Is ibuprofen (nonsteroidal anti-inflammatory drug (NSAID)) safe to take during pregnancy?

Ibuprofen Use During Pregnancy

Ibuprofen can be used cautiously during the first and second trimesters at the lowest effective dose for short durations (7-10 days maximum), but must be completely discontinued after gestational week 28 due to serious fetal risks including premature closure of the ductus arteriosus and oligohydramnios. 1, 2

Safety by Trimester

First and Second Trimesters (Before Week 28)

• Early pregnancy exposure to ibuprofen shows no evidence of increased risk of miscarriage or teratogenicity when used appropriately. 1, 2
• Ibuprofen has the most reassuring safety data among all NSAIDs, followed by diclofenac, while COX-2 inhibitors have limited data and should be avoided. 1, 2
• If an NSAID is necessary, use ibuprofen 200-400mg every 6-8 hours, limiting duration to 7-10 days maximum at the lowest effective dose. 2, 3
• Short-term use (7-10 days) during the second trimester does not appear to pose substantial fetal risks. 1, 3

Third Trimester (After Week 28)

• NSAIDs are strongly contraindicated after gestational week 28, not the traditional "third trimester" designation. 1, 2
• The critical cutoff is week 28 because fetal sensitivity to NSAID-related risks increases significantly after this point. 2
• Serious fetal risks after week 28 include premature closure of the ductus arteriosus, oligohydramnios (reduced amniotic fluid), pulmonary hypertension in the newborn, and neonatal renal impairment. 1, 3, 4

Special Considerations

Women Trying to Conceive

• Women actively trying to conceive should avoid NSAIDs entirely, as they can interfere with ovulation by inducing luteinized unruptured follicle (LUF) syndrome, potentially reducing fertility. 2, 3
• If NSAIDs must be used while trying to conceive, use intermittently rather than continuously to minimize interference with ovulation. 3

Monitoring Requirements

• If ibuprofen treatment is necessary between 20-30 weeks gestation and extends beyond 48 hours, monitor with ultrasound for oligohydramnios. 4
• If oligohydramnios occurs, discontinue ibuprofen immediately and follow up according to clinical practice. 4

Preferred Alternatives

First-Line Pain Management

• Acetaminophen is the first-line medication for pain management during pregnancy at the lowest effective dose (typically 650mg every 6 hours or 975mg every 8 hours) for the shortest possible duration. 5
• Acetaminophen can be used throughout all trimesters, though prolonged use (>28 days) should be avoided due to potential neurodevelopmental concerns. 5

For Chronic Inflammatory Conditions

• For women requiring long-term anti-inflammatory treatment, transition to pregnancy-compatible alternatives before conception or early in pregnancy. 2, 3
• Pregnancy-compatible options include hydroxychloroquine, sulfasalazine (with folate supplementation), low-dose prednisone (≤10 mg daily), azathioprine (up to 2 mg/kg daily), cyclosporine, tacrolimus, and colchicine. 1, 3

Breastfeeding

• Ibuprofen is considered safe during breastfeeding as it transfers in low amounts to breast milk. 2
• Most NSAIDs are compatible with breastfeeding due to minimal infant exposure. 6

Critical Clinical Pitfalls

Common Misconceptions

• The traditional "avoid in third trimester" guidance is imprecise—the actual cutoff is gestational week 28, not week 27 (when the third trimester technically begins). 2
• Over-the-counter availability does not mean ibuprofen is safe throughout pregnancy; many women are unaware of the strict gestational age restrictions. 4

When Ibuprofen Exposure Has Already Occurred

• If inadvertent exposure occurs after week 28, immediately discontinue the medication and arrange fetal assessment for ductal constriction and oligohydramnios. 3
• For first or second trimester exposure, reassure the patient that short-term use carries minimal risk, but avoid further use and transition to acetaminophen if ongoing pain management is needed. 1, 2

Contraindications Beyond Pregnancy Timing

• Do not use ibuprofen in patients with aspirin sensitivity or asthma, as cross-reactivity can cause bronchospasm. 4
• Avoid in patients taking low-dose aspirin for cardioprotection, as ibuprofen interferes with aspirin's antiplatelet effects; consider acetaminophen instead. 4