Management of Nonobstetric Pain During Pregnancy and Lactation

The Main Changes in Pregnancy—Therapeutic Approach to Musculoskeletal Pain

Background and Objectives: During pregnancy, women undergo various physiological and anatomical changes that are accentuated as the pregnancy progresses, but return to their previous state a few weeks/months after the pregnancy. However, a targeted therapeutic approach is needed. Most of the time, during this period, these changes precipitate the appearance of pain, musculoskeletal pain being the most common. Pregnant women should avoid treating musculoskeletal pain with medication and should choose alternative and complementary methods. Exercise along with rest is the basis for treating chronic musculoskeletal pain. Side effects of physical therapy are rare and, in addition, it is not contraindicated in pregnant women. The benefits of this type of treatment in combating pain far outweigh the risks, being an easy way to improve quality of life. The objective of this article is to discuss the management of musculoskeletal pain during pregnancy, to identify the main musculoskeletal pain encountered in pregnant women along with drug treatment, and to expose the beneficial effects of alternative and complementary methods in combating pain. Materials and Methods: A literature search was conducted using medical databases, including PubMed, Google Scholar, and ScienceDirect, using the keywords “changes of pregnancy”, “musculoskeletal pain”, “pregnancy pain”, “pain management”, “pharmacological approach”, “alternative and complementary treatment” and specific sites. Information was collected from studies whose target population included pregnant women who complained of musculoskeletal pain during the 9 months of pregnancy; pregnant women with other pathologies that could increase their pain were not included in this review. Results: The articles related to the most common non-obstetric musculoskeletal pain in pregnancy along with pharmacological treatment options and alternative and complementary methods for musculoskeletal pain management during pregnancy were selected. Conclusions: The results were used to guide information towards the safest methods of therapy but also to raise awareness of the treatment criteria in order to compare the effectiveness of existing methods. Treatment must consider the implications for the mother and fetus, optimizing non-pharmacological therapeutic options.

Meeting the Challenge of Analgesia in a Pregnant Woman With Burn Injury Using Subanesthetic Ketamine: A Case Report and Literature Review

Pain management guidelines for burn injury in pregnant women are scarce. Maternal and fetal morbidity and mortality in pregnant burn patients have been shown to be higher than that of the general population, especially in severe burns. Early intervention and interdisciplinary treatment are critical to optimize maternal and fetal outcomes. Proper pain management is central to wound treatment, as poor control of pain can contribute to delayed healing, re-epithelialization, as well as persistent neuropathic pain. We present this case of a 34-year-old female patient who suffered an 18% total body surface area burn during the third trimester of pregnancy to demonstrate that ketamine can be considered as an adjunct for procedural and background analgesia during the third trimester, as part of a multimodal strategy in a short-term, monitored setting after a thorough and complete analysis of risks and benefits and careful patient selection.

Ultrasound-guided caudal epidural steroid injection for successful treatment of radiculopathy during pregnancy

Aim: The aim of this case report is to describe ultrasound guidance for caudal epidural steroid injection during pregnancy. Case report: A 29-year-old, 32-week parturient presented with severe back and leg pain with MRI demonstrating herniation of the L5-S1 level. The disabling pain was refractory to conservative therapy, and an ultrasound-guided caudal epidural steroid injection was performed. There was significant pain relief in the first week with an uneventful subsequent pregnancy. Following delivery, the patient had no further recurrence of her presenting symptoms. Conclusion: Severe radiculopathy may be encountered during pregnancy, complicated by a limited number of treatment options. Ultrasound guidance should be considered during performance of caudal epidural injections in feasible cases.

Medications and Breast-Feeding: A Guide for Pharmacists, Pharmacy Technicians, and other Healthcare Professionals Part I

Objective:

To provide a guide for practicing pharmacists, pharmacy technicians, and other healthcare professionals so that they are able to counsel and advise breast-feeding mothers and fellow healthcare professionals on the safety and use of common ambulatory care, analgesic, and anesthetic medications during breast-feeding.

