From the Guidelines
For a pregnant patient in labor with a history of anaphylaxis to Percocet (oxycodone) and Tramadol, fentanyl is a recommended alternative opioid for pain control, as it belongs to a different chemical class and can provide effective pain relief with minimal risk of cross-reactivity. According to the American Journal of Obstetrics and Gynecology 1, opioid-dependent women, including those with a history of substance use disorders, can benefit from neuraxial labor analgesia, such as epidural or combined spinal-epidural, which has been found to be highly effective in managing labor pain.
Some key points to consider when managing pain in this patient population include:
- Continuing daily doses of maintenance medication, such as buprenorphine or methadone, to prevent acute withdrawal and manage underlying pain conditions 1
- Avoiding opioid agonist/antagonists, such as nalbuphine or butorphanol, which can precipitate opioid withdrawal 1
- Using a multimodal approach to manage postpartum pain, which may include systemic opioids like fentanyl or hydromorphone if needed 1
- Monitoring patients closely for signs of withdrawal, respiratory depression, and allergic reactions, particularly in the labor setting
In terms of specific medication options, fentanyl is a suitable alternative to oxycodone and tramadol, given its different molecular structure and effectiveness in managing acute pain. The dosage and administration of fentanyl can be tailored to the individual patient's needs, with typical doses ranging from 50-100 mcg IV every 1-2 hours. Patient-controlled analgesia (PCA) is also an option, with fentanyl settings of 10-20 mcg bolus with 6-minute lockout. Close monitoring and emergency preparedness are essential when administering any opioid to a patient with a history of severe drug reactions.
From the FDA Drug Label
If concomitant use is warranted, carefully observe the patient, particularly during treatment initiation and dose adjustment Consider discontinuing Remifentanil hydrochloride for injection if patient is not responding appropriately to treatment and institute alternative analgesic treatment. Examples: butorphanol, nalbuphine, pentazocine, buprenorphine
Alternative opioids that can be used for pain control in a pregnant patient in labor with a history of anaphylaxis to Percocet (oxycodone) and Tramadol are:
- Butorphanol
- Nalbuphine
- Pentazocine
- Buprenorphine 2
From the Research
Alternative Opioids for Pain Control in Pregnant Patients
In a pregnant patient in labor with a history of anaphylaxis to Percocet (oxycodone) and Tramadol, alternative opioids can be considered for pain control.
- Fentanyl is a potential alternative, as it has been shown to be effective in labor pain management 3.
- The study by 3 compared subcutaneous and intravenous fentanyl for labor pain management and found that both routes of administration significantly decreased labor pain.
- Another study by 4 evaluated the safety and analgesic efficacy of patient-controlled intravenous analgesia with tramadol, but given the patient's history of anaphylaxis to Tramadol, this option may not be suitable.
Considerations for Anaphylaxis in Pregnancy
When managing pain in a pregnant patient with a history of anaphylaxis, it is essential to consider the risk of anaphylaxis during pregnancy.
- A study by 5 found that the incidence of anaphylaxis during pregnancy was 3.8 per 100,000 hospitalizations, and that cesarean delivery and history of allergic reaction were risk factors for anaphylaxis.
- Another study by 6 estimated the frequency of anaphylaxis during maternity to be 1.5 to 3.8 per 100,000 pregnancies, and found that beta-lactam antibiotics, latex, and anesthetic agents were common causes of anaphylaxis during pregnancy.
- The management of anaphylaxis during pregnancy should include prompt injection of epinephrine, provision of high-flow supplemental oxygen, and maintenance of adequate maternal blood pressure 7.