Page 247 Guide to Pain Management in Low-Resource Settings

Chapter 31

Pain Management Considerations
in Pregnancy and Breastfeeding

Michael Paech

Case report 1 (analgesics in (30–60 mg every 6 hours as required, but only once or
pregnancy) two days each fortnight).

Should you be concerned about prescribing
You are visited by a woman, Shillah, and her partner,
pain killers in a pregnant or lactating woman?
Alusine, from a large rural town. Th ey have recently
married, and they plan to move to the regional city and We should be cautious about prescribing any drug to
stay with relatives because they are hoping to start a a pregnant woman! Nevertheless, almost 90% of wom-
family. Alusine says: “Doctor, my wife has bad back and en take prescribed drugs during pregnancy. Although
leg pain, and every day she takes medication prescribed the incidence of analgesic use during pregnancy varies
by the local doctor. We are trying to have a baby, so I am across diff erent countries, it is probably 5–10% during
worried about how those drugs might aff ect the baby. Is it the fi rst trimester and is likely to be much higher in later
okay for her to keep taking them?” pregnancy. Th e incidence of perinatal use of illicit drugs
You ask Shillah about her pain, and learn that (including opioids) also varies widely, but it ranges from
she has had it for over a year since a motor vehicle ac- 10% to 50%. Th us, it is extremely common for preg-
cident in which she broke some lumbar vertebrae. Th e nant women and their fetuses to be exposed to drugs
pain has persisted and is a burning sensation that radi- relevant to pain management during pregnancy and
ates from the low back down through the buttock past lactation. Th e incidence of fetal abnormalities among
the back of her knee, often occurring at night when she is live births is approximately 2%, so this background
lying quietly. She also has an area near her spine in the rate should be considered when comparing rates in the
lower back that tingles and feels sore, even when it is only whole pregnant population with those among women
touched lightly. He doctor has tried her on several diff er- taking specifi c drugs.
ent analgesic drugs, and the only one that helps a little is Despite the prevalence of their use, there is very
a tablet she takes at night before bed, although she is also little information about the eff ects of analgesic drugs
taking an anti-infl ammatory drug, and she takes some being taken prior to conception on fertility. Th ere are
codeine when the pain is bad—but it makes her consti- limited human epidemiological or observational data
pated, so she doesn’t like to use it much. On examination on the eff ects of pain-relieving drugs during early preg-
she has no obvious spinal abnormality. You later learn nancy. With the exception of aspirin and the nonsteroi-
she is taking a low dose of amitriptyline (10 mg) at night, dal anti-infl ammatory drugs (NSAIDs), the embryo ap-
regular diclofenac (100 mg twice a day), and codeine pears protected in the fi rst 2 weeks. Th e fetus is most
Guide to Pain Management in Low-Resource Settings, edited by Andreas Kopf and Nilesh B. Patel. IASP, Seattle, © 2010. No responsibility is assumed by IASP 235
for any injury and/or damage to persons or property as a matter of product liability, negligence, or from any use of any methods, products, instruction, or
ideas contained in the material herein. Because of the rapid advances in the medical sciences, the publisher recommends that there should be independent
verifi cation of diagnoses and drug dosages. Th e mention of specifi c pharmaceutical products and any medical procedure does not imply endorsement or
recommendation by the editors, authors, or IASP in favor of other medical products or procedures that are not covered in the text.