Data Sources:

Primary texts used by the breast-feeding community were searched, as well as Micromedex, MEDLINE, PubMed, Embase, and Embase2 (1984–July 2003).

Study Selection and Data Extraction:

Multiple sources were utilized whenever available to validate the data, and primary articles were used to verify all tertiary source information. Search terms included breast feeding, lactation, nursing, and medications, as well as specific drug names.

Data Synthesis:

Concerns regarding medication use during breast-feeding have caused mothers to either discontinue nursing or not take necessary medications. Complete avoidance of medications or cessation of breast-feeding is often unnecessary. Although there are medications that can be harmful to nursing infants, breast milk concentrations of most drugs are insufficient to cause any harm.

Conclusions:

Having objective and reliable information on medications enables pharmacists, pharmacy technicians, other healthcare providers, and mothers to make educated decisions regarding drug therapy and breast-feeding.

Advances in the Determination of Alcohol and Other Drug Consumption during Pregnancy: A Study of 900 Births in Montevideo, Uruguay

A study was performed in Uruguay to estimate the prevalence of drug consumption during pregnancy. The study consisted of a survey and biological samples to validate the responses and investigate information concerning risks involved in drug consumption during pregnancy. The survey consisted of 900 face-to-face interviews performed within 48 hours after birth. Perinatal registries were taken from hospital archives. Nine hundred meconium samples were tested for alcohol, tobacco, illegal drugs, and tranquilizers. The results of the survey indicated consumption during pregnancy of the following: 41.3% tobacco, 36.8% alcohol, 16.3% tranquilizers, 68% caffeine (more than 400 mg/day), and 1.4% illegal drugs. In addition, 8.9% of the pregnancies were unplanned. Among the planned pregnancies, some physicians warned their patients about risks associated with tobacco (34%), alcohol (27%) and illegal drugs (7%). Meconium analysis revealed tobacco (cotinine), 51.8%; alcohol (fatty acid ethyl esters, or FAEES), 43.5%; and cocaine (base paste), 2.5%. Newborns whose mothers smoked tobacco presented statistically lower birth weights: 11% of all newborns at low birth weight, with health problems reported for 14.8%.

Low Back Pain and Pelvic Girdle Pain in Pregnancy

Pregnancy has a profound effect on the human body, particularly the musculoskeletal system. Hormonal changes cause ligamentous joint laxity, weight gain, and a shift in the center of gravity that leads to lumbar spine hyperlordosis and anterior tilting of the pelvis. In addition, vascular changes may lead to compromised metabolic supply in the low back. The most common musculoskeletal complaints in pregnancy are low back pain and/or pelvic girdle pain. They can be diagnosed and differentiated from each other by history taking, clinical examination, provocative test maneuvers, and imaging. Management ranges from conservative and pharmacologic measures to surgical treatment. Depending on the situation, and given the unique challenges pregnancy places on the human body and the special consideration that must be given to the fetus, an orthopaedic surgeon and the obstetrician may have to develop a plan of care together regarding labor and delivery or when surgical interventions are indicated.

Polymorphism in the ADRB2 gene explains a small portion of intersubject variability in pain relative to cervical dilation in the first stage of labor

BACKGROUND

Variability in labor pain has been associated with demographic, clinical, and psychological factors. Polymorphisms of the β2-adrenergic receptor gene (ADRB2) influence sensitivity to experimental pain in humans and are a risk factor for chronic pain. The authors hypothesized that polymorphisms in ADRB2 may influence labor pain.

METHODS

After Institutional Review Board approval and written informed consent, the authors prospectively obtained hourly pain reports from 233 nulliparous parturients during the first stage of labor, of which 199 were included in the current analysis. DNA from blood samples was genotyped at polymorphisms in the genes for the β2-adrenergic receptor, the μ opioid receptor subtype 1, catechol-O-methyltransferase, fatty acid amide hydrolase, and the oxytocin receptor. Labor pain as a function of cervical dilation was modeled with previously described methods. Patient covariates, ADRB2 genotype, and obstetrical and anesthesia treatment were evaluated as covariates in the model.

