Editorial
3
Analgesics and Anti-inflammatory
Drugs Prescription during Pregnancy
Professor Ishag Adam, Department of
Obstetrics and Gynecology, Unaizah College of Medicine and Medical Sciences,
Qassim University, Saudi Arabia
Pregnant women encounter several challenges during pregnancy when
managing health conditions including pain and fever compared to the general
population.(1)
Poorly managed pain, fever, and conditions necessitating the use of analgesics
and anti-inflammatory drugs during pregnancy can have several adverse effects
on the mother and her unborn child. (2, 3) Generally, the use of most
medications during pregnancy is not without risks to the mothers and their
unborn children. (1, 4) This editorial aims to address analgesics and
anti-inflammatory drugs prescription during pregnancy and to suggest suitable
recommendations to improve pregnancy outcomes.
During pregnancy analgesics and anti-inflammatory drugs are used
solely or with other drugs in treating different kinds of health conditions
such as pain, rheumatic diseases, urinary tract infection, malaria,
tuberculosis, dengue, chikungunya, etc. (3, 5, 6) Moreover, some
anti-inflammatory drugs like low-dose acetylsalicylic acid (aspirin) are used
to reduce the risk for preeclampsia, and its related morbidity and mortality
(preterm birth and intrauterine growth restriction) .[2]
Fever during pregnancy including pyrexia of unknown origin (PUO) is associated
with several poor maternal and perinatal outcomes including maternal morbidity
and mortality, preterm birth, premature rupture of membranes (PROM), fetal
anomalies, intra uterine fetal demise (IUFD), development attention deficit
hyperactivity disorder (ADHD) and autism.(5) Such poor pregnancy outcomes
associated with fever necessitate urgent treatment. However, the use of
analgesics and anti-inflammatory drugs is not without risks and there is
limited research about their safety during pregnancy. (2, 4) The challenges
exist when pregnancy occurs with preexisting health conditions such as chronic
rheumatic diseases, where drugs are needed during pregnancy. Some
anti-rheumatic drugs have potential maternal or fetal toxicity, for
example, nonsteroidal anti-inflammatory drugs (NSAIDs) which are known to be
effective anti-inflammatory, antipyretic and analgesic drugs; but should be
avoided in the third trimester due to the risks of premature closure of the
ductus arteriosus. (3)
Although
pain in pregnancy exists, there is limited research addressing the impacts of
pain on maternal and perinatal outcomes. (6) Ray-Griffith, et al.
reviewed 144 articles that studied the evaluation and management of
pre-existing chronic pain in pregnancy, chronic pain associated with pregnancy,
and chronic pain in relation to the mode of delivery. They recommended seven
guidelines for chronic pain management during and after pregnancy: a) complete
history and physical examination; b) monitor patients for alcohol, nicotine,
and substance use; c) collaborate with the patient to set treatment goals; d) develop
a management plan; e) for opioids, use lowest effective dose; f) formulate a
pain management plan for labor and delivery and g) discuss reproductive health
with women with chronic pain. (6)
Even
for long-used drugs during pregnancy, which are considered to be safe in
pregnancy at the recommended dose, some side effects were reported recently.
(4) For example, there have been recent concerns about the safety of the use of
acetaminophen (paracetamol); which is the preferred antipyretic/analgesic for
pregnant women worldwide; when taken during early pregnancy. These include
negative impacts on offspring reproductive development (cryptorchidism and
hypospadias). (4)
This
indicates the need for continued monitoring of drug safety on unborn children
exposed to drugs during pregnancy until puberty and adulthood. In other words,
first approval of drug safety does not guarantee safety forever.
The need for proper management of pain, fever or any pre-existing
health condition that require treatment during pregnancy and the absence of
conclusive data regarding the usage of analgesic/anti-inflammatory drugs during
pregnancy; put more pressure on researchers to come up with a conclusive
solution without jeopardizing women and unborn children health. Based on the
evidence literature, the current situation of analgesics and anti-inflammatory
drugs during pregnancy remains a real challenge that needs to be overcome. We
came up with the following recommendations to overcome these challenges; aiming
to improve maternal health and pregnancy outcomes:
1.
