analgesia in pregnancy?

[Boatswain2PA]

What do you do for the pregnant woman with real pain & pathology? Tylenol is good....but often isn't enough.

[ventana]

straight traditional opiates

subutex is getting good reports

methadone used to be the gold standard for chronic pain in preg

 

T3, vicodin, percocet, methadone, subutex (not suboxone)

[Boatswain2PA]

But opiates are "C", especially in 1st trimester due to risks of congenital heart defects. Anyone else use them in preg??

[wilso2ar]

I've had chronic pain patients that suddenly became pregnant. I defer to OB and see them use buprenorphine in the two people I have seen in this situation. This is for chonic opioid patients. It does come in a patch Butrans which is fantastic.

[rcdavis]

There are few if any absolutely safe Meds in pregnancy, a couple of class Bs( some antihistamines, Tylenol, etc), but majority are class C, even most antibiotics.

 

Way I figure it, if the medication is needed, then it is needed.. There is a downside to the fetus with chronic maternal adrenocortical response due to stress and pain.

 

Discuss what class c means, and offer it to the mom.

 

Withholding class c Meds in pregnancy because of a small, or theoretical, risk, seems ludicrous... But should be a choice made by the both of you.. Patient and provider.

 

I have no problem with opiates in pregnancy.

[EMEDPA]

agree with Davis. a pregnant pt with real pain gets real drugs.

[ventana]

it is funny, when treating a pregnant patient I think we all pull out our A game, only to prescribe only went is absolutely necessary with good risk-benefit analysis.

 

should we not be doing this with every patient?

 

Yesterday news head line - there is a "super bug" which has a 50 percent mortality rate! Also, addiction is running rampant in our younger generation and OxyContin and Suboxone are huge drugs for pharmacy companies.

 

 

 

 

Overall do a good thorough evaluation of the patient, develop a reasonable plan, educate the patient as to the risks of both action and interaction. I occasionally let the patient made the choice if there really is not a medical differentiation.

 

 

 

PS I do prescribe opiates for pregnant patients however very small dosing for a very short duration after having a discussion with her on possible side effects. Which is worse, having mom being in pain and stress and physical duress for 4 weeks while her fractured ankle heals, or minimal opiate exposure.

[jmj11]

What kind of pain are you seeing in the pregnant population?

 

I see a lot of migraineurs whose headaches worsen during pregnancy. We have strategies that usually work, but not always as our arsenal is of course more limited. We use a lot of cat Cs. We now use selected triptans, codeine, prednisone and a handful of preventative medications. I use the CAM as much as I can, including acupuncture and a few supplements. Certainly avoiding most of the anti-epileptics (lamotrigine being about the only exception) and of course you must weight in the balance the benefits with the risk and document that you had very detailed conversations. But headache is different than other pain syndromes. It is a treatable disease state like asthma.

[Boatswain2PA]

Thanks to everyone.

 

As to the "what kind of pain I'm seeing in the pregnant population?"....just about everything. I'm in small-town America ER, standard here is pretty much nothing but tylenol unless your femur is visible, and maybe even then.

 

Again, thanks to everyone.

[EMEDPA]

I would treat significant fxs, burns, postop pain, etc with narcs.

all the minor sprains and stuff get tylenol.

[ajnelson]

I agree, I use opiates for real pain. I've had patients with kidney stones, fractures, sprains, migraines, essentially the same syndromes as a non-pregnant patient. I explain the risks and benefits of opiates in pregnancy with the patient and the fact that we do need to adequately address their pain for the safety of the pregnancy as well. When discharged home, I explain to them to use tylenol for mild pain, narcotics for moderate to severe pain and to try and not let the pain get to moderate to severe status, especially those with an acute injury or ureteral stone. I also tell them that is is more important than ever for close OB follow up.

[ventana]

Just a side comment

 

ER's have to pay attention to pain meds

 

don't over correct and give nobody narcotics - "it's not broken and therefor you get APAP" is a horrible argument on the ankle that is all black and blue and the size of a grapefruit, or the high speed MVA that is all banged up but no fractures. Use you head - treat with a small reasonable pain med

 

some funny one's

 

Dilaudid first line for renal colic - dumb

duragesic for a male UTI - dumber

nothing for horrible high speed MVA (turnpike) with a fatality in the car but no broken bones - ibuprofen - dumbest (they were not at fault - innocent bystanders...) fatality was from aortic arch deceleration injury......

 

 

 

I think T3 is reasonable for most skelatal complaints - maybe some vicodin

 

Perc's for confirmed mean fractures - sometimes just percolone so they can titrate up

 

if you suspect abuse write vicoprofen - the ibu portion makes it really hard to abuse..... not much street value

 

 

 

BUT if there is no tangible evidence of pain "my tooth aches, my back aches, I ran out of my perc's" send them to their PCP with a note saying the ER does not manage chronic pain. and keep doing it till they get the idea!

[medic25]

Oxycodone has the advantage of being a category B, so it's usually my go-to drug for severe pain in pregnancy.