Is oxycodone safe for use during pregnancy?

Oxycodone Safety in Pregnancy

Oxycodone is not safe for routine use during pregnancy and should be avoided whenever possible, as it is associated with significant maternal and fetal risks including stillbirth, poor fetal growth, preterm delivery, birth defects, and neonatal opioid withdrawal syndrome. 1, 2

Key Risks to Mother and Fetus

Maternal and Fetal Complications

• Opioid use during pregnancy is associated with stillbirth, poor fetal growth, preterm delivery, and birth defects 1
• The FDA label explicitly warns that prolonged opioid use during pregnancy causes neonatal opioid withdrawal syndrome 2
• Second trimester oxycodone exposure specifically reduces gestational length by approximately 0.83 weeks and birth weight by 188 grams, with a 5-fold increased risk of very preterm birth (<32 weeks) 3
• Third trimester exposure reduces gestational length by 0.33 weeks 3

Neonatal Opioid Withdrawal Syndrome (NOWS)

• Presents with irritability, hyperactivity, abnormal sleep pattern, high-pitched cry, tremor, vomiting, diarrhea, and failure to gain weight 2
• Onset, duration, and severity vary based on duration of maternal use, timing and amount of last use, and rate of drug elimination in the newborn 2
• Newborns require monitoring and management for withdrawal symptoms 2

Clinical Decision-Making Algorithm

Before Initiating Oxycodone in Pregnancy

• Carefully weigh risks and benefits with the patient before initiating any opioid therapy for chronic pain during pregnancy 1
• Discuss family planning with all reproductive-age women before starting long-term opioid therapy and how it may affect future pregnancy 1
• Prioritize non-opioid alternatives aggressively 1

For Women Already Taking Opioids Who Become Pregnant

• Do NOT abruptly discontinue opioids - this poses risk to both mother and fetus through withdrawal 1
• Access appropriate expertise (pain specialist, maternal-fetal medicine) before considering tapering 1
• For women with opioid use disorder, offer medication-assisted therapy with buprenorphine or methadone, which has been associated with improved maternal outcomes 1

Delivery Planning Requirements

• Arrange delivery at a facility prepared to monitor, evaluate, and treat neonatal opioid withdrawal syndrome 1
• If travel to such a facility creates undue burden, deliver locally but ensure capability to monitor the newborn and transfer for additional treatment if needed 1
• Oxycodone is not recommended during or immediately prior to labor when other analgesic techniques are more appropriate 2

Labor and Delivery Considerations

• Opioids cross the placenta and produce respiratory depression and psycho-physiologic effects in neonates 2
• Have naloxone available for reversal of opioid-induced respiratory depression in the neonate 2
• Opioids can prolong labor by temporarily reducing strength, duration, and frequency of uterine contractions, though this may be offset by increased cervical dilation 2
• Monitor neonates exposed to opioids during labor for excess sedation and respiratory depression 2

Breastfeeding Considerations

Safety Profile

• Oxycodone is present in breast milk at variable concentrations 2
• Oxycodone requires caution during breastfeeding, with greater risk of infant drowsiness at maternal doses >40 mg/day 4
• Infants must be monitored for excess sedation, respiratory depression, decreased alertness, and feeding problems 2

Preferred Alternatives for Nursing Mothers

• Morphine is the preferred strong opioid for breastfeeding women, transferring to breast milk in small amounts with minimal infant exposure 4
• Dihydrocodeine is the preferred weak opioid due to cleaner metabolism 4, 5
• Avoid codeine entirely due to unpredictable CYP2D6 metabolism 4

Monitoring Requirements

• Observe infants for behavioral changes including sedation, drowsiness, respiratory depression, decreased alertness, and poor feeding 4
• Withdrawal symptoms can occur in breastfed infants when maternal opioid administration or breastfeeding is stopped 2
• High-risk infants (preterm, neonates, <6 weeks age) require extra caution 4

Critical Pitfalls to Avoid

• Never abruptly discontinue opioids in pregnant women already taking them - this creates withdrawal risk for both mother and fetus 1
• Do not prescribe codeine to nursing mothers due to unpredictable metabolism and risk of neonatal toxicity and death 1, 4
• Avoid co-sleeping when taking opioids, as maternal responsiveness to the infant may be inhibited 4
• The "pump and dump" method is unnecessary for breastfeeding mothers on opioids 4

Evidence Quality Note

While the FDA label notes that animal studies at doses 2.6-8.1 times human doses showed no teratogenicity 2, the most recent human cohort study (2023) demonstrates clear associations with adverse neonatal outcomes including preterm birth and reduced birth weight 3. The CDC guidelines appropriately emphasize the documented human risks over animal safety data 1.