What pain medications are safe for use during pregnancy?

Safe Pain Medications During Pregnancy

Acetaminophen (paracetamol) is the first-line medication for pain management during pregnancy due to its favorable safety profile compared to other analgesics. 1, 2

First-Line Pain Medication

• Acetaminophen is recommended as the safest analgesic option during all trimesters of pregnancy, with a maximum daily intake of 4g to reduce the risk of liver injury 1, 2
• Acetaminophen should be used at the lowest effective dose for the shortest possible duration when medically necessary 1, 3
• Unlike NSAIDs, acetaminophen does not cause premature closure of the fetal ductus arteriosus or oligohydramnios, making it safer for third-trimester use 2

Second-Line Options and Trimester-Specific Considerations

• NSAIDs (like ibuprofen) can be used only during the second trimester if necessary, but should be avoided in the first and third trimesters 3
• NSAIDs are contraindicated after 28 weeks gestation due to risks of premature closure of the fetal ductus arteriosus, oligohydramnios, and potential neonatal renal impairment 4, 5
• For severe pain not managed effectively by acetaminophen, a short course of low-dose opioids can be considered, but only after careful evaluation of risks and benefits 3

Pain Management for Specific Conditions

Migraine During Pregnancy

• Acetaminophen is the first-line treatment for migraine during pregnancy despite relatively poor efficacy 3, 6
• Metoclopramide can be used for nausea associated with migraine in pregnancy 3, 6
• If prevention is required, propranolol has the best safety profile and is the first choice for preventive therapy 3, 6

Postpartum Pain Management

• For post-vaginal delivery pain in opioid-naïve women, NSAIDs and acetaminophen should be given as first-line treatments 3
• For post-cesarean delivery pain, acetaminophen (975 mg every 8 hours) is recommended as a standing medication, with NSAIDs added if not contraindicated 3
• If opioids are required for persistent pain after discharge, counsel about risks and prescribe a limited number of pills 3

Precautions and Monitoring

• Recent studies have suggested possible associations between prolonged prenatal acetaminophen exposure and neurodevelopmental outcomes in children, though the evidence is inconclusive 3, 7
• Pregnant women using acetaminophen should be closely monitored across all trimesters 3, 1
• Be cautious with combination products containing acetaminophen to prevent excess dosing 1, 2
• Severe pain during pregnancy that doesn't respond to acetaminophen warrants medical evaluation 1

Non-Pharmacological Approaches

• Consider non-pharmacological approaches first (rest, physical therapy, heat/cold therapy) before initiating medication 1, 6
• For migraine, non-pharmacological strategies include staying well hydrated, maintaining regular meals, securing sufficient sleep, and avoiding triggers 6

Medications to Avoid During Pregnancy

• Ergotamine derivatives and dihydroergotamine are contraindicated during pregnancy 6
• Topiramate, candesartan, and sodium valproate are contraindicated due to adverse effects on the fetus 3, 6
• CGRP antagonists (gepants) and ergot alkaloids have insufficient safety data in pregnancy and should be avoided 6
• Opioids should be limited due to risks of dependency and potential neonatal opioid withdrawal syndrome 3