Is it safe to use Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) during pregnancy?

NSAIDs During Pregnancy: Safety Guidelines and Recommendations

NSAIDs should be avoided in the third trimester of pregnancy due to significant risks of premature closure of the ductus arteriosus, and can be used with caution in the first and second trimesters for short-term treatment only. 1, 2

Safety by Trimester

First Trimester

• NSAIDs appear relatively safe during early pregnancy with no significant evidence of increased risk of miscarriage or teratogenicity 1, 2
• Most reassuring data are available for ibuprofen, followed by diclofenac 1
• Consider discontinuing NSAIDs if trying to conceive, as they can interfere with ovulation and cause luteinized unruptured follicle syndrome 1

Second Trimester

• Short-term use (7-10 days) of NSAIDs in the second trimester appears relatively safe 1, 3
• Prefer nonselective NSAIDs with short half-life (e.g., ibuprofen) in the lowest effective dose 1, 2
• Long-term use in the late second trimester requires monitoring as it may cause oligohydramnios and ductus arteriosus constriction similar to third-trimester effects 4, 5

Third Trimester

• Strongly contraindicated after gestational week 28 (end of second trimester) 1, 2
• Significant risks include:
  • Premature closure of the ductus arteriosus 1
  • Oligohydramnios 1, 4
  • Pulmonary hypertension in the newborn 6
  • Impaired fetal renal function 4, 7
  • Prolonged gestation and labor 6
  • Increased peripartum blood loss 6

Recommendations for Pain Management During Pregnancy

1. First choice throughout pregnancy: Acetaminophen (safest analgesic option) 2

2. If acetaminophen is insufficient:

   • First/Second trimester: Short-term, intermittent use of nonselective NSAIDs (preferably ibuprofen) for 7-10 days maximum 1, 2, 3
   • Third trimester: Avoid all NSAIDs; use acetaminophen or low-dose prednisone (≤5 mg/day) if necessary 1, 2

3. For chronic inflammatory conditions during pregnancy:

   • Consider pregnancy-compatible disease-modifying drugs like hydroxychloroquine, sulfasalazine, or low-dose prednisone 1, 2

Special Considerations

• Monitoring: If long-term NSAID use is required in the second trimester (which should be avoided if possible), monitor with fetal echocardiography to check for ductal constriction 2
• Postpartum/Breastfeeding: Ibuprofen, indomethacin, and naproxen are considered safe during breastfeeding 1, 2
• Preeclampsia: Avoid NSAIDs in women with preeclampsia, especially with acute kidney injury 1

Common Pitfalls to Avoid

1. Assuming all trimesters carry equal risk: The third trimester has significantly higher risk than earlier trimesters 1, 2
2. Prolonged use in second trimester: Even before week 28, prolonged use can cause complications similar to third-trimester exposure 4, 5
3. Self-medication: Many pregnant women are unaware of NSAID risks and self-medicate 7, 8
4. Inadequate monitoring: If NSAIDs must be used in the late second trimester, fetal monitoring is essential 2
5. Overlooking fertility impact: NSAIDs can interfere with conception by affecting ovulation 1

In conclusion, while NSAIDs can be used with caution during the first and early second trimesters for short periods, they should be completely avoided in the third trimester. Acetaminophen remains the safest analgesic throughout pregnancy, and when stronger anti-inflammatory effects are needed after week 28, low-dose prednisone is preferred over NSAIDs.