Over-the-counter pain medication in pregnancy

In this edition of EBM, we discuss data from a nationalsurvey about low back and pelvic pain in pregnancy, whichstates 70% of a convenience sample of UK women sufferfrom this under-estimated and under-reported condition(Sinclair et al, 2014). This high percentage was previouslycited in a Cochrane systematic review by Pennick and Liddle(2013) who reported 66% of pregnant women sufferedfrom low back pain. However, the women’s descriptions ofthe pain experienced are most harrowing and they challengeus to develop evidence-informed guidelines and effectivemanagement strategies.Naturally, we look towards NICE in the UK for guidanceon how to manage this problem but there are no specificguidelines. A guideline for pain in labour (NICE, 2007) comesup when you use the search facility on the NICE homepage,but this is currently under review and will be publishedin December 2014. However, advice and guidance forpregnant women about medication is particularly complex,as the conduct of gold standard randomised controlled trialresearch for efficacy and effectiveness on pregnant womenis taboo.We need to look at our target population – the modern‘Z’ generation that does not expect to suffer pain and hasgrown up in a culture of ‘pill for every ill’. This belief systemis fuelled by the commercial availability of over-the-counter(OTC) medications, where tablets are purchased like they aresweets. Medications routinely purchased at garages, streetcorner shops, newsagents, supermarkets and pharmaciesinclude paracetamol, ibuprofen and aspirin. However, whena woman becomes pregnant, decisions about which of thesecommon medications are safest to use in pregnancy becomesa key question. ‘Read the packet,’ you would wisely adviseand this is exactly what I did in my local supermarket.I picked up paracetamol (500mg) and was surprisedto note absolutely nothing written on the packet relatedto safety or dosage in pregnancy. This may change in thefuture, as recent evidence is casting a shadow over thesafety of the medication with Liew et al (2014) and Eyerset al (2011) reporting links with paracetamol usage duringpregnancy and the development of behavioural disordersin children. The next pain medication selected was aspirin(75mg) and there was a clear statement: ‘Medicines shouldnot be taken in pregnancy and when breastfeeding withoutconsulting a doctor.’ However, it did not say anythingabout taking aspirin. I picked up ibuprofen (200mg) andhere under WARNING was a clear statement: ‘If you arepregnant do not take this product and ask your doctor foradvice.’ The NHS Choices website has a clear statement:‘The use of ibuprofen in pregnant women, weeks one to 13,increases the risk of miscarriage and the baby could developa heart defect or other abnormalities, such as defects in theirabdominal wall (gastroschisis) or a cleft palate. After 28weeks, there is a risk of heart problems in the baby, highblood pressure in the baby’s lungs, delay in labour andreduced amniotic fluid levels’ (NHS Choices, 2014). This istaken directly from the Medicines and Healthcare productsRegulatory Agency website.What I thought yesterday was safe is a little less safetoday. This does not mean that pregnant women stop takingprescribed medication and expect to suffer unnecessarypain by refusing all pain medication. Indeed not. If thiswas so, the chances of raised blood pressure due to painwould increase, leading to the potential for additional harm– higher than the risk of taking two paracetamol? What wehave to learn to do is weigh up the individual situation, usethe best evidence available, ensure we have local protocolsand national guidelines, consult with medical colleaguesand most important of all is to be confident that it is partof our role to discuss medication usage openly with women.This includes prescribed and OTC medication. From aresearch perspective, epidemiological studies, such as thoseconducted by the EUROmediCAT team (euromedicat.eu),are extremely valuable, but it is important to note they arefocused on exploring medication outcomes for mothers whohave chronic conditions, such as epilepsy, diabetes, asthmaand depression. Other key databases for midwives to knowabout include: Safefetus (safefetus.com), NHS Choices(nhs.uk/conditions/pregnancy-and-baby), FDA for women(www.fda.gov/forconsumers/byaudience/forwomen) and theOrganization of Teratology Specialists (mothertobaby.org)and UKTIS (medicinesinpregnancy.org).