The Role of Psychological Factors in Persistent Pain After Cesarean Delivery

Ilioinguinal and Iliohypogastric Nerve Block for Acute and Chronic Pain Relief After Caesarean Section: A Randomized Controlled Trial

Background

There is an increasing cesarean section (CS) rate in Egypt. Multiple methods are used to manage pain after CS.

Objectives

This study aimed to assess the effect of ultrasound-guided bilateral ilioinguinal and iliohypogastric nerve block on pain reduction after CS.

Methods

We classified 64 cases of elective CS into two equal groups. The block group underwent the nerve block, and the control group did not. Postoperative pain, morphine consumption, time to analgesic request, and complications were compared between the two groups.

Results

No significant difference was detected between the two groups regarding patient characteristics or operation duration. However, pain scores during rest and movement were significantly lower in the block group than in controls, especially within the first 12 hours following the operation. Morphine consumption was significantly lower in the block group (4.53 ± 1.456) in group B vs. (8.87 ± 2.013) in group C with P-value < 0.001. Time to the first rescue analgesia was significantly longer in the intervention group than in the other group (12.25 vs. 3.81 hours). Pruritis and nausea incidence was significantly higher in controls than in the block group. The incidence of chronic postoperative pain was significantly lower in the block group.

Conclusions

The ilioinguinal and iliohypogastric nerve block is efficient and safe for managing postoperative pain following CS. It is associated with significant improvement of acute and chronic pain after such operations.

Pain Intensity Predicts Pain Catastrophizing During the Postpartum Period: A Longitudinal Random Intercept Cross-Lagged Panel Study

OBJECTIVE

Pain catastrophizing is an important psychological predictor of pain. Recent evidence suggests the relationship between catastrophizing and pain intensity could be bidirectional, but most studies have been conducted on chronic pain patients and using criticized statistical methods. The present study aimed to examine if the relationship between pain intensity and catastrophizing was bidirectional in the context of childbirth.

METHODS

A total of 504 women without chronic pain were recruited on their 32-37 gestational week. They completed measures of catastrophizing and pain intensity on the first encounter and then again at 1, 3, and 6 months postpartum. The temporal relationship between the variables was assessed using a random intercept cross-lagged panel model.

RESULTS

The hypothesis of reciprocal association did not receive support, as pain intensity predicted catastrophizing during the postpartum period, but catastrophizing did not show an effect over pain intensity at any moment.

CONCLUSIONS

Pain intensity predicting catastrophizing is consistent with previous literature, while the lack of effect of catastrophizing over pain intensity is an unexpected result, which may suggest that catastrophizing plays a different role in the postpartum period. These results highlight the importance of timely efforts for pain management during the postpartum period and contribute to the theoretical conceptualization of catastrophizing.

The incidence of chronic pain following Cesarean section and associated risk factors: A cohort of women followed up for three months

BACKGROUND

Chronic post-surgical pain (CPSP) is one of the post-surgical complications of a Cesarean section. Despite the high rates of Cesarean section worldwide, the incidence of CPSP and the risk factors for this condition remain relatively unknown. The objective of this study was to calculate the incidence of CPSP in women submitted to Cesarean section and to analyze the associated risk factors.

MATERIALS AND METHODS

A prospective cohort of 621 women undergoing Cesarean section was recruited preoperatively. Potential presurgical (sociodemographic, clinical and lifestyle-related characteristics) and post-surgical risk factors (the presence and intensity of pain) risk factors were analyzed. Pain was measured at 24 hours and 7, 30, 60 and 90 days after surgery. Following discharge from hospital, data were collected by telephone. The outcome measure was self-reported pain three months after a Cesarean section. The risk factors for chronic pain were analyzed using the log-binomial regression model (a generalized linear model).

RESULTS

A total of 462 women were successfully contacted 90 days following surgery. The incidence of CPSP was 25.5% (95%CI: 21.8-29.7). Risk factors included presurgical anxiety (adjusted relative risk [RR] 1.03; 95%CI: 1.01-1.05), smoking (adjusted RR 2.22; 95%CI: 1.27-3.88) and severe pain in the early postoperative period (adjusted RR 2.79; 95%CI: 1.29-6.00).

