The management of chronic pain in pregnancy

M R C O G PA R T 2 · S O S P O C K E T C A R D · K N O W L E D G E A R E A 5 – A N T E N ATA L C A R E

The Management of Chronic Pain in Pregnancy Hutchinson L, Petrosellini C, McGuckin D et al. The management of chronic pain in pregnancy. TOG 2026;28:16–29. doi:10.1111/tog.70025

3 months up to 28% 55–94% DEFINES CHRONIC PAIN PREGNANT WOMEN WITH PRE-EXISTING NEONATAL ABSTINENCE SYNDROME AFTER CHRONIC PAIN ANTENATAL OPIOIDS

DO N' T-M IS S FA C TS

  1. NSAIDs only before 28 weeks, shortest course — late use risks oligohydramnios (5×) and ductus arteriosus constriction (0.5%). Analgesic aspirin >300 mg/day in late pregnancy not advised

  2. NAS in 55–94% of opioid-exposed newborns — involve neonatology early; NICE prefers replacement over detoxification; breastfeeding reduces need for withdrawal treatment

  3. Codeine avoided in breastfeeding (CYP2D6 ultra-rapid metabolisers) — use dihydrocodeine. Ibuprofen/diclofenac are the postnatal NSAIDs of choice

  4. Serotonergic drugs → PPH RR 1.32 (SNRI 1.79); ~34% vs 26% background — active management of the third stage; no excess risk if stopped ≥1 month before birth

  5. Late SSRI: neonatal adaptation syndrome ~30% (background 10%); persistent pulmonary hypertension of the newborn ~2/1000 (background 3/1000)

  6. Valproate = major teratogen; carbamazepine → dose-dependent neural tube defects; lamotrigine/levetiracetam = background 2–3%. Folic acid for all + ultrasound screening essential

  7. Headache in pregnancy: exclude pre-eclampsia and cerebral venous thrombosis. Sumatriptan safe; propranolol preferred prophylaxis; no opioids for migraine/tension/cluster headache

  8. Sacral nerve stimulators must not be placed or used in pregnancy; invasive neuromodulation not recommended — contact the implanting service early (spinal anaesthesia for caesarean may still be possible)

FRAMEWORK

Chronic pain >3 months; up to 28% of pregnant women have a pre-existing condition; WHO ladder does not apply Classify: primary vs secondary (ICD-11) and nociceptive / neuropathic / nociplastic No pregnancy-specific chronic pain guideline; NICE NG193 omits pregnancy. Non-specialists should not initiate treatment — refer to a specialist/ad hoc MDT (maternal medicine, pain physician, neonatologist, physiotherapist, psychologist) Try non-pharmacological first; anticipate higher peripartum analgesic requirements — early anaesthetic input

DRUGS AT A GLANCE

Paracetamol — safe, pregnancy & breastfeeding Sumatriptan — safe

Amitriptyline — 1st choice neuropathic pain in pregnancy NSAIDs — only <28 weeks, short course

Gabapentinoids — specialist, neonatal withdrawal Sodium valproate — major teratogen Codeine — not in breastfeeding

Intravesical dimethyl sulfoxide — teratogenic (animal)

GUIDELINE MAP

NICE NG193 chronic primary pain · NG59 low back pain · CG173 neuropathic pain · CG150 headaches RCOG GTG 70 bladder pain syndrome · GTG 41 chronic pelvic pain · SIP 59 antenatal/postnatal analgesia RCP fibromyalgia (2022) and CRPS (2018) · resources: UKTIS, BUMPS, LactMed, BPS PMP directory NICE recommends CBT/ACT, exercise, acupuncture; PMPs endorsed by FPM/BPS but not by NICE; TENS not recommended for chronic pain

ABBREVIATION KEY

ACT — acceptance and commitment therapy ICD-11 — International Classification of Diseases, 11th revision

ADHD — attention deficit hyperactivity disorder LactMed — Drugs and Lactation Database

AED — antiepileptic drug MHRA — Medicines and Healthcare products Regulatory Agency

aOR / aRR — adjusted odds ratio / adjusted relative risk NAS — neonatal abstinence syndrome

BPS — British Pain Society NICE — National Institute for Health and Care Excellence

BUMPS — Best Use of Medicines in Pregnancy NSAID — non-steroidal anti-inflammatory drug

CBT — cognitive behavioural therapy OR / RR — odds ratio / relative risk

CLBP — chronic low back pain PMP — pain management programme

COX — cyclooxygenase PPH — postpartum haemorrhage

CRPS — complex regional pain syndrome SNRI — serotonin–noradrenaline reuptake inhibitor

CYP2D6 — cytochrome P450 2D6 enzyme SSRI — selective serotonin reuptake inhibitor

FPM — Faculty of Pain Medicine TENS — transcutaneous electrical nerve stimulation

HR — hazard ratio UKTIS — UK Teratology Information Service

IASP — International Association for the Study of Pain WHO — World Health Organization

Source: The Obstetrician & Gynaecologist (TOG), RCOG journal — doi:10.1111/tog.70025

Clinically reviewed by NHS obstetricians and gynaecologists

MRCOG AI is an independent educational tool. It is not affiliated with, endorsed by, or connected to the Royal College of Obstetricians and Gynaecologists (RCOG).

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