Condition management

It is important to complete an individual risk assessment for your patient and to apply the principles of prescribing during pregnancy when making treatment decisions. Check to see if a risk assessment has already been completed by the specialist team.

Untreated or inadequately treated severe or chronic pain, can have adverse effects on the mother and therefore on the foetus.

Non-pharmacological management

A stepwise approach is recommended starting with non-pharmacological measures if appropriate, before a medicine is considered.

• Hot and cold packs, TENS, pain management programmes and physiotherapy

Pharmacological management

If non-pharmacological measures are ineffective or unsuitable, oral analgesia may be considered at the lowest effective dose for the shortest possible duration.

The choice of analgesic should be guided by treatment recommendations for the same type or severity of pain in non-pregnant patients, but will need to take possible risks to the foetus into account. Not all analgesics recommended in pain ladders are suitable for use during, or at certain stages of, pregnancy.

Avoid using medicines in the first trimester wherever possible – the period of greatest susceptibility to teratogenic effects, such as malformations is usually the first 12 weeks of pregnancy.

Guidelines

There are no specific guidelines for the management of pain in pregnancy. Check if there is local guidance in your area.

Follow analgesic recommendations in commonly used pain ladders, such as the NICE Clinical Knowledge Summary Analgesia, taking into consideration risks to the foetus for specific analgesics.

Treatment Options

Paracetamol

Paracetamol is the analgesia of choice for mild to moderate pain in pregnancy.

NSAIDs

Ibuprofen is the preferred NSAID in pregnancy.

First trimester

NSAIDs may be used if needed, particularly for inflammatory pain in first trimester.

Week 20 pregnancy

Avoid using systemic NSAIDs from week 20 of pregnancy unless clinically necessary. Use the lowest effective dose for the shortest duration, which is usually no longer than three days.

A MHRA Drug Safety alert highlights the risk oligohydramnios (low amniotic fluid) and foetal renal dysfunction from prolonged use of NSAIDs from week 20 of pregnancy.

For topical NSAIDs (gels and creams containing NSAIDs), follow the contraindications and warnings in the product information in relation to pregnancy.

Week 28 pregnancy

Do not use systemic NSAIDs from week 28 of pregnancy. This is due to the risks of premature closure of the ductus arteriosus and renal dysfunction in the foetus, and increased maternal bleeding time and reduced uterine contractions during labour.

For topical NSAIDs (gels and creams containing NSAIDs), follow the contraindications and warnings in the product information in relation to pregnancy.

Opioids

Information to guide choice of individual opioids is given below, in no order of preference.

The use of opioids at any stage in pregnancy would not usually be considered as medical grounds for termination of pregnancy.

Weak opioids

Consider weak opioids (codeine or dihydrocodeine) first with paracetamol for mild to moderate pain taking into account the risk to the foetus.

Strong opioids

Consider strong opioids for more severe pain taking into account the risk to the foetus.

Examples of strong opioids are buprenorphine, fentanyl, morphine, oxycodone and tramadol.

Codeine

The weak opioid codeine may be used where paracetamol has not been effective. There are more data available in pregnancy compared to the other weak opioid, dihydrocodeine.

The duration of treatment required may influence the choice of weak opioid used in pregnancy as codeine is contra-indicated during breastfeeding. This is due to concerns of toxicity to the infant from codeine and its metabolite, morphine. See our content on using codeine, dihydrocodeine or tramadol during breastfeeding for more information.

Risk of malformations

Most data on codeine in pregnancy (any trimester), whilst limited, do not suggest an increase in risk of foetal malformations. Possible associations with respiratory malformations, spina bifida and cardiac malformations have been reported following first trimester exposure.

Dihydrocodeine

Dihydrocodeine has an analgesic efficacy similar to codeine. Higher doses may provide some additional pain relief compared with codeine, but this may be at the cost of more nausea and vomiting.

Risk of malformations

There are no published data on the safety of dihydrocodeine in human pregnancy though it has been used without apparent adverse effects for several years. Any risks are expected to be similar to those for codeine.

Buprenorphine

Buprenorphine is a strong semi-synthetic opioid that only partially activates opioid receptors.

Risk of malformations and other complications

The limited data on buprenorphine in pregnancy do not indicate associations with congenital malformations, stillbirth, preterm delivery or low infant birth weight. However, increased risk cannot be excluded.

Fentanyl

Fentanyl is a very potent opioid analgesic.

The very limited data available are insufficient to assess the risk of teratogenicity or other pregnancy outcomes. The UKTIS fentanyl monograph has more detailed information on pregnancy outcomes.

Morphine

Morphine remains the most used opioid analgesic for severe pain although it frequently causes nausea and vomiting. RCOG guidance suggests that morphine can be taken during all stages of pregnancy at the lowest effective dose for the shortest possible duration.

Risk of malformations and other complications

There is no robust evidence of an increased malformation risk; a possible association with childhood strabismus (a visual defect) has been suggested but not confirmed.

Some studies suggest a possible association between morphine in pregnancy and altered foetal growth and an increased risk of preterm delivery.

Oxycodone

Oxycodone has an efficacy and side-effect profile similar to that of morphine. It is commonly used as a second-line medication if morphine is not tolerated or ineffective.

Risk of malformations and other complications

There is no indication that oxycodone in early pregnancy increases malformation rates, but the risks cannot be excluded. One study suggested a possible association between pulmonary valve stenosis and first trimester oxycodone exposure, but this requires confirmation. The UKTIS oxycodone monograph reports one study of over 2,000 exposed pregnancies which found that oxycodone exposure in the first and second trimesters was associated with a small increased risk of preterm delivery (absolute risk ~10% vs. background risk ~7%).

Tramadol

Tramadol is used to treat moderate to severe pain and has fewer of the typical opioid side-effects (respiratory depression, constipation and addiction potential) though psychiatric reactions have been reported. Reserve tramadol use in pregnancy where other alternative analgesics have been ineffective.

Risk of malformations and other complications

Possible associations between first trimester exposure and cardiovascular defects and a foot defect (talipes equinovarus) have been identified, but not confirmed. Most data regarding risks of congenital malformation following first trimester tramadol exposure are reassuring and do not indicate associations with miscarriage or pre-term delivery.

Monitoring in pregnancy

Maternal

Opioids may exacerbate constipation, nausea and vomiting, which may already be a problem in pregnant women.

Fetal

NSAID use beyond 20 weeks of pregnancy may increase the risk of fetal complications and require additional antenatal monitoring as described by the MHRA.

Use of codeine and dihydrocodeine would not usually warrant any additional fetal monitoring at any stage in pregnancy, unless other risk factors are present.

Pregnancies complicated by severe pain or those receiving long term opioids may require additional foetal monitoring or prenatal investigations. This should be assessed on a case-by-case basis.

Neonatal

Complications from neonatal withdrawal may occur with the prolonged use of opioid analgesics in pregnancy. Use of any opioid during pregnancy, particularly if it has been used long-term and/or around the time of delivery, confers a risk of neonatal respiratory depression.

Pregnancy outcome information for specific analgesics

UK Teratology Information Service (UKTIS) provides an overview on pain management in pregnancy including neuropathic pain; and more detailed information on pregnancy outcomes for many common analgesics including paracetamol, NSAIDs, ibuprofen, codeine or dihydrocodeine, buprenorphine, fentanyl, morphine, oxycodone and tramadol.

Patient information

Best Use of Medicines in Pregnancy (BUMPS) patient information.

The NHS website provides overviews of various pains in pregnancy: back pain, headaches, pelvic pain and stomach pain.

NHS Medicines A-Z provides a summary statement on the use in pregnancy of specific analgesics.

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