CONCLUSION

One in four women submitted to Cesarean section may develop CPSP; however, the risk factors identified here are modifiable and preventable. Preventive strategies directed towards controlling anxiety, reducing smoking during pregnancy and managing pain soon after hospital discharge are recommended.

Preoperative anxiety-induced glucocorticoid signaling reduces GABAergic markers in spinal cord and promotes postoperative hyperalgesia by affecting neuronal PAS domain protein 4

Preoperative anxiety is common in patients undergoing elective surgery and is closely related to postoperative hyperalgesia. In this study, a single prolonged stress model was used to induce preoperative anxiety-like behavior in rats 24 h before the surgery. We found that single prolonged stress exacerbated the postoperative pain and elevated the level of serum corticosterone. Previous studies have shown that glucocorticoid is associated with synaptic plasticity, and decreased spinal GABAergic activity can cause hyperalgesia in rodents. Here, single prolonged stress rats’ lumbar spinal cord showed reduced glutamic acid decarboxylase-65, glutamic acid decarboxylase-67, GABA type A receptor alpha 1 subunit, and GABA type A receptor gamma 2 subunit, indicating an impairment of GABAergic system. Furthermore, neuronal PAS domain protein 4 was also reduced in rats after single prolonged stress stimulation, which has been reported to promote GABAergic synapse development. Then, intraperitoneal injection of RU486 (a glucocorticoid receptor antagonist) rather than spironolactone (a mineralocorticoid receptor antagonist) was found to relieve single prolonged stress-induced hyperalgesia and reverse neuronal PAS domain protein 4 reduction and the impairment of GABAergic system. Furthermore, overexpressing neuronal PAS domain protein 4 could also restore the damage of GABAergic system caused by single prolonged stress while interfering with neuronal PAS domain protein 4 caused an opposite effect. Finally, after stimulation of rat primary spinal cord neurons with exogenous corticosterone in vitro, neuronal PAS domain protein 4 and GABAergic markers were also downregulated, and RU486 reversed that. Together, our results demonstrated that preoperative anxiety led to GABAergic system impairment in spinal cord and thus caused hyperalgesia due to glucocorticoid-induced downregulation of neuronal PAS domain protein 4.

Factors associated with persistent pain after childbirth: a narrative review

A systematic literature search was performed to identify studies that reported risk factors for persistent pain after childbirth. Many studies have sought to identify risk factors for post-delivery pain in different populations, using different methodologies and different outcome variables. Studies of several different but interrelated post-partum pain syndromes have been conducted. Factors strongly and specifically associated with persistent incisional scar pain after Caesarean delivery include a coexisting persistent pain problem in another part of the body and severe acute postoperative pain. For persistent vaginal and perineal pain, operative vaginal delivery and the magnitude of perineal trauma have been consistently linked. History of pregnancy-related and pre-pregnancy back pain and heavier body weight are robust risk factors for persistent back pain after pregnancy. Unfortunately, limitations, particularly small samples and lack of a priori sample size calculation designed to detect specific effect sizes for risk of persistent pain outcomes, preclude definitive conclusions about many other predictors and the strength of outcome associations. In future studies, assessments of specific phenotypes using a rigorous analysis with appropriate predetermined sample sizes and validated instruments are needed to allow elucidation of stronger and reliable associations. Interventional studies targeting the most robustly associated, modifiable risk factors, such as acute post-partum pain, may lead to solutions for the prevention and treatment of these common problems that impact a large population.

