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Study suggests link between NSAIDs, aspirin, miscarriage

Some specialists say pregnant patients should avoid these painkillers, though many acknowledge shortcomings in the research and call for more data.

By Victoria Stagg Elliott, amednews staff. Oct. 6, 2003.

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It's an age-old saying: Take two aspirins and call me in the morning. But new findings suggest caution in offering this advice to patients who are pregnant.

A study in the Aug. 16 British Medical Journal reopened the complicated question of what medications a woman can take safely during pregnancy and how to balance the health of the woman with that of the fetus.

The study found that taking aspirin or nonsteroidal anti-inflammatory drugs around the time of conception or for longer than a week during pregnancy increased the chance of miscarriage by 80%. No such link was found for acetaminophen. That drug is already the preferred painkiller for pregnant women, and study authors said these data suggested it should also be the drug of choice of women trying to get pregnant.

"Women who are planning on pregnancy or women who are sexually active, but not necessarily planning on pregnancy, and are casual users of painkillers, should switch to acetaminophen or just not use painkillers," said De-Kun Li, MD, PhD, MPH, the study's lead author and reproductive epidemiologist in the division of research at Kaiser Permanente in Oakland, Calif. "For the women who are chronic users, they should talk to their doctors and balance the benefit and the risks."

The Food and Drug Administration already states that NSAIDs should be avoided in the third trimester and that aspirin is only recommended for specific indications throughout pregnancy. Experts, however, said the study was interesting but far too preliminary. Few previous studies of note have suggested such a link.

"There's a lot more information that needs to be collected," said Mark A. Klebanoff, MD, MPH, director of the division of epidemiology, statistics and prevention research at the National Institute of Child Health and Human Development. "Were I pregnant or thinking about becoming pregnant or a physician taking care of women who are pregnant, I wouldn't panic based on this report."

But while most doctors try to keep their pregnant patients from taking any medications, they do recommend the drugs cited in this study for specific indications. Low-dose aspirin is suggested for some pregnant women because a handful of studies have indicated it may prevent recurrent miscarriages or preeclampsia, although those studies are also far from conclusive. Short courses of NSAIDs are used to stop preterm labor.

"Generally, I tell women not to use the NSAIDs and not to use aspirin unless they're on baby aspirin because they've had fertility problems," said Julian Parer, MD, PhD, a professor of obstetrics and gynecology at the University of California, San Francisco, who specializes in high-risk pregnancies. "If they have headaches and aches and pains, I tell them to use acetaminophen."

Questions persist

Experts were also highly critical of this study's methods and numbers. The study was retrospective, and some would like to see a prospective one before making any definitive conclusions. They acknowledge, though, that such a study would be challenging to carry out.

Additionally, researchers relied on a pool of more than 1,000 pregnant women, but only a few dozen in the sample actually took painkillers during pregnancy.

Finally, the data were also based on interviews and could be subject to recall bias.

"The study is too weak for any conclusions to be drawn that the use of aspirin increases the risk of miscarriage," said Thomas E. Bryant, MD, president of the Aspirin Foundation of America, a nonprofit education foundation funded by those economically vested in aspirin production.

But with such a common drug as aspirin apparently causing some problems, it also begs the question of whether women should be taking anything at all during pregnancy or while attempting to conceive -- unless absolutely necessary.

"I do recommend that women stay away from just about as much as they can during the first trimester," said Sandra Ann Carson, MD, professor of ob-gyn at Baylor College of Medicine in Houston. "And for women who are trying to get pregnant, I tell them to stay away from NSAIDs and aspirin around the time of ovulation. It just makes good sense."

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