Page 253 Guide to Pain Management in Low-Resource Settings

Chapter Title 241

colic, degenerating uterine fi broids, or bowel pain); impairment, premature closure of the ductus arterio-
neuropathic pain (intercostal neuralgia, meralgia par- sus with subsequent neonatal pulmonary hyperten-
esthetica of the lateral cutaneous nerve of the thigh, sion, and neonatal intracranial hemorrhage. Th ere is
iliohypogastric and genitofemoral neuralgia, various insuffi cient information about the eff ects of the COX-2
cancer-induced neuralgias, post-traumatic complex inhibitors (e.g., celecoxib), so these agents should also
regional pain syndrome, or post-amputation pain); be avoided.
migraine; and invasive cancer pain.
Would local anesthetics or opioid drugs
What initial treatment would you be suitable in this case?
suggest for Martine? It is the case with many painful conditions (including

Irrespective of the cause of the pain, nonpharmacologi- Martine’s) that the treatment you start with ultimate-
cal pain management options should be considered and ly proves insuffi cient. Th e possibility of a neuropathic
tried, where possible, before analgesic drugs are used component should be considered in Martine’s case, and
for acute pain that appears likely to require prolonged the appropriate drug treatment is discussed in case 1
treatment or a stepwise approach to continued manage- above. However, the two main options to consider next
ment. Your plan for Martine should start with physi- for Martine are local anesthetic infi ltration and oral
cal therapies (for example referral to a therapist for a opioid analgesia. Infi ltration with local anesthetic pro-
sacroiliac pelvic support belt; gentle manipulation and vides temporary (and sometimes prolonged) relief of
postural exercises; and local application of heat or ice, joint pain (another example is into the coccyx for coc-
transcutaneous electrical nerve stimulation, acupunc- cydynia, or into the facet joint for back pain) and myo-
ture or similar treatments), but it would also be reason- fascial pain (for example into trigger points in the ab-
able to introduce nonopioid analgesic drugs, bearing in dominal wall, neck, or shoulders or the costochondral
mind their safety for the fetus and neonate. Paracetamol and intercostal area). A steroid such as triamcinolone
(acetaminophen) has been used in millions of pregnant could be included if infl ammation is suspected, but
women and is safe. Aspirin is acceptable, but its pro- steroids are best omitted in the fi rst trimester and in
longed use is best avoided (see case 2 above). Tramadol repeated injections. Provided the operator has knowl-
has not been evaluated in large trials during pregnancy edge of the relevant anatomy and adequate expertise,
but is widely used after the fi rst trimester, so it would be infi ltration is generally a low-risk procedure that can
acceptable for short-term use for Martine to reduce the be useful both diagnostically and therapeutically. Th e
severe pain until other measures have had a chance to local anesthetic drugs are of no or minimal risk to the
become eff ective. It would not be ideal to continue tra- fetus, although maximum dose limits for the individu-
madol for several weeks until the time of delivery, be- al drug and the type of block should be applied. Extra
cause a neonatal withdrawal syndrome at 24–36 hours care must be taken when injecting near major organs
has been reported. or the fetus (for example, when injecting near the blad-
NSAIDs have a limited role during pregnancy, der and lower uterine segment or cervix at the pubic
and it is very important to understand the implications symphysis). As a fi nal option, if epidural techniques are
of prescribing them. Th ese drugs prevent prostaglan- available in a referral hospital, a period of epidural an-
din-induced myometrial gap junction formation and algesia with a combined local anesthetic and opioid can
transmembrane infl ux and sarcolemmal release of cal- be very benefi cial.
cium, making indomethacin an eff ective tocolytic drug If opioid analgesia is commenced during
that has been used to prevent preterm labor after the pregnancy, it would be best to arrange inpatient care
period of organogenesis. However, they are contrain- for a few days. This strategy allows oral opioid titra-
dicated in later pregnancy, certainly after 32 weeks tion and stabilization (see case 1 above) and supple-
gestation (as applies to Martine), and some would ar- mentation with intravenous opioid or intravenous
gue from the start of fetal viability (23–24 weeks in re- ketamine to establish pain control. Oral or sublingual
source-rich countries and hospitals). Th is leaves only a opioids (morphine, methadone, codeine, and in some
short period during the second trimester of pregnancy countries oxycodone, buprenorphine, and fentanyl)
when these drugs may be useful. Fetal exposure in late can be used safely for short periods during pregnancy
pregnancy may result in oligohydramnios due to renal (and in some cases will already be prescribed or are