Persistent pain after cesarean delivery

The incidence of persistent pain after cesarean deliveries (CD) varies but is much lower than after comparable surgeries. However, with over four million deliveries annually and a rising CD rate, even a low prevalence of persistent pain after CD impacts many otherwise healthy young women. Consideration of the pathophysiology of persistent pain after surgery and the risk factors predisposing women to persistent and chronic pain after CD provides insights into the prevention and treatment of persistent pain; and improves the quality of care and recovery after CD. The findings that the peripartum state and oxytocin confer protection against persistent pain may provide new and interesting perspectives for the prevention and treatment of chronic pain caused by trauma or surgery. Predictive tools available to identify and target patients at high risk of acute and chronic pain have mostly weak to modest predictive correlations and many are either not clinically feasible or too time-consuming to apply. Persistent pain has been linked to the severity of acute postoperative pain and opioid exposure. Modified surgical techniques, neuraxial anesthesia and opioid-sparing analgesia may help limit the development of persistent and chronic pain. The goal of this narrative review is to examine the incidence of persistent pain after CD; review briefly the underlying pathophysiology of persistent pain and the transition from acute to chronic pain (with particular emphasis on the uniqueness after CD); and to review modifiable risk factors and prevention strategies that identify at-risk patients and allow tailored treatment.

The Effect of Spinal versus General Anesthesia on Quality of Life in Women Undergoing Cesarean Delivery on Maternal Request

Introduction

The proportion of women electing for cesarean delivery has increased in both developed and developing countries. Cesarean delivery on maternal request (CDMR) refers to a primary cesarean delivery performed because the mother requests this method of delivery in the absence of standard medical/obstetrical indications.

Several studies compared anesthesia modalities in cesarean section regarding clinical outcomes such as maternal mortality, post-operative pain and bleeding, but only a few compared health-related quality of life (HRQoL) of women undergoing general anesthesia versus spinal anesthesia. The aim of this study was to determine whether pregnant women who undergo general anesthesia (GA) for cesarean delivery compared with spinal anesthesia (SA) differ regarding their perceived HRQoL.

Methodology

We enrolled 160 pregnant women with American Society of Anesthesiologists (ASA) class II, scheduled for CDMR with GA or SA. Anesthesia modality was based on patient’s preference. Participants assessed their state of health with the EuroQoL-5 Dimensions-3 Levels (EQ-5D-3L) self-administered questionnaire at four time points: six hours before cesarean delivery, 24 hours after cesarean delivery, one week and one month after cesarean delivery. Patients also rated their health on the EQ visual analog scale (EQ-VAS) from 100 mm “best imaginable health state” to 0 mm “worst imaginable health state”.

Results

More women who underwent spinal anesthesia reported “no problem” with regards to “mobility’ (64% vs. 30%, p = 0.00), “usual activities” (90% vs. 38%, p = 0.00), and “pain/discomfort” (20% vs. 5%, p = 0.007). Repeated measurement analysis showed that the two groups started off with the same EQ-VAS score, however, both decreased over time with different slope resulting in different scores at 24 hours after CS. Then the scores increased in both groups over time and ended up being rather close at one month after CS.

Discussion

Unless there is a contraindication, neuraxial anesthesia is the anesthetic technique of choice for cesarean delivery in all parturient in general. This concept is based on more mortality and morbidity that have been seen with general anesthesia in this particular population. Our study demonstrated significant advantages of spinal anesthesia compared to general anesthesia in cesarean section regarding postoperatively perceived HRQoL. We showed that more pregnant women who chose spinal anesthesia as their anesthesia modality reported “no problem” with respect to “mobility” and “Self-care” 24 hours after cesarean section. On the top of that, more women in this group had “no problem” in their “usual activities” at one week and one month after cesarean delivery time points. Moreover, EQ-5D general health score was higher 24 hours after cesarean delivery with regional anesthesia comparing to general anesthesia.

Conclusion

We determined that compared to general anesthesia, spinal anesthesia is the technique of choice for cesarean section because not only it avoids a general anesthetic and the risk of failed intubation, but also because it provides effective pain control, mobility and fast return back to daily activities for new mothers and increase their quality of life.

