Management of Costochondritis in Pregnancy
Costochondritis in pregnancy should be managed primarily with conservative measures including reassurance, activity modification, and acetaminophen for analgesia, while avoiding NSAIDs after 20 weeks gestation due to risks of fetal renal dysfunction and premature ductus arteriosus closure.
First-Line Conservative Management
Reassurance and education are essential, as costochondritis is a self-limiting benign condition that typically resolves within weeks to months 1, 2.
Acetaminophen is the preferred analgesic throughout pregnancy for pain control, as it lacks the fetal risks associated with NSAIDs 3.
Activity modification should include avoiding repetitive movements, heavy lifting, and activities that exacerbate chest wall pain 1, 4.
Local heat application can provide symptomatic relief without systemic medication exposure 1.
NSAIDs: Critical Timing Considerations
NSAIDs like ibuprofen may be considered only before 20 weeks gestation, but must be strictly avoided from 20 weeks onward.
Before 20 weeks gestation: Short-term, lowest-dose NSAID use may be considered if acetaminophen fails, though this should be weighed carefully 3.
At or after 20 weeks gestation: NSAIDs cause fetal renal dysfunction leading to oligohydramnios, with adverse outcomes seen after days to weeks of treatment, though sometimes as early as 48 hours 3.
At or after 30 weeks gestation: NSAIDs increase risk of premature closure of the fetal ductus arteriosus and are contraindicated 3.
If NSAID treatment between 20-30 weeks is deemed absolutely necessary, use the lowest effective dose for the shortest duration possible, with ultrasound monitoring of amniotic fluid if treatment extends beyond 48 hours 3.
Physical Therapy Interventions
Stretching exercises and manual therapy techniques offer effective non-pharmacologic treatment options that are safe throughout pregnancy.
Stretching exercises targeting the costochondral junctions showed progressive significant improvement compared to controls (p<0.001) in treating costochondritis pain 1.
Manual therapy including rib manipulation and soft tissue mobilization can address rib dysfunction and myofascial pain generators 2, 5.
Impairment-based physical therapy combining manual therapy and therapeutic exercise demonstrated clinically meaningful improvements, with mean pain reduction of 5.1 points on the numerical pain rating scale 5.
Physical therapy is particularly valuable in pregnancy as it avoids medication exposure while addressing the underlying musculoskeletal dysfunction 2, 5.
Red Flags Requiring Further Evaluation
Rule out serious pathology before confirming the diagnosis of costochondritis, as it remains a diagnosis of exclusion.
Infectious costochondritis must be considered if there is fever, purulent drainage, or systemic signs of infection, though this is rare and typically occurs post-operatively or with direct spread from adjacent tissues 4.
Cardiac causes of chest pain must be excluded through appropriate history, examination, and testing as clinically indicated 2.
Persistent symptoms beyond several months warrant re-evaluation for alternative diagnoses 2, 5.
Treatment Algorithm
Initial approach: Reassurance, acetaminophen, activity modification, and local heat application throughout pregnancy 3, 1.
If inadequate relief before 20 weeks: Consider short-term, low-dose NSAIDs with careful risk-benefit discussion 3.
At or after 20 weeks: Refer to physical therapy for stretching exercises and manual therapy; absolutely avoid NSAIDs 3, 1, 5.
Refractory cases: Continue conservative management with emphasis on physical therapy modalities, as costochondritis typically resolves with time even in atypical cases 1, 2, 5.
Common Pitfalls to Avoid
Never prescribe NSAIDs after 20 weeks gestation without recognizing the serious fetal risks of oligohydramnios and renal impairment 3.
Do not assume all chest wall pain is benign costochondritis without appropriate evaluation to exclude cardiac and other serious causes 2.
Avoid dismissing patient concerns about prolonged symptoms; refer to physical therapy for active intervention rather than simply waiting for spontaneous resolution 5.