What medications can be given to a pregnant patient with abdominal pain?

Medications for Abdominal Pain in Pregnancy

For pregnant patients with abdominal pain, acetaminophen is the first-line analgesic, with antacids (aluminum/magnesium hydroxide) for reflux-related pain, antispasmodics for cramping, and specific treatments based on the underlying cause—while opioids like hydrocodone can be used for severe pain when necessary. 1, 2

Initial Assessment and Cause-Specific Treatment

The medication choice depends critically on identifying the underlying cause of abdominal pain, as pregnancy-related pain has multiple etiologies requiring different approaches. 3

For Reflux/Indigestion-Related Pain

• Antacids containing aluminum/magnesium hydroxide are safe first-line medications for reflux-related abdominal pain in pregnancy. 1
• H2-receptor antagonists are considered safe first-line pharmacologic therapy when antacids fail to control symptoms. 1
• Lifestyle modifications including small frequent meals, avoiding trigger foods, and elevating the head of bed should accompany medication use. 1
• Avoid metoclopramide due to its unfavorable risk-benefit profile in pregnant patients, despite its antiemetic properties. 1

For Cramping/Spasmodic Pain

• Antispasmodic medications (anticholinergic agents) can be used for abdominal cramping, particularly when symptoms are exacerbated by meals. 4
• These agents work by reducing smooth muscle spasm in the gastrointestinal tract. 4

For Severe Pain

• Acetaminophen is the safest analgesic and should be tried first for any abdominal pain in pregnancy. 2
• Hydrocodone/acetaminophen combination can be used for severe pain when acetaminophen alone is insufficient, as demonstrated in clinical practice. 2
• Opioids like codeine (30-60 mg, 1-3 times daily) may be considered, though CNS effects are often less well tolerated. 4

Condition-Specific Medication Protocols

Inflammatory Bowel Disease (IBD)

If the pregnant patient has known IBD causing abdominal pain:

• Continue 5-ASA therapy (oral and/or rectal) throughout pregnancy for maintenance. 4
• Continue thiopurine maintenance therapy throughout pregnancy without interruption. 4
• Continue anti-TNF therapy throughout pregnancy for disease control. 4
• Systemic corticosteroids or anti-TNF therapy should be used for disease flares causing pain. 4
• Methylprednisolone (16 mg IV every 8 hours for up to 3 days) can be given as last resort for severe flares, though use caution in first trimester due to slight increased risk of cleft palate before 10 weeks. 4

Hyperemesis Gravidarum/Severe Nausea with Pain

• Vitamin B6 (pyridoxine) as first-line treatment for mild cases with associated abdominal discomfort. 4
• Metoclopramide can be given and has similar efficacy to promethazine with less drowsiness and dystonia. 4
• Ondansetron as second-line therapy for severe symptoms requiring hospitalization, used cautiously before 10 weeks due to potential cardiac defect risk. 4

Constipation-Related Pain

• Bulk-forming agents (psyllium husk or methylcellulose) are safe due to lack of systemic absorption. 1
• Osmotic laxatives like polyethylene glycol or lactulose can be safely administered. 4, 1
• Increase dietary fiber to approximately 30g/day through fruits, vegetables, and whole grains. 1

Infectious Enteritis

• For perianal sepsis requiring antibiotics, metronidazole and/or ciprofloxacin may be used. 4, 5
• For Salmonella gastroenteritis, use ampicillin, cefotaxime, ceftriaxone, or TMP-SMZ; avoid fluoroquinolones. 5

Critical Safety Considerations

Medications to Avoid

• Fluoroquinolones should be avoided during pregnancy due to potential fetal risks. 5
• NSAIDs are not mentioned in pregnancy guidelines for abdominal pain and should generally be avoided, particularly in third trimester.
• Metoclopramide has an unfavorable risk-benefit profile and should be avoided when alternatives exist. 1

When to Hospitalize

• Pregnant patients with severe dehydration require hospitalization for IV hydration and electrolyte replacement. 4, 5
• If symptoms worsen or don't improve with initial management, consider hospitalization for IV therapy. 1
• Pregnant women requiring hospitalization for IBD should be transferred to a tertiary center with access to gastroenterology and high-risk obstetrics. 4

Common Pitfalls to Avoid

• Do not delay treatment of severe symptoms, as this can lead to dehydration, malnutrition, and adverse pregnancy outcomes. 1
• Do not discontinue necessary IBD medications due to unfounded safety concerns, as active disease poses greater risk than medication exposure. 4, 1
• Do not use medications without considering trimester-specific risks, particularly in the first trimester when organogenesis occurs. 1
• Do not assume all abdominal pain is pregnancy-related—maintain high suspicion for surgical pathology like appendicitis, which requires different management. 3, 6

Multidisciplinary Approach

A multidisciplinary team including obstetricians, gastroenterologists, and when needed, surgeons should be involved in managing pregnant patients with severe or complex abdominal pain. 4, 1