From the Guidelines
Pain management for pregnant patients should prioritize non-pharmacological approaches first, followed by the safest medications when necessary, with acetaminophen being the preferred initial pharmacologic treatment. According to the most recent and highest quality study 1, for pain management in the postpartum period, acetaminophen or NSAIDs are recommended, and if needed, adding an opioid. The American College of Obstetricians and Gynecologists (ACOG) recommends stepwise, multimodal, shared decision-making, incorporating pharmacologic treatments that might include opioids.
Some key points to consider in pain management for pregnant patients include:
- Non-pharmacological approaches such as physical therapy, massage, heat/cold therapy, acupuncture, and relaxation techniques are valuable first-line options.
- Acetaminophen is generally considered the safest pain medication during pregnancy, with a recommended dosage of 650-1000 mg every 6 hours, not exceeding 4000 mg daily.
- For more severe pain, certain opioids like codeine or oxycodone may be used for short durations under close medical supervision.
- NSAIDs such as ibuprofen and naproxen should be avoided, especially in the third trimester, as they can cause complications including premature closure of the fetal ductus arteriosus.
- Pregnant patients should always consult their healthcare provider before taking any medication, as recommendations may vary based on gestational age, medical history, and the specific pain condition.
It's also important to note that for women with opioid use disorder (OUD), maintenance therapy with methadone or buprenorphine should be continued, and the patient should be maintained on her baseline dosage of opioids postoperatively 1. Additionally, non-opioid scheduled multimodal analgesics should be ordered, with as-needed oral opioids available to the woman.
The goal is to balance effective pain relief for the mother while minimizing potential risks to the developing fetus, using the lowest effective dose for the shortest duration necessary.
From the FDA Drug Label
Pregnancy Teratogenic Effects Pregnancy Category C There are no adequate and well-controlled studies in pregnant women Hydrocodone Bitartrate and Acetaminophen Tablets should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus
Pregnancy: May cause fetal harm.
Fetal Toxicity Inform pregnant women to avoid use of ibuprofen tablets and other NSAIDs starting at 30 weeks gestation because of the risk of the premature closing of the fetal ductus arteriosus
The recommended pain management options for pregnant patients are limited.
- Acetaminophen is generally considered safe for use during pregnancy, but it is essential to use it under the guidance of a healthcare provider.
- Ibuprofen should be avoided after 30 weeks of gestation due to the risk of premature closure of the fetal ductus arteriosus.
- Opioids, such as hydrocodone and oxycodone, should be used with caution and only when the potential benefits outweigh the risks, as they can cause physical dependence in the neonate and neonatal opioid withdrawal syndrome. It is crucial to consult a healthcare provider before taking any medication during pregnancy to determine the best course of treatment for managing pain. 2, 3, 4
From the Research
Pain Management Options for Pregnant Patients
Pregnant patients have limited options for pain management due to the potential risks associated with various medications. The following are some of the recommended pain management options:
- Acetaminophen (paracetamol) is widely used for mild to moderate pain and fever relief 5, 6, 7, 8
- Ibuprofen may be used for postpartum pain management, but its effects on postpartum hypertension are still being studied 9
- Opioid analgesics may be used for breakthrough pain, but their use should be limited due to potential risks 9
Precautions and Recommendations
When using pain medications during pregnancy, the following precautions and recommendations should be considered:
- Acetaminophen should be used at the lowest effective dose and for the shortest possible time 5, 6, 7
- Pregnant women should be cautioned against using acetaminophen unless medically indicated 5
- Ibuprofen may not be suitable for women with postpartum hypertension, and its use should be monitored closely 9
- Health care providers should inform pregnant women about the potential risks and benefits of pain medications and help them make informed decisions 6
Potential Risks and Complications
The use of pain medications during pregnancy may be associated with potential risks and complications, including: