Is it safe to take ibuprofen (Nonsteroidal Anti-Inflammatory Drug (NSAID)) during pregnancy?

Ibuprofen During Pregnancy

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

Trimester-Specific Recommendations

First and Second Trimesters (Before Week 28)

• Ibuprofen is conditionally compatible for use when clinically necessary, with the most reassuring safety data among all NSAIDs 1, 2, 3
• Use only at the lowest effective dose (typically 200-400mg every 6-8 hours) for the shortest possible duration, ideally limiting to 7-10 days 2, 4
• Early pregnancy exposure shows no evidence of increased miscarriage risk or teratogenicity when used appropriately 2, 3
• Prefer nonselective NSAIDs like ibuprofen over COX-2 selective inhibitors due to limited safety data for the latter 1, 3

Third Trimester (After Week 28)

• Ibuprofen is strongly contraindicated after gestational week 28 - this is the critical cutoff, not the traditional "third trimester" designation 1, 2, 5
• Fetal risks after week 28 include:
  • Premature closure of the ductus arteriosus with potential for persistent pulmonary hypertension 1, 3, 6
  • Oligohydramnios (reduced amniotic fluid) from fetal renal dysfunction 2, 3, 5
  • Neonatal renal impairment 5, 6
  • Necrotizing enterocolitis and intracranial hemorrhage 6

Pre-Conception Considerations

• Women actively trying to conceive should discontinue ibuprofen if disease control permits, as NSAIDs can induce luteinized unruptured follicle (LUF) syndrome, interfering with ovulation and reducing fertility 1, 2, 3
• If NSAIDs must be used while trying to conceive, use intermittently rather than continuously to minimize ovulation interference 3

Clinical Decision Algorithm

Step 1: Determine Gestational Age

• Before week 28: Ibuprofen may be considered if benefits outweigh risks
• Week 28 or later: Ibuprofen is absolutely contraindicated - use alternatives

Step 2: First-Line Treatment (All Trimesters)

• Acetaminophen is the preferred first-line analgesic at 650mg every 6 hours or 975mg every 8 hours, maximum 4g daily 4
• Use at the lowest effective dose for the shortest duration possible 4

Step 3: If Acetaminophen Insufficient (Before Week 28 Only)

• Consider ibuprofen 200-400mg every 6-8 hours for maximum 7-10 days 2, 4
• Monitor closely and discontinue as soon as possible 7

Step 4: For Chronic Inflammatory Conditions

• Transition to pregnancy-compatible alternatives before conception or early in pregnancy 2, 3, 4:
  • Hydroxychloroquine (strongly recommended as compatible throughout pregnancy) 1
  • Sulfasalazine with folate supplementation 1, 3
  • Low-dose prednisone (≤10mg daily) 1, 4
  • Azathioprine 1, 3
  • Colchicine 1, 3

Critical Monitoring for Late Second Trimester Use

• If ibuprofen treatment extends beyond 48 hours at or after 20 weeks gestation, consider ultrasound monitoring for oligohydramnios 5
• If oligohydramnios develops, discontinue immediately and follow up according to clinical practice 5

Common Pitfalls to Avoid

• Do not rely on "third trimester" terminology - the critical cutoff is gestational week 28, which occurs before the traditional third trimester begins 2, 3
• Do not use combination products containing ibuprofen without accounting for total NSAID dose 4
• Do not continue NSAIDs in women with difficulty conceiving - even periovulatory exposure can prevent ovulation 2, 3
• Do not assume all NSAIDs are equivalent - ibuprofen has the most reassuring safety data, followed by diclofenac 2, 3

Breastfeeding

• Ibuprofen is considered safe during breastfeeding as it transfers in low amounts to breast milk 2, 3, 6