What are the guidelines for using topical Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) in pregnancy?

From the Guidelines

Topical NSAIDs should be avoided during pregnancy, especially in the third trimester, due to potential risks to the developing fetus. The most recent and highest quality study, published in 2020 by the American College of Rheumatology, conditionally recommends against the use of NSAIDs in the third trimester because of the risk of premature closure of the ductus arteriosus 1. If pain management is necessary, topical diclofenac (Voltaren gel) has the most safety data but should only be used at the lowest effective dose for the shortest duration possible, and only after the first trimester. Application should be limited to small areas (less than 10% of body surface) to minimize systemic absorption.

• Key considerations for the use of topical NSAIDs during pregnancy include:
  • Mechanism of action: NSAIDs inhibit prostaglandin synthesis, which can potentially affect fetal development, particularly the cardiovascular system and kidneys.
  • Trimester-specific risks: In the third trimester, NSAIDs may cause premature closure of the ductus arteriosus or delay labor.
  • Alternative pain management options: For most mild to moderate pain during pregnancy, acetaminophen (Tylenol) remains the preferred first-line analgesic, with any pain medication use requiring healthcare provider consultation.
• The American College of Rheumatology guideline for the management of reproductive health in rheumatic and musculoskeletal diseases provides recommendations for medication use during pregnancy and breastfeeding, including the use of NSAIDs 1.
• It is essential to weigh the potential benefits and risks of NSAID use during pregnancy and to consider alternative pain management options to minimize fetal exposure and ensure the best possible outcomes for both mother and baby.

From the FDA Drug Label

Taking NSAIDs at about 20 weeks of pregnancy or later may harm your unborn baby If you need to take NSAIDs for more than 2 days when you are between 20 and 30 weeks of pregnancy, your healthcare provider may need to monitor the amount of fluid in your womb around your baby. You should not take NSAIDs after about 30 weeks of pregnancy. 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 If treatment with ibuprofen tablets is needed for a pregnant woman between about 20 to 30 weeks gestation, advise her that she may need to be monitored for oligohydramnios, if treatment continues for longer than 48 hours

The guidelines for using topical Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) in pregnancy are as follows:

• Topical NSAIDs are not explicitly mentioned in the provided drug labels, but the guidelines for oral NSAIDs can be applied with caution.
• Pregnancy risks: Taking NSAIDs at about 20 weeks of pregnancy or later may harm the unborn baby.
• Monitoring: If NSAIDs are needed for more than 2 days between 20 and 30 weeks of pregnancy, the healthcare provider may need to monitor the amount of fluid in the womb around the baby.
• Avoidance: NSAIDs should be avoided after about 30 weeks of pregnancy due to the risk of premature closing of the fetal ductus arteriosus.
• Oligohydramnios monitoring: If treatment with NSAIDs is needed between 20 and 30 weeks of pregnancy, the patient may need to be monitored for oligohydramnios if treatment continues for longer than 48 hours 2 2.

From the Research

Guidelines for Topical NSAIDs in Pregnancy

• There is limited information available on the use of topical Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) in pregnancy, as most studies focus on oral or systemic NSAID use 3, 4, 5.
• Oral NSAIDs are known to pose risks to the fetus, particularly in the third trimester, including renal injury, oligohydramnios, and constriction of the ductus arteriosus 3, 4.
• Topical medications, in general, are considered safer than oral or parenteral agents due to limited systemic absorption 6, 7.
• However, the safety profile of topical NSAIDs in pregnancy must be assessed cautiously due to the limited available data.
• It is recommended that NSAIDs be given in pregnancy only if the maternal benefits outweigh the potential fetal risks, at the lowest effective dose and for the shortest duration possible 4.
• As there is no specific information available on topical NSAIDs, it is essential to consult with a healthcare provider before using any medication during pregnancy.

Key Considerations

• The potential risks and benefits of using topical NSAIDs in pregnancy should be carefully evaluated 3, 4.
• The use of topical NSAIDs in pregnancy should be guided by the principles of minimizing fetal exposure and maximizing maternal benefits 4, 5.
• Healthcare providers should be consulted before using any medication, including topical NSAIDs, during pregnancy.