Abstract
The rise in pregnancy-related overdose deaths has been driven by the use of high-potency illicitly-manufactured synthetic opioids including fentanyl. Xylazine, a veterinary sedative, is increasingly noted as a common adulterant in the United States illicit opioid supply. Exposure to the xylazine-fentanyl combination has been associated with severe harms including sedation, necrotic wounds, and symptoms of xylazine withdrawal. Due to limited data that directly addresses the risks of xylazine exposure during human pregnancy, we conducted a narrative review to summarize the available evidence about the clinical implications of xylazine exposure in pregnancy drawing from evidence from animal models, the general adult population, and the authors' clinical experiences. Because xylazine exposure presents unique risks to pregnant persons, management of xylazine exposure and related clinical sequelae in pregnant persons warrants nuanced clinical management. Further, additional research is critically needed to develop best practice guidelines related to the management of co-occurring xylazine-opioid exposure during pregnancy including harm reduction strategies to reduce exposure risk during pregnancy.