Women of childbearing age

The Opioid Prescribing Work Group (OPWG) reached consensus to develop opioid prescribing recommendations specific to women of childbearing age. Given the potential risk of maternal opioid use to both the mother and the baby, the work group determined that it was important to specifically address this population.

Prescription opioid use is common in pregnant women, and is strongly associated with neonatal complications. Providers should avoid prescribing opioids to pregnant women, and prescribe with caution when it is necessary. In addition, universal screenings of substance use should be part of comprehensive obstetric care. Conduct screenings with validated assessment tools, when available.

Clinical recommendations

Assess pregnancy risk in all women of childbearing age prior to prescribing an opioid.
Avoid prescribing opioids to pregnant women. Educate pregnant women about the known risks of opioids to both the mother and the fetus.
If opioids are prescribed to a pregnant woman for acute pain, prescribe the lowest dose and duration appropriate.
Prescribe no more opioids than will be needed for initial tissue recovery following a cesarean section or complicated vaginal birth. Consider prescribing 100 morphine milligram equivalents (MME) when opioid therapy is prescribed.
Provide proper pain control to lactating women experiencing acute pain following birth and surgical procedures. If opioids are prescribed to lactating women for acute pain, check an evidence-based resource (for example, LactMED on the NCBI webpage) for preferred opioid types and prescribe the lowest dose and duration adequate to manage the pain.
Monitor reproductive health in all women of childbearing age who receive chronic opioid analgesic therapy (COAT) or medication-assisted treatment (MAT). Provide family planning services and counsel women on using effective contraception while on COAT or MAT. Effective contraception is the primary way to prevent unintended pregnancy and risk of delivering a baby with Neonatal Abstinence Syndrome (NAS) or Neonatal Opioid Withdrawal Syndrome (NOWS).

Resources

Opioid Use and Opioid Use Disorder in Pregnancy. ACOG Committee Opinion No. 711. American College of Obstetricians and Gynecologists.

Discussion

Maternal opioid use is associated with pregnancy-related maternal and fetal morbidity and mortality. Babies exposed to opioids in utero are likely to develop symptoms of Neonatal Abstinence Syndrome (NAS) or Neonatal Opioid Withdrawal Syndrome (NOWS). NAS or NOWS are terms used to represent the pattern of clinical findings typically associated with opioid withdrawal in newborns.

The Minnesota Department of Human Services conducted a study in 2014 to determine trends and levels of opiate exposed newborns in the Minnesota Health Care Programs (MHCP) population. Analysis of the MHCP population found that:

Diagnosed neonatal opiate withdrawal use has risen from 0.04% of all births in 2010, to 1.0 % in 2014.
The per-capita rate for opiate abuse diagnosis in pregnancy is one and a half times greater in rural Minnesota than in the seven-county metro area.
Only 50% of NAS newborns were born to moms with a noted diagnosis of opiate dependency, implying that providers were unaware of the exposure.
30% of NAS newborns were born to moms who received MAT, while 70% of such newborns had moms who did not receive this standard treatment for opiate dependency in pregnancy.
24% of NAS newborns are born premature.
Mothers of NAS newborns are 12 times more likely to have not received any prenatal care.
Over half of all NAS newborns are white and over a quarter are American Indian.
More than one in ten pregnancies among American Indian women have a diagnosis of opiate dependency or abuse.
Compared to whites, American Indian women are more than 8 times more likely to be diagnosed with maternal opiate dependency and more than 7 times more likely to give birth to a NAS newborn.

Clinicians should consider pregnancy risk in all women of childbearing age prior to prescribing opioids. Given that many pregnancies are unplanned, assessment of pregnancy risk should be included in the overall biopsychosocial assessment.

