Medication Use and Pain Management in Pregnancy: A Critical Review

Abstract

Background Pain during pregnancy is common, and its management is complex. Certain analgesics may increase the risk for adverse fetal and pregnancy outcomes, while poorly managed pain can result in adverse maternal outcomes such as depression and hypertension. Guidelines to assist clinicians in assessing risks and benefits of exposure to analgesics for the mother and unborn infant are lacking, necessitating evidence‐based recommendations for managing pain in pregnancy. Methods A comprehensive literature search was conducted to assess pregnancy safety data for pharmacological and nonpharmacological pain management methods. Relevant clinical trials and observational studies were identified using multiple medical databases, and included studies were evaluated for quality and possible biases. Results Paracetamol and nonsteroidal anti‐inflammatory drugs (NSAIDs) are appropriate for mild to moderate pain, but NSAIDs should be avoided in the third trimester due to established risks. Short courses of weaker opioids are generally safe in pregnancy, although neonatal abstinence syndrome must be monitored following third trimester exposure. Limited safety data for pregabalin and gabapentin indicate that these are unlikely to be major teratogens, and tricyclic antidepressants and serotonin‐norepinephrine reuptake inhibitors have limited but overall reassuring safety data. Many of the included studies were limited by methodological issues. Conclusions Findings from this review can guide clinicians in their decision to prescribe analgesics for pregnant women. Treatment should be tailored to the lowest therapeutic dose and shortest possible duration, and management should involve a discussion of risks and benefits and monitoring for response. Further research is required to better understand the safety profile of various analgesics in pregnancy.

Metabolites from midtrimester plasma of pregnant patients at high risk for preterm birth

“…Acetaminophen is the most common analgesic used in pregnancy, and in general is considered 'low risk' to the pregnancy and fetus. 45 However, these data add to other emerging data suggesting an associated between acetaminophen exposure and adverse birth outcomes. For example, in a cohort of 1200 patients in Ontario, selfreported acetaminophen use was associated with small for gestational age and low birthweight.…”

Safety profile of erenumab, galcanezumab and fremanezumab in pregnancy and lactation: Analysis of the WHO pharmacovigilance database

“…We observed that, over 1.5 years since the first-in-class erenumab was authorised by the FDA, no specific maternal toxicities, patterns of major birth defects, or spontaneous abortion have emerged as hallmarks of toxicity with erenumab, galcanezumab and fremanezumab. Because of ethical restrictions on the inclusion of pregnant women in randomised clinical trials, the majority of information on drug safety in pregnancy and lactation either derives from observational studies in the post-marketing setting or relies on experts' opinions (25). Expert-based guidelines from the European Headache Federation suggest avoiding the use of monoclonal antibodies acting on the CGRP system for migraine prevention in pregnant or nursing women (26).…”

Safe use of paracetamol and high-dose NSAID analgesia in dentistry during the COVID-19 pandemic

“…The GP may still recommend using an NSAID regime such as that outlined for moderate dental pain, as NSAIDs are not absolutely contraindicated until 30 weeks' gestation and beyond. 14 Patients who are breastfeeding can be given NSAIDs, but the higher doses should only be used in exceptional circumstances and after discussion with the GP. Paracetamol is preferred.…”