critical transition from the hospital or treatment facility to home after birth.4
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