This health topic is an expert opinion about use of fentanyl during pregnancy and lactation.
* The information provided is the expert opinion of the First Exposure Medical Advisors. It is for informational purposes only and does not replace medical care and advice from a healthcare provider. Please contact your healthcare provider if you have any concerns or wish to discuss any questions that you believe may be relevant to you or your baby. In case of emergency, please go to the emergency room or call 911.
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Clinical scenario:
I was in a motor vehicle accident recently and having a lot of pain. I was recommended Fentanyl to treat my pain. I am currently nursing my child and planning for another pregnancy.
Is fentanyl safe for use during pregnancy and nursing?
Q. What is fentanyl?
A: Fentanyl is a type of opioid pain medication (analgesic). Other opioid pain medications include codeine, morphine, oxycodone, hydromorphone, and tramadol. Opioids are prescribed for the treatment of severe, acute (short term), or chronic (long term) pain. Fentanyl is stronger than other opioids and can be injected directly into a vein (intravenously, IV), injected in the muscle with a needle (intramuscularly), as dissolvable oral films, and through skin patches (transdermally). Skin patches are the most used forms outside of a hospital setting.
Q. Are opioids used to treat pain during pregnancy?
A. Pain during pregnancy, labour, and postpartum (period after birth) is common, and often requires various types of treatments. Fentanyl is sometimes used to treat severe labour pain or may be one of the drugs in the epidural. Patients should speak to their healthcare providers to determine which treatments are safest for use at specific times during pregnancy and after delivery.
Approximately 5 out of 100 pregnancies have exposure to prescription opioids, of which less than 1 in a hundred (<1%) are prescription fentanyl. Opioids are sometimes prescribed to treat severe pain that does not respond to other treatments.
Q. Can fentanyl be used while trying to get pregnant?
A. Studies have not been conducted to see if fentanyl use might make it harder to become pregnant. Chronic opioid use may impact the levels of sex hormones, which could impact the ability to get pregnant.
Q. Should people stop using fentanyl if they become pregnant?
A. Pregnant people using fentanyl, or other opioids, should contact their healthcare provider as soon as possible to discuss the risks and benefits. Pregnant people should not suddenly stop taking opioids due to risks of withdrawal. Abruptly stopping opioids can cause fetal distress, preterm birth (delivery before 37 weeks of pregnancy), or miscarriage. Talk to your healthcare provider about non-pharmacologic (not involving medications e.g. physiotherapy) options for pain management, using the lowest effective dose of opioids for the shortest possible duration, and safe ways to stop taking opioids, if possible.
Q. Does using fentanyl in pregnancy increase the chance of a miscarriage?
A. Miscarriage occurs in approximately 15-25% of all pregnancies (1 in 4 pregnancies). Specific studies have not been done to assess whether fentanyl increases the risk of miscarriage. Fentanyl is sometimes prescribed for severe pain or after a surgical procedure. In these cases, it is difficult to determine whether it is the drug or the underlying health condition or surgical procedure that might be associated with pregnancy loss.
Q. Does using fentanyl in pregnancy increase the chance of a birth defect?
A. The baseline risk of major birth defects in Canada is 3-5%. This means that 3-5 out of 100 babies born in the general population in Canada will be born with a major birth defect. Although fentanyl use in early pregnancy is not well studied, its safety is expected to be similar to that of other opioids. Some studies on opioids suggest use of opioids in the first trimester might be associated with an increased risk of birth defects, while other studies did not find an increased risk. It seems that if a risk exists it will be a small one.
Q. Does using fentanyl in pregnancy increase the risk of any other harmful outcomes?
A. Opioids cross the placenta and can increase the risk of health complications for infants exposed in utero (while in the uterus). While there is limited information specifically on fentanyl use in pregnancy, infants exposed to other opioids in utero, compared to unexposed infants, have a higher risk of stillbirth (loss of a baby before or during delivery), lower birthweight, preterm birth, and fetal growth restriction (e.g. smaller length and head size than expected for gestational age). However, most people with short-term opioid analgesic use in pregnancy have healthy pregnancies.
Q. Does fentanyl use during pregnancy result in any risks to the infant immediately postpartum?
A. Opioid use in pregnancy can lead to withdrawal symptoms in the baby, called neonatal abstinence syndrome (NAS). NAS presents shortly after birth up to 7 days postpartum, as opioids passed to the baby during pregnancy start to leave the infant’s body. Approximately 50% to 75% (50-75 out of a 100) of infants with prenatal (while in the uterus, before birth) opioid exposure develop NAS. Clinical symptoms of NAS include central nervous system irritability (e.g. persistent crying, difficulty sleeping, increased muscle tone), gastrointestinal dysfunction (e.g. feeding difficulties, vomiting), and autonomic nervous system activation (e.g. sweating, fever).
NAS is more common among infants with prenatal exposure to chronic opioid use, opioids close to the time of birth, and smoking. NAS has not been specifically studied among pregnancies exposed to fentanyl.
NAS is commonly treated with both non-pharmacologic approaches that prioritize the mother-infant bond (e.g. rooming-in) and pharmacologic approaches (e.g. oral morphine).
It is important for healthcare providers to be aware of opioid use in pregnancy, so they can monitor infants for symptoms of withdrawal.
Individuals interested on more information can see the Neonatal Abstinence Syndrome- A guide for caregivers with a newborn withdrawing from drugs and medications. Healthcare providers that are interested in more information can see the Canadian Pediatric Society Practice Point.
