What are strong pain killers (analgesics) safe for use during pregnancy?

From the Guidelines

Acetaminophen is the recommended first-line treatment for pain management during pregnancy, with a recommended dosage of 500-1000mg every 6 hours, not exceeding 4000mg per day 1.

Key Considerations for Pain Management in Pregnancy

• Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen should be avoided, especially in the third trimester, as they can cause complications including premature closure of the ductus arteriosus in the baby and potential bleeding risks 1.
• For stronger pain that doesn't respond to acetaminophen, consult your healthcare provider as they may recommend limited use of certain opioids or other medications based on your specific situation and stage of pregnancy 1.
• Non-medication approaches such as rest, heat or cold therapy, gentle massage, and physical therapy may also help manage pain during pregnancy.
• Always discuss any medication use with your healthcare provider before taking it, as the risks and benefits must be carefully weighed based on your specific circumstances, the severity of your pain, and your stage of pregnancy 1.

Additional Guidance

• The American College of Obstetricians and Gynecologists (ACOG) recommends stepwise, multimodal, shared decision-making, incorporating pharmacologic treatments that might include opioids for pain management in the postpartum period 1.
• After vaginal delivery, ACOG recommends acetaminophen or NSAIDs, and if needed, adding an opioid, while after cesarean delivery, ACOG recommends standard oral and parenteral medications such as acetaminophen, NSAIDs, or low-dose, low-potency, short-acting opioids with duration of opioid use limited to the shortest reasonable course expected for treating acute pain 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. Ibuprofen tablets should be used in pregnancy only if the potential benefit justifies the potential risk to the fetus

Ibuprofen is not recommended as a strong pain killer in pregnancy, especially after 30 weeks of gestation, due to the risk of premature closure of the fetal ductus arteriosus and fetal renal dysfunction. If used between 20 and 30 weeks of gestation, the dose and duration should be limited to the lowest effective dose and shortest duration possible 2.

From the Research

Strong Pain Killers in Pregnancy

• Paracetamol (acetaminophen) is considered the safest analgesic and antipyretic medicine for pregnant women, but its use should be limited to the lowest effective dose for the shortest possible time 3, 4.
• Ibuprofen is also used for mild to moderate pain, but it is contraindicated after 28 weeks of gestation due to the risk of premature closure of the ductus arteriosus and impairment of fetal kidney function 5, 6.
• Opioids can be used for severe pain, but their use should be cautious due to the risk of neonatal respiratory depression and adaptation disorders, as well as long-term therapy leading to neonatal withdrawal symptoms 5, 6.
• Other options for pain management during pregnancy include:
  • Diclofenac and metamizole, which can be administered carefully depending on the trimester 6.
  • Amitriptyline, duloxetine, and venlafaxine for neuropathic pain 6.
  • Non-pharmacological treatment concepts, such as transcutaneous electrical nerve stimulation (TENS therapy), kinesio tapes, and acupuncture 6.
• It is essential to weigh the benefits and risks of each medication and to use the lowest effective dose for the shortest possible time to minimize potential harm to the fetus 3, 4.

Considerations for Pain Management in Pregnancy

• Patient compliance and in-depth knowledge of the fetotoxicity and teratogenicity of substances are necessary to maintain a balance between therapy for the mother and safety of the unborn child 6.
• Health care providers should inform pregnant women about the potential risks and benefits of each medication and help them make informed decisions about their pain management 3, 4.
• A deliberated concept for pain therapy during pregnancy should be initiated with a non-pharmacological intervention and, if necessary, supplemented with pharmacological agents 6.