Analgesics
and anti-inflammatory drugs should only be prescribed by qualified health
professionals, after a thorough diagnosis and determination of the needs for
prescription. However, at present, this is not the case, as taking
over-the-counter drugs is common during pregnancy. The successful approach of
any patient should start with a complete history and physical examination and
with the lowest effective dose if needed. (6)
2.
Whenever
possible, health professionals should avoid using drugs during pregnancy. The
majority of pregnant women’s conditions (aches and pains) can be treated
without the use of analgesic/anti-inflammatory drugs. For example, some
pregnant women may experience headaches often, so taking enough rest may be the
best treatment approach. In case drugs are needed, using the lowest dose of the
prescribed analgesic and/or anti-inflammatory drugs for the minimum period to
relieve the discomfort during periods of ill health during pregnancy should be
the strategic approach. (4. 6)
3.
Establishing
effective collaboration between health professionals and women even before
pregnancy. (6) Encouraging preconception counseling to implement appropriate
preventive measures, and to manage any existing health conditions that may
require treatment including analgesics and anti-inflammatory drugs during
pregnancy, such as chronic pain, rheumatic diseases, PUO, malaria, visceral
leishmaniasis (Kala-azar) and tuberculosis. For example, unplanned pregnancy,
especially among women with rheumatic diseases can pose a threat to the health
of the woman and the fetus. Therefore, appropriate management of rheumatic
diseases during pregnancy (consisting of a multidisciplinary care team) can
prevent maternal end-organ damage and minimize the adverse effects of the
disease on pregnancy outcomes. (3)
4.
Honest
and accurate sharing of information with pregnant women is essential to support
them in making choices that are in the best interests of their unborn babies.
These information include thorough counseling of pregnant women about using
medications during pregnancy and the probable risks based on the current
evidence. (1) In case a pregnant woman encounters drug side effects such as
teratogenic or fetotoxic effects, the risk must be assessed on an individual
base and a risk management strategy must be determined. (1)
5.
More
research is needed regarding drug safety in pregnancy including analgesics and
anti-inflammatory drugs. Women should not be excluded from drug trials,
especially when there are preliminary benefits to mother and her fetus, and the
benefits outweigh the risks of the potential tested drug. Currently, pregnant
women depend on drugs that are usually studied on the general population and
the results may not be suitable for pregnant women due to physiological changes
during pregnancy.
In conclusion, prescription of analgesics and anti-inflammatory
drugs during pregnancy is often challenging. Not prescribing such drugs, may
lead to increased maternal and fetal morbidity and mortality including
abortion, PROM, preterm birth, anomalies, IUFD, etc. Preconception counseling,
timely investigations, and early appropriate drug doses and duration may help
prevent the aforementioned poor outcomes. Further research trials are needed to
ensure safety of analgesics and anti-inflammatory drugs during pregnancy; and
whenever possible, pregnant women should participate in such researches. This
is in the hope that drug safety during pregnancy should not be extrapolated
from the results of observational studies on the general population.
References
1.
Dathe K,
Schaefer C. The use of medication in pregnancy. Dtsch Arztebl Int.
2019;116:783–90.
2.
Davidson KW, Barry MJ,
Mangione CM, Cabana M, Caughey AB, Davis EM, et al. Aspirin use to prevent
preeclampsia and related morbidity and mortality: US Preventive Services Task
Force Recommendation Statement. JAMA - J Am Med Assoc. 2021;326:1186–91.
3.
Peterson EA, Lynton J,
Bernard A, Santillan MK, Bettendorf B. Rheumatologic medication use during
pregnancy. Obstet Gynecol. 2020;135:1161–76.
4.
Tadokoro-Cuccaro R,
Fisher BG, Thankamony A, Ong KK, Hughes IA. Maternal paracetamol intake during
pregnancy—impacts on offspring reproductive development. Front Toxicol. 2022;4
April:884704.
5.
Mulders-Manders CM,
Banerjee RR. Pyrexia of unknown origin. Med (United Kingdom). 2021;49:719–22.
6.
Ray-Griffith SL, Wendel
MP, Stowe ZN, Magann EF. Chronic pain during pregnancy: a review of the
literature. Int J Womens Health. 2018;10:153–64.