Q. Does fentanyl use during pregnancy result in any long-term risks to the child?
A. It is not known if prenatal fentanyl exposure is associated with long-term health complications. However, studies that have followed children with prenatal opioid exposure have identified an increased risk of pediatric mortality and a range of neurodevelopmental deficits (e.g. cognition, language, motor function, socio-emotional skills, visual impairments) compared to children without prenatal opioid exposure. However, it can be challenging to separate the effects of prenatal opioid exposure from factors associated with opioid use (e.g. low socio-economic status, polysubstance use). Findings are likely due to a combination of prenatal opioid exposure, biological, and environmental factors.
Nevertheless, it is essential that all pregnant/postpartum people who use opioids and their children have access to care to ensure all children with prenatal opioid exposure receive ongoing care, developmental screening, and early intervention to support child development.
Q. Can fentanyl be used while nursing?
A. When fentanyl is used epidurally or intravenously immediately during, or after delivery, quantities of drug ingested by the newborn through breastmilk are small and are not anticipated to harm the newborn. However, newborns may take longer to clear the fentanyl from their system. Therefore, for patients that use fentanyl beyond the first few days after delivery, while providing their breastmilk to an infant, it is recommended to watch the baby for signs of increased sleepiness (more than usual), difficulty feeding, breathing difficulties, or limpness. If any of these occur a healthcare provider should be contacted immediately.
Q. Advice for specific health populations?
A. It’s estimated that up to 20% of people (20 out of a 100) who use prescription opioids for pain management develop an opioid use disorder. The recommended treatment during pregnancy, for those with an opioid use disorder, is opioid agonist therapy (e.g. methadone, buprenorphine, buprenorphine with naloxone). Studies show that pregnant people with opioid use disorder who receive treatment during pregnancy have increased rates of prenatal care, and improved maternal and infant outcomes (e.g. longer gestation, higher birth weights), compared to those who do not receive treatment. In addition, they are more likely to retain custody of their newborn, have reduced rates of unregulated opioid use, other drug use, criminal activity, and mortality. Your healthcare provider should work with you to ensure that you have access to harm reduction services, housing, and safe food supplies. For more information about harm reduction services, please click here Harm Reduction
The postpartum period can be a vulnerable time for people who use opioids. The first year postpartum, specifically late postpartum (7-12 months after birth), is associated with higher rates of opioid toxicity and death. As such, it is important to ensure continuity of comprehensive care, including treatment for opioid use disorder, from pregnancy through postpartum to prevent opioid-related harm.
Q. What about the street use of fentanyl?
A. Fentanyl and drugs similar to fentanyl, such as carfentanil, can also be made and sold through the street supply. These types of fentanyl can be extremely dangerous due to their strength. Depending on where you live, and who your supplier is the amount of fentanyl in fentanyl sold through the street supply may vary widely and include other substances such as benzodiazepines, substances similar to fentanyl (possibly much stronger veterinary tranquilizers), amphetamines, methamphetamine, and/or other fillers. It is not possible to comment on the safety of fentanyl purchased through the street supply without knowing the identity of contaminating substances. For this reason, the information provided above on the safety in pregnancy and while nursing is for the use of fentanyl as prescribed by your health care provider.
Using drugs beyond what your clinician prescribes during pregnancy or parenting in a way that harms you or your baby may result in a community member or care provider contacting child protective services. Please click here Harm Reduction for additional information.
Q. Are there special considerations to be aware of?
A. Providing high quality care, both before and after birth, requires an understanding of the complicated health and social needs of people who use opioids in pregnancy. These include elevated rates of coexisting mental illness, polysubstance use, chronic disease, poverty, unstable housing, and histories of trauma and violence. Pregnancy is an important opportunity to identify and address these needs, in addition to substance use disorders, through screening all pregnant patients and coordinating comprehensive care (addressing the range of issues they are facing). Easy to access comprehensive care coordinated around obstetrical, clinical, and psychosocial needs is recommended. Comprehensive care can improve health outcomes for people who use opioids in pregnancy and their children. For more information on caring for patients with perinatal substance use, please see The Society of Obstetricians and Gynaecologists of Canada clinical practice guidelines.
Pregnant people who use substances often face barriers to accessing healthcare, including stigma, discrimination, judgement from healthcare practitioners, and fear of child welfare services. Providing non-judgmental, flexible care is one way for healthcare providers to encourage pregnant people to seek appropriate care. For more information on how to provide culturally safe and trauma-informed addictions care, please see the Mothering and Opioids Toolkit developed by the BC Centre of Excellence for Women’s Health.
Key References:
American Psychiatric Association. Opioid Use Disorder. Washington, D.C.: American Psychiatric Association; 2022 [updated December 2022. Available from: https://www.psychiatry.org/patients-families/opioid-use-disorder.
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Bowie AC, Werler MM, Velez MP, Li W, Camden A, Guttmann A, et al. Prescribed opioid analgesics in early pregnancy and the risk of congenital anomalies: a population-based cohort study. Cmaj. 2022;194(5):E152-e62.[PMID: 35131753].
Brogly SB, Velez MP, Werler MM, Li W, Camden A, Guttmann A. Prenatal Opioid Analgesics and the Risk of Adverse Birth Outcomes. Epidemiology. 2021;32(3):448-56.[PMID: 33625160].
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Disclaimer
First Exposure does not offer health care treatment. If you have an urgent question about your pregnancy or your baby’s health, you should contact your health care provider directly. If you don’t have a health care provider and you live in Ontario, you have a variety of health care options. In the case of an emergency, visit a hospital emergency room or call 911.