What medications are safe for pain control in a pregnant patient?

From the Guidelines

Acetaminophen (Tylenol) is the safest first-line medication for pain control during pregnancy, recommended at a dose of 650-1000mg every 6 hours as needed, not exceeding 4000mg daily. For more severe pain, certain NSAIDs like ibuprofen (Advil, Motrin) may be used cautiously during the first and second trimesters at 400-600mg every 6 hours, but should be avoided in the third trimester due to risks of premature closure of the ductus arteriosus and potential bleeding complications 1. If pain persists, consult your healthcare provider about opioid options such as codeine or oxycodone, which may be prescribed for short-term use when benefits outweigh risks.

Key Considerations for Pain Management in Pregnancy

• Non-pharmacological approaches including physical therapy, massage, heat/cold therapy, and proper body mechanics should be incorporated into your pain management plan.
• The safety profile of medications changes throughout pregnancy, with the first trimester being most critical for organ development, so always inform your healthcare provider about your pregnancy before taking any medication, even over-the-counter options.
• For opioid-naïve women, nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen, unless contraindicated, should be given as first-line treatments for pain after a routine vaginal birth or cesarean delivery 1.
• Neuraxial analgesia during labor should be encouraged, and postpartum pain should be managed with a multimodal approach that starts with nonopioid pain relief 1.

Opioid Use in Pregnancy

• If pain persists, a short course of low-dose opioids can be considered for severe pain that is not managed effectively by nonopioid options 1.
• 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.
• Non-opioid scheduled multimodal analgesics should be ordered, with as-needed oral opioids available to the woman, and patient-controlled analgesia with a full agonist with strong affinity for the mu receptor, such as fentanyl or hydromorphone, may be considered for 24 hours 1.

From the FDA Drug Label

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 Prolonged use of opioid analgesics during pregnancy for medical or nonmedical purposes can result in physical dependence in the neonate and neonatal opioid withdrawal syndrome shortly after birth

Pregnancy: May cause fetal harm. Available data with oxycodone hydrochloride tablets in pregnant women are insufficient to inform a drug-associated risk for major birth defects and miscarriage. Prolonged use of opioid analgesics during pregnancy may cause neonatal opioid withdrawal syndrome

The FDA drug label does not answer the question of what medications are safe for pain control in a pregnant patient. Both hydrocodone and oxycodone have potential risks to the fetus and are not recommended for use during pregnancy unless the potential benefit justifies the potential risk. Key considerations include:

• Prolonged use of opioid analgesics during pregnancy can result in physical dependence in the neonate and neonatal opioid withdrawal syndrome
• Insufficient data on the safety of oxycodone in pregnant women
• Potential risk to the fetus with hydrocodone use It is essential to consult a healthcare professional to determine the best course of treatment for pain management in pregnant patients. 2 3

From the Research

Medications for Pain Control in Pregnant Patients

• Paracetamol (acetaminophen) is considered the agent of choice for mild to moderate pain in any stage of pregnancy 4, 5, 6
• Ibuprofen is the non-steroidal anti-inflammatory drug (NSAID) of choice, but its use is contraindicated after 28 weeks of gestation due to the increasing risk of premature closure of the ductus arteriosus and impairment of fetal kidney function 5, 7
• Opioids can be used for severe pain, but peripartum administration can lead to neonatal respiratory depression and adaptation disorders, and long-term therapy up to the end of pregnancy can lead to neonatal withdrawal symptoms 5, 7
• Sumatriptan can be used to treat migraine 5
• Antiepileptic drugs should not be taken during pregnancy due to the risk of teratogenicity, but well-studied antidepressants such as amitriptyline can be used for chronic pain with appropriate indications 5, 7
• Other medications that can be administered carefully in the event of pain include diclofenac, metamizole, and COX-2 inhibitors, although the latter is not recommended in the last trimester 7
• For neuropathic pain, amitriptyline, duloxetine, and venlafaxine are considered safe 7

Non-Pharmacological Treatment Concepts

• Transcutaneous electrical nerve stimulation (TENS therapy) is a non-pharmacological treatment concept available for pain management during pregnancy 7
• Kinesio tapes and acupuncture are also available as non-pharmacological treatment concepts 7
• Lymphatic drainage is recommended in cases of edema, if not caused by preeclampsia 7

Precautions and Recommendations

• Pregnant women should be cautioned to use paracetamol only when medically indicated, and to minimize exposure by using the lowest effective dose for the shortest possible time 4, 6
• Health care providers should inform pregnant women about the potential risks and benefits of using medications for pain control during pregnancy 4, 6
• A deliberated concept for pain therapy during pregnancy should be initiated with a non-pharmacological intervention and, if necessary, supplemented with pharmacological agents 7