Is oxycodone (opioid analgesic) contraindicated in pregnancy?

Oxycodone in Pregnancy: Safety Considerations and Recommendations

Oxycodone is not absolutely contraindicated in pregnancy but should be used with extreme caution due to significant risks to both mother and fetus, including neonatal opioid withdrawal syndrome.

Risks of Oxycodone Use During Pregnancy

FDA Labeling and Warnings

• The FDA label explicitly states that prolonged use of oxycodone during pregnancy can result in neonatal opioid withdrawal syndrome (NOWS), which may be life-threatening if not recognized and treated 1
• Oxycodone crosses the placenta and may produce respiratory depression and psycho-physiologic effects in neonates 1
• Animal studies show potential neurobehavioral effects in offspring when oxycodone is administered during gestation 1

Trimester-Specific Risks

• Second trimester exposure is associated with:
  • Reduction in average length of gestation
  • Decreased birth weight
  • Increased risk of very preterm birth (<32 weeks)
  • Higher rates of admission to special care nursery 2
• Third trimester exposure is associated with:
  • Reduction in average length of gestation
  • Risk of neonatal opioid withdrawal syndrome 2

Clinical Recommendations for Pain Management in Pregnancy

Non-Opioid Options (First-Line)

• Begin with non-pharmacological interventions:
  • Physical therapy
  • Exercise
  • Proper postural hygiene
  • Heat or cold therapy 3
• For pharmacological management, use acetaminophen as first-line:
  • Dosage: 650 mg every 6 hours or 975 mg every 8 hours (maximum 3000-4000 mg daily) 3
• Consider NSAIDs for short-term use (7-10 days) ONLY during the second trimester:
  • Ibuprofen 600 mg every 6 hours 3
  • Strongly contraindicated in first and third trimesters due to risk of congenital malformations and premature closure of the ductus arteriosus 3

Opioid Use in Pregnancy (Last Resort)

• Opioids, including oxycodone, should be reserved for severe pain unresponsive to other treatments 4, 3
• If opioids are deemed necessary:
  • Use the lowest effective dose for the shortest duration possible
  • Limit oxycodone to a maximum daily dose of 30 mg (or 6 5-mg tablets) 4
  • Monitor closely for signs of dependence or misuse
  • Inform patients about the risk of neonatal opioid withdrawal syndrome 1

Special Considerations for Cesarean Delivery

For post-cesarean pain management in opioid-naïve women:

1. Neuraxial morphine (or hydromorphone)
2. Scheduled acetaminophen and NSAIDs
3. Short course of oxycodone only if pain is poorly controlled with the above regimen
4. If opioids are needed at discharge, engage in shared decision-making to select the minimum necessary quantity (no more than 20 5-mg tablets of oxycodone) 4

Risk Factors and Monitoring

Risk Factors for Adverse Outcomes

• Strong opioid agonists (like oxycodone) have a 2-fold higher risk of causing NOWS compared to weak agonists 5
• Long half-life opioids show increased risk compared to short half-life products 5
• Maternal opioid levels at birth correlate with neonatal exposure 6

Monitoring Requirements

• For pregnant women receiving oxycodone:
  • Regular assessment for signs of dependence or misuse
  • Monitor for respiratory depression, especially during initiation or dose increases 1
• For neonates exposed to oxycodone in utero:
  • Monitor for signs of NOWS (irritability, hyperactivity, abnormal sleep patterns, high-pitched cry, tremor, vomiting, diarrhea, and failure to gain weight) 1
  • Have naloxone available for reversal of opioid-induced respiratory depression 1

Conclusion

While oxycodone is not absolutely contraindicated in pregnancy, its use carries significant risks to both mother and fetus. The decision to use oxycodone during pregnancy should follow a stepwise approach, with non-pharmacological methods and acetaminophen as first-line options, NSAIDs (in the second trimester only) as second-line, and opioids as a last resort for severe, unresponsive pain. When oxycodone is deemed necessary, use the lowest effective dose for the shortest duration possible with appropriate monitoring.