What analgesics are safe to administer during pregnancy?

From the Guidelines

Acetaminophen (Tylenol) is the safest pain medication to use during pregnancy, and it is recommended as the first-line treatment for pain and fever. The typical adult dose is 650-1000 mg every 6 hours, not exceeding 4000 mg per day 1. For more severe pain, certain NSAIDs like ibuprofen (Advil, Motrin) may be used during the first and second trimesters at doses of 400-600 mg every 6 hours, but should be avoided in the third trimester as they can cause premature closure of the fetal ductus arteriosus and other complications 1. Aspirin is generally not recommended during pregnancy except in specific medical conditions under doctor supervision. For severe pain, opioids such as codeine or oxycodone may be prescribed for short-term use when benefits outweigh risks, but they should be used at the lowest effective dose and for the shortest duration possible due to risks of dependency and neonatal withdrawal 1.

Some key points to consider when using pain medications during pregnancy include:

• Always consult with your healthcare provider before taking any medication during pregnancy, as individual health circumstances may affect recommendations.
• Non-pharmacological pain management strategies like rest, physical therapy, heat/cold therapy, and massage should be considered before or alongside medication use.
• The use of acetaminophen should be limited to the lowest effective dose for the shortest possible duration, and pregnant women who use acetaminophen should be closely monitored across all trimesters of pregnancy 1.
• Ibuprofen and other NSAIDs can be used during breastfeeding, but aspirin should be used with caution due to the risk of salicylate intoxication and bleeding problems in the neonate 1.

It is essential to weigh the benefits and risks of each medication and to prioritize the health and well-being of both the mother and the fetus. The most recent and highest quality study recommends using acetaminophen as the first-line treatment for pain and fever during pregnancy, and using NSAIDs and opioids with caution and under medical supervision 1.

From the FDA Drug Label

Use of NSAIDs, including ibuprofen tablets, can cause premature closure of the fetal ductus arteriosus and fetal renal dysfunction leading to oligohydramnios and, in some cases, neonatal renal impairment Because of these risks, limit dose and duration of ibuprofen tablets use between about 20 and 30 weeks of gestation, and avoid ibuprofen tablets use at about 30 weeks of gestation and later in pregnancy If an NSAID is necessary at about 20 weeks gestation or later in pregnancy, limit the use to the lowest effective dose and shortest duration possible.

Pain medications that can be given during pregnancy are not explicitly listed in the provided drug labels. However, it is mentioned that NSAIDs, including ibuprofen, can be used between 20 and 30 weeks of gestation with limited dose and duration, and should be avoided at 30 weeks of gestation and later in pregnancy.

• Ibuprofen can be used with caution and under strict monitoring between 20 and 30 weeks of gestation.
• Non-NSAID analgesics may be considered as an alternative to NSAIDs, especially for patients taking low-dose aspirin for cardioprotection. 2 2

From the Research

Pain Medications During Pregnancy

The following pain medications can be given during pregnancy:

• Paracetamol (acetaminophen) is the most widely used drug to treat pain or fever in pregnant women or neonates 3
• Nonsteroidal anti-inflammatory drugs, including ibuprofen and aspirin, can be used during pregnancy, but with caution and under the guidance of a healthcare provider 4, 5
• Opioids can be used during pregnancy, but with caution and under the guidance of a healthcare provider, as they may be associated with a small reduction in fecundability 4, 6
• Gabapentinoids and muscle relaxants can be used during pregnancy, but with caution and under the guidance of a healthcare provider 4

Safety and Risks

It is essential to balance the treatment of maternal pain with the potential risks of medication exposure on fetal development 4

• Paracetamol is generally considered safe for use during pregnancy, but high doses may result in oxidative toxic metabolites 3
• Ibuprofen and aspirin may interfere with prostaglandins biosynthesis and have been shown to induce abnormalities in early developing structures in human fetal kidneys 5
• Opioids may be associated with a small reduction in fecundability and may have other risks, such as congenital anomalies and neonatal withdrawal syndrome 4, 6

Precautions and Guidance

Healthcare providers must weigh the benefits and risks of pain management strategies through informed, shared decision-making with patients 4

• Pregnant women should only use pain medications under the guidance of a healthcare provider and with caution 4, 5, 7
• The choice of analgesia selected by pregnant women differs across populations, and location may have an effect on prevalence of use 7