Page 248 Guide to Pain Management in Low-Resource Settings

236 Author(s)

at risk during the period of organogenesis, between 17 anesthetist or pain specialist, a physiotherapist, a chi-
and 70 days postconception; however, the use of some ropractor, a psychologist, a pharmacist, and/or a com-
drugs during the second and third trimesters of preg- munity nurse. Th is multidisciplinary team approach
nancy can also cause organ abnormalities, especially will optimize her care, and regular review of her pain
in the central nervous and cardiovascular systems. It is management can be organized. Shillah may well have
thus important to know, in detail, the potential risks as- physical and psychological factors contributing to
sociated with analgesic drug administration at any stage her pain that can be treated in various ways, includ-
of pregnancy. ing physical therapies and even invasive pain therapy
Fortunately, we know it is likely that millions procedures or surgery, such that her reliance on drugs
of women have taken some of the commonly used might be reduced or even eliminated. Th e latter would,
pain killers, both at the time of conception and dur- of course, solve all the issues related to the potential
ing early pregnancy. For a number of analgesic drugs, pharmacological toxicities of drugs administered dur-
extensive clinical experience indicates a very low risk ing pregnancy. Even if drug treatment remains the only
of problems, which is reassuring. When clinical in- way of controlling her pain, her response to the types
formation is combined with analysis of animal data of drugs, their doses, and the regimens prescribed will
about potential teratogenic or carcinogenic eff ects, need to be reviewed once she becomes pregnant and
or data about how much drug is transferred into the as pregnancy advances.
breast milk, the level of concern about a drug can be
estimated. Consequently, regulatory bodies and edu- What would your advice be
for Shillah and Alusine?
cational organizations in many countries have classi-
fi ed drugs into risk categories that are used to guide Shillah has chronic nonmalignant pain with neuro-
a risk versus benefi t assessment in the pregnant and pathic features, and you should refer to the chapters
lactating woman. For example, there is no evidence on back pain and neuropathic pain for information.
that opioids are risky in early pregnancy, but they may You also need to be in a position to advise her about
cause depression of the neonate at birth, so most opi- the specifi c risks of the drugs she is currently taking
oids are classifi ed as drugs that have harmful but re- and about any risks associated with alternative drugs.
versible pharmacological eff ects on the human fetus First, what about a tricyclic antidepressant such as am-
or neonate, without causing malformations. itriptyline, an NSAID such as diclofenac, and an opioid
It is imperative to relieve maternal suff ering, but such as codeine?
at the same time, harm to the fetus should be avoided. It is important to be honest and transpar-
Breastfeeding is also a critical imperative for optimizing ent in all communication. Although there can be no
the infant’s health, possibly with life-long benefi ts. It is guarantees of complete safety with any drug, and be-
important that we know where to look and are able to cause controlling neuropathic pain can be challenging,
access information about these topics when specifi c in- it is not necessary for her to abandon all pain killers.
formation is required. Indeed, there is no evidence that continuing amitrip-
tyline in early pregnancy signifi cantly increases the
What would be the ideal approach to pain risk of malformations. Th is is a drug many pregnant
management in pregnancy and lactation? women have used, so the couple can be reassured of its
During and immediately prior to pregnancy, nonphar- relative safety, and it could be continued. Th e NSAIDs
macological pain management options should be con- such as diclofenac and indomethacin (and a similar
sidered and explored before analgesic drugs are used. drug, aspirin) are not eff ective against neuropathic
Ideally, if available in the regional city, and prior to pain but may be very helpful for a few days for mus-
Shillah becoming pregnant, she should be reviewed by culoskeletal or postoperative wound pain. However,
a group of health care providers, particularly those with unless there is active infl ammation, which is unlikely
an interest in pain medicine and clinical experience in Shillah’s case, they should not be continued long-
dealing with patients with diffi cult pain management term. Although these drugs do not cause fetal mal-
problems. In Shillah and Alusine’s case, for example, formations, they adversely infl uence fertility, increase
this group might include an orthopedic surgeon, a reha- the risk of miscarriage by interfering with blastocyst
bilitation physician, an obstetrician, a family doctor, an implantation, and can cause serious problems in late