PAIN MANAGEMENT IN PREGNANCY

PLEASE BE AWARE: The advice about use of NSAIDs in pregnancy has recently changed. It is now recommended that prolonged use of NSAIDs should be avoided after 20 weeks of pregnancy (rather than the 30 weeks discussed throughout this document). For more details, please see the information from the MHRA here. This document is currently under review, and will be updated as soon as possible to include the new advice.

There are no specific guidelines for the management of pain in pregnancy. Choice of analgesic should largely be guided by treatment recommendations for the same type/severity of pain in non-pregnant patients, but will also need to take into account possible risks to the fetus. Severe or chronic pain, if left inadequately treated or untreated, can potentially have adverse effects on the mother and therefore the fetus.

Where possible/appropriate, non-pharmacological measures should be attempted before drug therapy is considered. If non-pharmacological measures are not effective or are considered inappropriate, medication should be initiated appropriate to the level of pain indicated by a pain scale, as is routine in the non-pregnant population. However, it should be borne in mind that not all analgesics recommended in commonly used pain ladders are suitable for use during, or at certain stages of, pregnancy. Neuropathic, chronic, or other complex pain syndromes are likely to require specialist management and women with these conditions who are pregnant or considering pregnancy should be referred to a specialist with expertise in managing pain in pregnancy.

The final decision regarding the pain relief regimen for a pregnant patient remains the clinical responsibility of the prescriber. Consideration should be given to the balance between known or unquantified fetal risk and maternal benefit from pain relief.

Certain medications used as analgesics are associated with increased risk of fetal malformation (e.g. carbamazepine) or other adverse effects at particular stages of pregnancy (e.g. NSAIDS after the first trimester) and are therefore not recommended for use in pregnancy or at particular stages of pregnancy unless absolutely necessary. Human pregnancy safety data are extremely limited for some anticonvulsants and antidepressants used in the management of certain pain syndromes and these limitations should be discussed with the patient when considering possible treatments. Please refer to the respective UKTIS monograph(s) for the relevant drugs, or telephone UKTIS for case-specific advice.

Neonatal withdrawal may occur with use of centrally acting analgesics late in pregnancy. Use of any opioid during pregnancy, particularly around the time of delivery, confers a risk of neonatal respiratory depression.

Exposure to medications used in the treatment of pain at any stage of pregnancy would not usually be regarded as medical grounds for termination of pregnancy, however other risk factors may be present in individual cases which may independently increase the risk of adverse pregnancy outcome. Clinicians are reminded of the importance of consideration of such factors when performing case-specific risk assessments.