From the Guidelines
Morphine should not be the first-line treatment for pain during pregnancy, and its use should be carefully considered and monitored due to potential risks to the fetus and mother. According to the most recent and highest quality study, 1, nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen are recommended as first-line treatments for pain after a routine vaginal birth or cesarean delivery, unless contraindicated. A short course of low-dose opioids, such as morphine, can be considered for severe pain that is not managed effectively by nonopioid options. However, the use of morphine during pregnancy can lead to respiratory depression in newborns if used near delivery, and long-term use may result in neonatal abstinence syndrome.
Some key points to consider when managing pain during pregnancy include:
- Screening for substance use disorder, including opioid use disorder (OUD), at the first prenatal visit using a validated questionnaire, such as the National Institute on Drug Abuse (NIDA) Quick Screen Tool 1.
- Using a multimodal approach to manage postpartum pain, starting with nonopioid pain relief, and considering a full opioid agonist, such as fentanyl or hydromorphone, if pain persists for more than 24 hours 1.
- Encouraging neuraxial analgesia during labor and considering a transversus abdominis plane field block for postoperative analgesia after cesarean delivery 1.
- Carefully weighing the benefits and risks of opioid use during pregnancy and considering alternative pain management strategies, such as acetaminophen or physical therapy, before prescribing morphine or other opioids.
It is essential to note that the management of pain during pregnancy requires a multidisciplinary approach, and healthcare providers should be aware of the potential risks and benefits of opioid use in this population. Any pregnant woman currently taking morphine or considering its use should discuss this with her healthcare provider to weigh individual risks and benefits based on her specific medical situation and stage of pregnancy.
From the FDA Drug Label
Prolonged use of opioid analgesics during pregnancy can cause neonatal opioid withdrawal syndrome [see Warnings and Precautions (5. 4)] There are no available data with morphine sulfate tablets in pregnant women to inform a drug-associated risk for major birth defects and miscarriage. In published animal reproduction studies, morphine administered subcutaneously during the early gestational period produced neural tube defects Based on animal data, advise pregnant women of the potential risk to a fetus.
Morphine is not recommended for use in pregnant women, especially during and immediately prior to labor, due to the potential risk of neonatal opioid withdrawal syndrome and other fetal/neonatal adverse reactions. The use of morphine during pregnancy may cause:
- Neonatal opioid withdrawal syndrome
- Respiratory depression in neonates
- Neural tube defects (in animal studies)
- Growth retardation (in animal studies)
- Increased incidence of abortion (in animal studies)
Key considerations:
- Prolonged use of opioid analgesics during pregnancy can cause physical dependence in the neonate
- Monitor neonates exposed to opioid analgesics during labor for signs of excess sedation and respiratory depression
- Opioid antagonist, such as naloxone, must be available for reversal of opioid-induced respiratory depression in the neonate 2 2
From the Research
Analgesics in Pregnancy
- The use of analgesics, including opioids, during pregnancy is common, with over 60% of women self-reporting their use 3.
- However, the safety of opioid use in pregnancy is a concern, and providers must weigh the benefits to the mother against the risks to the fetus 4.
- Morphine is one of the opioids that may be used in pregnancy, but its use should be carefully considered and monitored 3, 4.
Safety of Morphine in Pregnancy
- There is limited research on the pharmacokinetic changes of morphine in pregnancy, making it difficult to determine the optimal dose and safety profile 3.
- However, studies suggest that opioids, including morphine, may be necessary for some patients in pregnancy, and providers should be prepared to manage their use 4.
- The American Journal of Perinatology provides guidance on the use of opioids in pregnancy, including morphine, and emphasizes the importance of individualized care and counseling 4.
Alternatives to Opioids in Pregnancy
- Nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen may be effective alternatives to opioids for pain management in pregnancy 5.
- However, these agents also carry risks, and their use should be carefully considered and monitored 3, 5.
- Combination therapy using a small amount of opioid with a nonopioid pain reliever may be an effective and safer alternative for acute pain management 5.