Acute pain in pregnant women and lactating women

Pain during pregnancy and following childbirth is common. However, it is beyond the scope of the OPWG to make specific recommendations about non-opioid pain management options. Prescribe the lowest dose and duration appropriate when a pregnant woman experiences acute pain and the benefit of using an opioid outweighs the risk to the woman and fetus. Educate the women about the risks and unknown effects of opioids when pregnant, to both the mother the fetus.

Consider prescribing 100 MME when prescribing opioids to women following a cesarean section. Two recent studies analyzing the patterns of opioid prescribing and opioid use following a cesarean section found that most women are prescribed opioids in excess of the amount needed (Osmundson, 2017; Bateman, 2017). A survey of women who underwent cesarean sections at six academic health centers in the U.S. found that the median number of tablets prescribed was 40, and the median number of tablets consumed was 20 (Bateman, 2017). This suggests that post-discharge opioid prescribing to women who underwent a cesarean section can be aligned with acute pain opioid prescribing recommendations (100 MME total prescription).

If opioids are prescribed to lactating women for acute pain, prescribe the lowest dose and duration adequate to manage the pain. The American College of Obstetricians and Gynecologists (ACOG), the Society for Maternal-Fetal Medicine (SMFM), the Academy of Breastfeed Medicine (ABM) and the American Academy of Pediatrics cautions against the use of codeine and tramadol for lactating women (ACOG, 2017). Recommended opioids for lactating women—based on lower rates of excretion into breast milk--include hydromorphone and oral morphine. Consult NCBI’s LactMed webpage for current and comprehensive information about the secretion of specific opioids into breastmilk.

Encourage breastfeeding for women using opioids to manage acute pain following delivery and surgical procedures, but provide education about how to minimize opioid exposure in the baby. Educate the mother and other caregivers to monitor the baby for excess sedation, constipation and failure to achieve weight milestones.

Pregnant women and chronic opioid analgesic therapy (COAT)

Clinicians should not initiate COAT in pregnant women. Opioid therapy for pain during pregnancy has been associated with stillbirth, poor fetal growth, pre-term delivery, neonatal abstinence syndrome or neonatal opioid withdrawal syndrome and birth defects (CDC, 2016b). For women of childbearing age on COAT, clinicians should carefully monitor reproductive health. This may include, but is not limited to: contraceptive counseling; prevention, diagnosis and treatment of sexually transmitted infections (STI); and options counseling for unintended pregnancies.

Clinicians caring for pregnant women on COAT should access appropriate expertise if considering tapering opioids due to the possible risk to the pregnant woman and fetus if the woman goes into withdrawal (CDC, 2016a). Clinicians should routinely screen all pregnant women receiving COAT for opioid use disorder (OUD), using a brief validated assessment tool.

For pregnant women who develop OUD, MAT with buprenorphine or methadone has been associated with improved maternal outcomes (ACOG, 2017). Abrupt discontinuation of opioids during pregnancy can result in premature labor, fetal distress and miscarriage. Because NAS is treatable, MAT is recommended instead of withdrawal or abstinence (Jones, 2008). Offer the patient MAT, or refer to a MAT provider. The use of MAT, in combination with counseling and behavioral therapies, and access to a range of supportive services, such as housing and employment services, assists the mother in achieving a more stable life. MAT also stabilizes the intrauterine environment and avoids subjecting the fetus to repeated episodes of withdrawal, which places the fetus at higher risk for morbidity and mortality.

Providers caring for pregnant women with OUD should arrange for delivery at a facility prepared to monitor, evaluate for and treat NAS (CDC, 2016a). Studies suggest that somewhere between 30-80% of newborns exposed to opioids in utero develop symptoms of NAS/NOWS. A multi-site, randomized clinical trial found that among women maintained on methadone or buprenorphine, 53% of the infants born required treatment for NAS (Kaltenbach, 2017). The range and severity of the symptoms experienced by the infant depends on a variety of factors, including the type of opioid the infant was exposed to and whether the infant was exposed to multiple substances. Treatment of NAS includes non-pharmacologic and pharmacological methods.