Postpartum chronic pain

Postpartum chronic pain is a clinical reality which affects 6.1% to 11.5% of women after delivery and affects their recovery. The large range of incidence observed in the literature relies on criteria used to define chronic postpartum pain. The features depend on the type of delivery. Cesarean delivery which rate is increasing worldwide seems currently associated with lower risk of chronic postpartum pain, specifically chronic pelvic pain. Further chronic scar pain which often involves a neuropathic component is often of mild intensity. In opposite, after vaginal delivery, chronic pelvic pain and perineal pain have an important negative impact on women's mood and quality of life. As for any chronic pain, individual risk factors account more than degree of tissue trauma. From actual reports in the field, better pain education of both women and health care providers might help to reduce the problem.

Chronic pain during pregnancy: a review of the literature

BACKGROUND AND PURPOSE

The majority of the reviews and studies on chronic pain in pregnancy have primarily focused on the pharmacological and non-pharmacological treatment options. The purpose of our review was to identify evidence-based clinical research for the evaluation and management of preexisting chronic pain in pregnancy, chronic pain associated with pregnancy, and chronic pain in relation to mode of delivery.

METHODS

A literature search was undertaken using the search engines PubMed, CINAHL, EBSCOhost, and Web of Science. Search terms used included "chronic pain" AND "pregnant OR pregnancy" OR "pregnancy complications" from inception through August 2016.

RESULTS

The basis of this review was the 144 articles that met inclusion criteria for this review. Based on our review of the current literature, we recommend 7 guidelines for chronic pain management during and after pregnancy: 1) complete history and physical examination; 2) monitor patients for alcohol, nicotine, and substance use; 3) collaborate with patient to set treatment goals; 4) develop a management plan; 5) for opioids, use lowest effective dose; 6) formulate a pain management plan for labor and delivery; and 7) discuss reproductive health with women with chronic pain.

CONCLUSION

The management of chronic pain associated with pregnancy is understudied. Obstetrical providers primarily manage chronic pain during pregnancy. Some general guidelines are provided for those health care providers until more information is available.

Incidence and severity of chronic pain after caesarean section: A systematic review with meta-analysis

BACKGROUND

The frequency of caesarean section has increased dramatically in recent decades. Despite this, robust data regarding the consequences of caesarean section in terms of developing chronic postsurgical pain (CPSP) are still lacking.

OBJECTIVE

This systematic review analysed the incidence and severity of CPSP in women 3 to less than 6, 6 to less than 12, and at least 12 months after caesarean section.

DESIGN

Systematic review of prospective and retrospective observational studies and randomised controlled trials with meta-analysis.

DATA SOURCE

We searched MEDLINE to May 2015.

ELIGIBILITY CRITERIA

We included all studies investigating the incidence and/or severity of CPSP at least 3 months after caesarean section. The primary outcome was chronic postsurgical wound pain (CPSP 'wound'). Secondary outcomes were persistent pain in the back area, pelvic region or reported as residual pain, and severity of 'birth-related' chronic pain.

RESULTS

Meta-analysis using the random-effects model based on 15 studies (n = 4475) reporting CPSP 'wound' at 3 to less than 6 months after caesarean section revealed an incidence of 15.4% [95% confidence interval (CI): 9.9 to 20.9%]. For 6 to less than 12 and at least 12 months after caesarean section, the incidence of CPSP 'wound' was estimated at 11.5% (95% CI: 8.1 to 15.0%, n = 3345) and 11.2% (95% CI: 7.4 to 15.0%, n = 3451), respectively. Meta-regression analysis using the publication year as predictor revealed stable CPSP 'wound' incidences at each postoperative time slot from 2002 to the present. Of those patients who reported chronic pain, 9.6% (95% CI: 0.0 to 21.0%) had severe pain, 23.5% (95% CI: 10.0 to 37.0%) had moderate pain and 49.2% (95% CI: 18.9 to 79.4%) had mild pain at 6 months.

LIMITATIONS

Major limitations are high statistical heterogeneity of the meta-analyses and inconsistencies in reporting severity of chronic 'birth-related' pain.

CONCLUSION

This meta-analysis finds a clinically relevant incidence of CPSP 'wound' after caesarean section ranging from 15% at 3 months to 11% at 12 months or longer that has been largely stable in recent years.