Published: 1 September 2022

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Non-steroidal anti-inflammatory drugs (NSAIDs): avoid use in pregnancy

Prescriber Update 43(3): 31–32
September 2022

The Medicines Adverse Reactions Committee (MARC) recently reviewed the safety of non-steroidal anti-inflammatory drug (NSAID) use in the third trimester of pregnancy.

The MARC concluded that all NSAIDs should be contraindicated in the third trimester of pregnancy and recommended that the pregnancy information in the data sheets for all NSAIDs should be updated and aligned.

Non-steroidal anti-inflammatory drugs should be avoided in pregnancy

Maternal use of NSAIDs in the third trimester of pregnancy may have adverse effects for the mother, fetus and neonate.^1,2 Possible adverse effects include the following.

• Maternal effects: prolonged labour, post-partum haemorrhage.
• Fetal effects: premature closure of the ductus arteriosus, fetal renal impairment, oligohydramnios.
• Neonatal effects: respiratory distress syndrome, persistent pulmonary hypertension of the newborn (PPHN), bronchopulmonary dysplasia, renal failure, intraventricular haemorrhage, necrotising enterocolitis.

MARC recommendations

Medsafe is working with the New Zealand sponsors of NSAIDs to update the data sheets, as per the MARC recommendations, to contain the following information.

• NSAIDs are contraindicated in the third trimester of pregnancy.
• NSAIDs should not be used during the first two trimesters of pregnancy unless the expected benefits to the mother outweigh the risks to the fetus. If there is a compelling need for NSAID treatment during the first or second trimester, limit use to the lowest effective dose and shortest duration possible.
• NSAID use in early pregnancy is associated with an increased risk of miscarriage and congenital malformation.
• Use of NSAIDs in the second or third trimester may cause fetal renal dysfunction leading to oligohydramnios and, in some cases, neonatal renal impairment. Oligohydramnios is generally seen after days to weeks of treatment, although it has been reported as soon as 48 hours after NSAID initiation. Oligohydramnios is usually, but not always, reversible after treatment discontinuation. Consider ultrasound monitoring of amniotic fluid if treatment extends beyond 48 hours. Discontinue NSAID treatment if oligohydramnios occurs.
• NSAID use during the third trimester may cause premature closure of the fetal ductus arteriosus, fetal renal impairment, inhibition of platelet aggregation, and may delay labour and birth. NSAID use in the third trimester of pregnancy is therefore contraindicated.

Data sheets are available on the Medsafe website.

Advise people who are pregnant to avoid using NSAIDs

Some systemic NSAIDs are classified as pharmacy-only or general sale medicines. The package labelling for NSAIDs that are available over-the-counter states that the medicine should not be used in pregnancy.

Healthcare professionals are reminded to enquire about NSAID use in people who are pregnant or planning pregnancy and to advise them not to self-medicate with these medicines during pregnancy.

Health Navigator has information for consumers about the risks associated with taking NSAIDs.

References

1. Bloor M and Paech M. 2013. Nonsteroidal anti-inflammatory drugs during pregnancy and the initiation of lactation. Anesthesia and Analgesia 116(5): 1063-75. DOI: 10.1213/ANE.0b013e31828a4b54 (accessed 4 July 2022).
2. Koren G, Florescu A, Costei AM, et al. 2006. Nonsteroidal antiinflammatory drugs during third trimester and the risk of premature closure of the ductus arteriosus: a meta-analysis. Annals of Pharmacotherapy 40(5): 824-9. DOI: 10.1345/aph.1G428 (accessed 17 February 2022).