Analgesia during pregnancy or while breastfeeding
- November 19, 2024
Treatment of acute pain (e.g. headache, soft tissue injuries, or following minor procedures) in pregnant and breastfeeding women follows the same principles as for all adults (illustrated below).
| Mild to moderate pain:
Paracetamol +/- NSAID e.g. ibuprofen or celecoxib |
Moderate pain:
Add NSAID or weak opioid e.g. codeine, tramadol |
Severe pain:
Strong opioid with a laxative (+ paracetamol) e.g. morphine |
As pain resolves cease opioids before paracetamol and NSAIDs.
In pregnancy assume all medicines cross the placenta and the benefits to the mother taking the medicine need to be weighed against possible risks to the developing foetus. When breast feeding most medicines are only in small amounts in breastmilk, often not enough to affect the infant.
| Pregnancy | Breastfeeding | |
| Paracetamol | Safe to use at any stage of pregnancy. | Safe to use. |
| NSAIDs | Use up to week 20 of pregnancy if clinically indicated. Avoid from week 20. Consider avoiding if planning pregnancy. |
The safety of most NSAIDs is known. For example, the relative infant dose (RID) for ibuprofen, diclofenac, and naproxen is 0.4%, 0.1%, and 3.3% respectively. These are considered ‘safe’ to use in breast feeding1,2,3 |
| Codeinea | Use at any stage of pregnancy when stronger pain relief than paracetamol or NSAID is required. | Safe to use in breastfeedingb. |
| Tramadola | Limited and conflicting data when used in first trimester. Safe to use in 2nd or 3rd trimester. | Short courses are safe to use. |
| Morphinea | Use at any stage of pregnancy when maximum doses of paracetamol plus codeine or tramadol are insufficient. | Safe to usec. |
aUse near term may be associated with withdrawal symptoms in the neonate and respiratory depression
bNote: Some guidance incorrectly suggests codeine is unsafe in breast feeding, based on a misunderstanding of one case report4
cCaution at higher doses with young infants, particularly if premature.
Paracetamol
There is extensive experience in millions of pregnancies that paracetamol is safe at any stage of pregnancy1,2,5.
A small amount of paracetamol is excreted into breast milk, but the quantity is low1,2.
Nonsteroidal Anti-Inflammatory Drugs (NSAIDs, e.g., ibuprofen or diclofenac)
NSAIDS should only be used in the first 2 trimesters if benefits to mother outweigh risks to fetus (including fetal renal dysfunction and oligohydramnios), using lowest effective dose for shortest duration possible6.
Cautions: Use of NSAIDs at or in the days following conception reduces the chance of implantation. If attempting to conceive avoiding NSAIDs may increase the chances of success7.
Women with hyperemesis should avoid NSAIDs because of the risk of acute kidney injury (AKI).
All NSAIDs are contraindicated after week 20 of pregnancy as they are known to cause adverse foetal effects including premature closure of the ductus arteriosus and neonatal pulmonary hypertension. NSAIDs can inhibit uterine contraction, prolong the length of gestation and delay the onset of labour when given late in pregnancy. At the time of parturition, they have also been associated with excess bleeding in both the mother and the infant.
NSAIDs should be avoided in oligohydramnios (they are used to treat polyhydramnios)6.
Strong opioids or codeine
Codeine is a prodrug of morphine. There is extensive experience of safe use of morphine and codeine in pregnancy.1,10 There is limited evidence for the safe use of other strong opioids in pregnancy. Methadone and buprenorphine have been used in pregnancy to treat opioid dependence11.
Regular use of high doses of strong opioids near term are associated with neonatal withdrawal symptoms and respiratory depression1,2.
Small amounts of morphine and other strong opioids are transferred to breastmilk3, in quantities unlikely to cause harm1,
Tramadol
Tramadol is a synthetic opioid analogue with similar potency to codeine. There is limited and conflicting information on the safety of tramadol use early in pregnancy, some studies have reported a small increase in congenital malformations1,2, while other have found no increase12. Tramadol, like other opioids, if used in high doses late in pregnancy has the potential to cause neonatal withdrawal symptoms1,2. Overall, short courses appear safe, especially in the 2nd and 3rd trimesters1.
Small amounts of tramadol and its active metabolite are transferred to breastmilk in quantities unlikely to cause harm1,2,13.
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