Is Ketorolac (NSAID) safe for use in pregnant patients?

Ketorolac is Contraindicated in Pregnancy

Ketorolac should not be used at any point during pregnancy due to significant maternal and fetal risks, and is explicitly contraindicated in labor and delivery. 1, 2

Clear Contraindications Across All Trimesters

Labor and Delivery (Absolute Contraindication)

• The FDA drug label explicitly states that ketorolac is contraindicated in labor and delivery because it may adversely affect fetal circulation and inhibit uterine contractions, increasing the risk of uterine hemorrhage through prostaglandin synthesis inhibition 2

Third Trimester (Strong Contraindication)

• NSAIDs including ketorolac are strongly contraindicated after 28 weeks gestation due to risk of premature closure of the ductus arteriosus 1
• Additional third trimester risks include oligohydramnios (reduced amniotic fluid), pulmonary hypertension in the newborn, and renal impairment 1, 3
• The American College of Rheumatology provides a strong recommendation against NSAID use in the third trimester 1

First and Second Trimesters (Not Recommended)

• While early pregnancy NSAID exposure shows no clear evidence of increased teratogenicity or miscarriage with ibuprofen and diclofenac 1, ketorolac specifically is not mentioned as safe in any guideline for pregnancy use
• The American Urological Association/Endourological Society explicitly states that "non-steroidal anti-inflammatory agents (e.g., ketorolac) are contraindicated in pregnancy" 1
• Even when NSAIDs are conditionally recommended in first/second trimesters, guidelines specifically mention ibuprofen and diclofenac as having the most reassuring data—not ketorolac 1, 4

Why Ketorolac is Particularly Problematic

Potency and Duration Concerns

• Ketorolac is significantly more potent than other NSAIDs like aspirin or ibuprofen, with much longer duration of action 5
• This increased potency translates to greater potential for adverse effects including organ dysfunction 5
• The FDA classifies ketorolac as Pregnancy Category C, meaning it should only be used "if the potential benefit justifies the potential risk to the fetus" 2

Lack of Safety Data

• Unlike ibuprofen (which has the most reassuring pregnancy safety data) or diclofenac (second most reassuring), ketorolac lacks adequate safety studies in pregnant women 2
• Animal reproduction studies at therapeutic doses showed no teratogenicity, but higher doses caused dystocia and increased pup mortality when given after gestation day 17 2

Safe Alternatives for Pain Management in Pregnancy

First-Line: Acetaminophen

• Acetaminophen is the recommended first-line analgesic throughout all trimesters at the lowest effective dose for the shortest duration 6
• Use 650-975 mg every 6-8 hours as needed, limiting chronic use to ≤3 g daily 6

Second-Line: Short-Term NSAIDs (First/Second Trimester Only)

• If NSAID therapy is absolutely necessary in weeks 1-27, ibuprofen 200-400 mg every 6-8 hours has the most reassuring safety data 1, 4
• Limit duration to 7-10 days maximum 1
• Must discontinue by 28 weeks gestation 1

For Inflammatory Conditions Requiring Long-Term Treatment

• Hydroxychloroquine, sulfasalazine (with folic acid supplementation), azathioprine, low-dose prednisone (≤10 mg daily), or colchicine are pregnancy-compatible alternatives 1

Critical Clinical Pitfalls to Avoid

1. Never assume all NSAIDs have equivalent pregnancy safety profiles—ketorolac's increased potency and lack of pregnancy-specific data distinguish it from ibuprofen 5

2. Do not use ketorolac for postoperative pain in pregnant patients—despite its popularity in surgical settings, it is contraindicated 1

3. Avoid combination products—ketorolac is sometimes combined with other medications; verify all components before prescribing to pregnant patients 2

4. Consider fertility implications—ketorolac may impair fertility through cyclooxygenase/prostaglandin synthesis inhibition and is not recommended in women attempting to conceive 2