What are the treatment options for pregnancy-related osteoarthritis?

Treatment of Pregnancy-Related Osteoarthritis

For osteoarthritis during pregnancy, use acetaminophen (paracetamol) as first-line pharmacological therapy, combined with core non-pharmacological interventions including exercise, weight management counseling, and physical therapy. 1

Core Non-Pharmacological Treatments (Essential for All Pregnant Patients)

All pregnant women with osteoarthritis should receive these foundational interventions regardless of pharmacological treatment 1:

• Exercise programs including local muscle strengthening and general aerobic fitness adapted for pregnancy 1
• Patient education about the condition, emphasizing that osteoarthritis can be managed and is not inevitably progressive 1
• Weight management counseling appropriate for pregnancy (avoiding excessive gestational weight gain while ensuring adequate nutrition) 1
• Physical therapy interventions such as manipulation and stretching, particularly for hip osteoarthritis 1
• Assistive devices including walking aids, joint supports, or insoles for biomechanical joint pain 1
• Local heat or cold applications for symptomatic relief 1
• TENS (transcutaneous electrical nerve stimulation) as an adjunct therapy 1

Pharmacological Treatment Algorithm

First-Line: Acetaminophen (Paracetamol)

• Use regular dosing of acetaminophen for pain relief as the primary pharmacological agent 1
• This is the safest analgesic option throughout all trimesters of pregnancy 1

Second-Line: NSAIDs (With Critical Timing Restrictions)

NSAIDs can be used conditionally in the first and second trimesters only, but are absolutely contraindicated in the third trimester 1:

• Conditionally recommend NSAIDs as compatible for use during the first two trimesters if acetaminophen provides insufficient relief 1
• Strongly recommend against NSAID use in the third trimester due to risk of premature closure of the fetal ductus arteriosus 1
• Consider discontinuing NSAIDs pre-conception if the patient is having difficulty conceiving, as NSAIDs may cause unruptured follicle syndrome leading to subfertility 1
• Prefer nonselective NSAIDs over COX-2 inhibitors in the first two trimesters due to lack of safety data on COX-2 specific inhibitors during pregnancy 1
• Use NSAIDs at the lowest effective dose for the shortest possible duration 1

Third-Line: Topical Therapies

• Topical NSAIDs may be considered for knee and hand osteoarthritis before escalating to systemic therapy 1
• Topical capsaicin can be considered as an adjunct 1

Glucocorticoids (For Severe Cases Only)

If disease control requires glucocorticoids, use nonfluorinated formulations at the lowest effective dose 1:

• Continue low-dose glucocorticoids (≤10 mg daily prednisone equivalent) during pregnancy if clinically indicated 1
• Strongly recommend tapering higher doses to <20 mg daily of prednisone or nonfluorinated equivalent 1
• Intra-articular corticosteroid injections may be used for localized joint involvement 2, 3

Critical Safety Considerations and Pitfalls

Absolute Contraindications During Pregnancy

• Avoid glucosamine and chondroitin products - these are not recommended for osteoarthritis treatment generally and lack safety data in pregnancy 1
• Do not use electroacupuncture 1
• NSAIDs must be discontinued by the third trimester to prevent fetal complications 1

Timing-Specific Warnings

The most common pitfall is continuing NSAIDs into the third trimester, which carries significant fetal risk 1. Healthcare providers must:

• Establish clear timelines for NSAID discontinuation (ideally by 28-30 weeks gestation)
• Transition to acetaminophen-based regimens before the third trimester begins
• Monitor for oligohydramnios if NSAIDs are used in the second trimester 3

Monitoring Requirements

• Assess functional impact on activities of daily living, mood, and quality of life throughout pregnancy 1
• Provide periodic review tailored to the individual's changing needs during pregnancy 1
• Coordinate care between rheumatology/orthopedics and obstetrics 1

Evidence Quality and Nuances

The NICE guidelines 1 provide the strongest framework for osteoarthritis management, emphasizing that non-pharmacological interventions are core treatments that should never be omitted. The 2020 ACR reproductive health guidelines 1 provide the most recent and authoritative guidance on medication safety during pregnancy, with strong recommendations against third-trimester NSAID use based on well-established fetal risks.

The evidence strongly supports a conservative, stepwise approach prioritizing non-pharmacological interventions and acetaminophen, with judicious use of NSAIDs only in the first two trimesters when absolutely necessary for disease control. This approach balances maternal symptom management with fetal safety, which is the paramount concern during pregnancy.