What pain medication can be given to a pregnant patient?

Pain Management in Pregnancy

Acetaminophen is the first-line medication for pain management throughout pregnancy, used at the lowest effective dose (650-975 mg every 6-8 hours, maximum 4 grams daily) for the shortest duration necessary. 1, 2

First-Line Treatment: Acetaminophen

• Acetaminophen should be the initial choice for pain relief across all trimesters due to its favorable safety profile compared to other analgesics, with no risk of premature ductus arteriosus closure or oligohydramnios that occurs with NSAIDs 1, 2

• Recommended dosing is 975 mg every 8 hours or 650 mg every 6 hours, with a maximum daily dose of 4 grams to prevent hepatotoxicity 1, 2

• Use acetaminophen only when medically necessary, at the lowest effective dose for the shortest possible duration, particularly avoiding prolonged use exceeding 28 days due to emerging concerns about potential neurodevelopmental effects with extended exposure 1, 3

• Counsel pregnant women early in pregnancy to use acetaminophen only when needed, consulting with a physician or pharmacist if uncertain whether use is indicated 3

Second-Line Treatment: NSAIDs (Timing-Specific)

• NSAIDs (ibuprofen 600 mg every 6 hours, ketorolac) can ONLY be used during the second trimester (approximately 14-28 weeks gestation) if acetaminophen is insufficient 1, 2

• Absolutely avoid NSAIDs during the first trimester due to increased risk of gastroschisis and small intestinal atresia 1

• Absolutely avoid NSAIDs after 28-30 weeks gestation due to risk of premature fetal ductus arteriosus closure, oligohydramnios, and fetal renal dysfunction 4, 5

• The FDA specifically warns that NSAIDs can cause premature closure of the fetal ductus arteriosus and fetal renal dysfunction leading to oligohydramnios after 20 weeks, with increased risk after 30 weeks 5

Third-Line Treatment: Opioids (For Severe Uncontrolled Pain)

• When severe pain is not adequately managed by acetaminophen (or acetaminophen plus NSAIDs in second trimester), a short course of low-dose opioids is appropriate 4, 2

• Preferred opioids include:

  • Morphine (preferred if strong analgesia required) 2
  • Hydrocodone 5 mg (limit to 5-10 tablets total) 2
  • Oxycodone (maximum 30 mg daily or 6 5-mg tablets) 2

• Never prescribe codeine during pregnancy or breastfeeding due to risk of neonatal toxicity 2

• Avoid meperidine due to poor efficacy, multiple drug interactions, and increased risk of toxicity 6

• Counsel patients about benefits, risks, side effects, and potential for misuse before prescribing, and prescribe a limited number of pills (typically no more than equivalent of 20 5-mg oxycodone tablets) 4, 2

• Be aware that 1 in 300 women will become dependent on opioids after cesarean delivery 4

Postpartum Pain Management Algorithm

After Vaginal Delivery:

• Start with non-pharmacologic measures (ice packs, heating pads) 2
• Add scheduled acetaminophen (975 mg every 8 hours or 650 mg every 6 hours) PLUS ibuprofen (600 mg every 6 hours) 4, 2
• If inadequate, add ketorolac 15-30 mg IV/IM every 6 hours (maximum 48 hours) OR short course of hydrocodone 5 mg (5-10 tablets maximum) 2

After Cesarean Delivery:

• Neuraxial morphine or hydromorphone (requires 24-hour respiratory monitoring) 2
• Scheduled acetaminophen 975 mg every 8 hours 2
• Scheduled ketorolac 30 mg IV every 6 hours for 24 hours, then ibuprofen 600 mg every 6 hours 2
• Short course of oxycodone (maximum 30 mg daily or 6 5-mg tablets) ONLY if pain interferes with mobilization, breastfeeding, or infant care despite scheduled non-opioids 2

Special Populations

Women with Preeclampsia:

• Avoid NSAIDs if possible, especially with acute kidney injury 2
• Use acetaminophen as the preferred analgesic 2

Women with Opioid Use Disorder:

• Continue maintenance therapy (methadone or buprenorphine) throughout pregnancy and postpartum 4, 2
• Encourage neuraxial analgesia during labor 4, 2
• Start with multimodal non-opioid approach for postpartum pain, with full opioid agonists (fentanyl or hydromorphone) added if needed after 24 hours 4, 2

Critical Pitfalls to Avoid

• Never use NSAIDs after 28 weeks gestation due to fetal risks including ductus arteriosus closure and oligohydramnios 2, 5
• Never prescribe codeine during pregnancy or breastfeeding 2
• Never combine oral decongestants with acetaminophen in the first trimester due to increased risk of gastroschisis 1
• Never withhold appropriate pain management due to opioid concerns 2
• Never prescribe routine opioids at discharge if the patient is not using them in the hospital 2

Labor Pain Management

• Neuraxial analgesia (epidural) should be strongly encouraged during labor as it is the most effective method for labor pain 4, 2
• Consider early epidural catheter insertion for complicated pregnancies (twins, preeclampsia) 2