Analgesic Medications in Pregnancy

1. See Also
   1. Medications in Pregnancy
2. Precautions: Pregnancy
   1. NSAIDs should generally be avoided in pregnancy (despite Category B before third trimester)
      1. Second trimester use is likely safe
      2. Miscarriage risk in first trimester
      3. Premature Ductus Arteriosus closure in third trimester
   2. Tramadol should be avoided in pregnancy
      1. Second trimester use may be safe
      2. Fetal toxicity in animals (highest risk in first trimester)
      3. Respiratory problems and withdrawal symptoms in newborn (avoid in third trimester)
   3. Opioids should be avoided in pregnancy unless there is no viable alternative
      1. First trimester use is associated with heart defects and Spina bifida
3. Class B: No risk in controlled animal studies
   1. Acetaminophen (Tylenol)
      1. Analgesic of choice in pregnancy
   2. Narcotics (Class D if prolonged use or high dose)
      1. Nalbuphine (Nubain)
      2. Meperidine (Demerol)
      3. Butorphanol (Stadol)
      4. Fentanyl (Duragesic)
      5. Hydromorphone (Dilaudid)
      6. Methadone (Dolophine)
      7. Morphine Sulfate
      8. Oxycodone (Percocet)
   3. NSAIDs (first and second trimester only)
      1. Ibuprofen (Motrin)
      2. Indomethacin (Indocin)
      3. Ketoprofen (Orudis)
      4. Naproxen (Naprosyn)
      5. Piroxicam (Feldene)
      6. Sulindac (Clinoril)
4. Class C: Small risk in controlled animal studies
   1. Narcotics (Class D if prolonged use or high dose)
      1. Codeine (Tylenol with codeine)
      2. Hydrocodone (Vicodin)
      3. Tramadol (Ultram)
      4. Propoxyphene (Darvocet)
   2. Barbiturates
      1. Butalbital (Fiorinal)
         1. Class D if prolonged use or high dose
   3. NSAIDs (first or second trimester only)
      1. Aspirin
      2. Etodolac (Lodine)
      3. Ketorolac (Toradol)
      4. Nabumetone (Relafen)
      5. Oxaprozin (Daypro)
5. Class D: Strong evidence of risk to the human fetus
   1. Aspirin
      1. Used only with specific indications in pregnancy
      2. Risk of neonatal Hemorrhage, IUGR, perinatal death
      3. Low dose Aspirin may be safer
         1. Hauth (1995) Obstet Gynecol 85:1055-8
   2. All NSAIDs (Third Trimester)
   3. Prolonged use or high dose of any Narcotic
   4. Prolonged use or high dose Butalbital (Fiorinal)
   5. General Anesthesia - not in Briggs (1998)
6. Preparations: Lactation Safe Analgesic Medications
   1. Acetaminophen (Tylenol)
   2. Ibuprofen (Motrin)
   3. Tramadol
      1. Small amount crosses into Breast Milk
7. Preparations: Avoid Opioids in Lactation
   1. Opioids that are converted to active metabolites by CYP2D6
      1. Codeine
      2. Hydrocodone
      3. Oxycodone
   2. Risk of overdose in babies if mother is a ultra-rapid CYP2D6 metabolizer
      1. Ultrarapid CYP2D6 metabolism occurs in 10% caucasians, 3% african americans, 1% chinese and hispanic
   3. Preacutions if these Opioids are used in Lactation
      1. Avoid use beyond 4 days of life when milk intake increasing substantially
         1. Consider pumping and dumping while taking the Opioid
         2. Transition to Acetaminophen or NSAID as soon as possible
      2. Use the lowest effective dose of the shortest acting agent
      3. Limit dosing to immediately after feeding
8. References
   1. Briggs (1998) Drugs in Pregnancy and Lactation, 5th ed
   2. (2012) Presc Lett 19(2): 11
   3. Black (2003) Am Fam Physician 67(12):2517-24
   4. Larimore (2000) Prim Care 27(1):35-53