Page 255 Guide to Pain Management in Low-Resource Settings

Chapter Title 243

Drug Recommendation during Pregnancy Recommendation during Breastfeeding
Paracetamol (acet-
aminophen) Compatible throughout Compatible
Aspirin Avoid at conception and avoid chronic high doses dur- Potential toxicity
ing pregnancy
Indomethacin Avoid at conception, during fi rst 10 weeks of gestation, Probably compatible
and after 32 weeks of gestation
Diclofenac Avoid at conception, during fi rst 10 weeks of gestation, Compatible
and after 32 weeks of gestation
Ibuprofen As indomethacin Compatible
Naproxen As indomethacin Compatible
Ketoprofen As indomethacin Compatible
Ketorolac As indomethacin Compatible
Celecoxib As indomethacin Limited data, potential toxicity
Tramadol Probably avoid in the fi rst trimester, but thereafter low
risk (neonatal abstinence syndrome is possible)
Morphine Compatible, but possible neonatal depression at birth Probably compatible
and abstinence syndrome with third-trimester use
Codeine As morphine, but less eff ective Probably compatible
Pethidine (meperidine) As morphine, but use alternative opioids if possible Compatible, but use alternative opioids
Methadone As morphine Probably compatible
Oxycodone As morphine Probably compatible
Fentanyl As morphine
Amitriptyline Low risk throughout Limited data, potential toxicity
Carbamazepine Compatible if used for epilepsy, but preferably avoid Compatible
(risk of malformations)
Gabapentin Limited evidence suggests low risk No data—probably compatible
Pregabalin Insuffi cient data No data—probably compatible
Ketamine Low risk throughout
Clonidine Probably avoid in the fi rst trimester Probably compatible
Bupivacaine Low risk throughout Probably compatible
Ropivacaine Compatible throughout Probably compatible
Lidocaine (lignocaine) Compatible Probably compatible

References Prescribing Medicines in Pregnancy, 4th edition 1999, and amendments.
Australian Government. Department of Health and Aging. Th erapeutic
Goods Administration. http://www.tga.gov.au/docs/html/medpreg.htm or
[1] American Academy of Pediatrics Committee on Drugs. Th e transfer of http://www.tga.gov.au/DOCS/HTML/mip/medicine.htm
drugs and other chemicals into human milk. Pediatrics 2001;108:776– Drugs in Pregnancy and Breastfeeding. http://www.perinatology.com/expo-
89. sures/druglist.htm
[2] McDonnell NJ, Keating ML, Muchatuta NA, Pavy TJ, Paech MJ. Anal-
gesia after caesarean delivery. Anaesth Intensive Care 2009;37:539–51. Th erapeutic Guidelines. http://www.tg.com.au
[3] Rathmell JP, Viscomi CM, Ashburn MA. Management of nonobstetric National Institutes of Health. US National Library of Medicine. Drugs
pain during pregnancy and lactation. Anesth Analg 1997;85:1074–87. and Lactation Database (LactMed). http://toxnet.nlm.nih.gov/cgi-bin/sis/
[4] Roche S, Hughes EW. Pain problems associated with pregnancy and htmlgen?LACT
their management. Pain Reviews 1999;6:239–61.
ObFocus. High risk pregnancy directory. http://www.obfocus.com/resources/
medications.htm
Websites

Acute Pain Management: Scientifi c Evidence. Chapter 10.2. Th e pregnant
patient. Second edition 2005, Dec 2007 update. Australian and New Zealand
College of Anaesthetists and Faculty of Pain Medicine. Approved by Austra-
lian Government and National Health and Medical Research Council. http://
www.anzca.edu.au/resources/books-and-publications