RESULTS

Labor pain more rapidly became severe in parturients heterozygous or homozygous for the G allele at rs1042714 in the ADRB2 gene. Labor pain increased more rapidly after artificial rupture of membranes, augmentation with oxytocin, and in younger women. Inclusion of covariates explained approximately 10% of the variability between subjects. ADRB2 genotype explained less than 1% of the intersubject variability.

CONCLUSION

ADRB2 genotype correlates with labor pain but explained less than 1% of the intersubject variance in the model.

Prenatal exposure to acetaminophen and asthma in children

OBJECTIVE

To estimate whether prenatal exposure to acetaminophen is associated with risk of diagnosed asthma and asthma symptoms in children.

METHODS

The authors prospectively followed 1,505 pregnant women and their children until 6 years (+/-3 months) of life. Acetaminophen use in the first and third trimesters of pregnancy was assessed before 24 weeks of gestation and within 1 month of delivery, and asthma in children was assessed when the child was 6 years old. Adjusted odds ratios (aORs) were derived from logistic regression models controlling for potential confounders.

RESULTS

Acetaminophen was used by 69% of women during pregnancy. Use of acetaminophen did not significantly increase the risk of asthma (aOR 0.76, 95% confidence interval [CI] 0.53-1.10). Acetaminophen use during both the first and the third trimester was associated with a significantly reduced risk of asthma (aOR 0.59, 95% CI 0.36-0.98). There was no evidence of a dose response, and consumption greater than 10,400 mg (32 tablets) a month did not increase risk (aOR 0.99, 95% CI 0.19-5.30).

CONCLUSION

Our results suggest that acetaminophen use during pregnancy does not increase risk of asthma in children.

LEVEL OF EVIDENCE

II.

Auricular acupuncture as a treatment for pregnant women who have low back and posterior pelvic pain: a pilot study

OBJECTIVE

The primary aim of this study was to examine whether 1 week of continuous auricular acupuncture could reduce low back and posterior pelvic pain associated with pregnancy.

STUDY DESIGN

A randomized controlled trial was conducted on pregnant women who have lower back and posterior pelvic pain. These women were randomly assigned into an acupuncture group, a sham acupuncture group, or a waiting list control group. All participants were monitored for 2 weeks.

RESULTS

Baseline and day 7 showed significant group differences in pain (F = 15; P < .0001) and in the disability rating index score (F = 7; P < .0001). The participants in the acupuncture group reported a significant reduction of pain and improvement of functional status as compared with those in the sham acupuncture and control groups.

CONCLUSION

One week of continuous auricular acupuncture decreases the pain and disability experienced by women with pregnancy-related low back and posterior pelvic pain.

Non-Obstetric Pain in Pregnancy

The hormonal and mechanical changes which result from pregnancy have the capacity to exacerbate existing chronic pain conditions as well as produce pain unique to this physiological and anatomical state.Pain in pregnancy is very common and can impact negatively on maternal satisfaction with the pregnancy.Management of pain requires a multidisciplinary, biopsychosocial approach. The possible presence of co-existing pathology and obstetric conditions must be borne in mind when assessing pain in pregnancy.Treatment of pain in pregnancy should focus on non-pharmacological interventions in the first instance with due consideration of the risk of medications to the mother, fetus and the course of the pregnancy.

Acetaminophen use during pregnancy: effects on risk for congenital abnormalities

OBJECTIVE

We evaluated if acetaminophen, one of the most frequently used drugs among pregnant women is associated with an increased prevalence of congenital abnormalities.

STUDY DESIGN

We selected 88,142 pregnant women and their liveborn singletons from the Danish National Birth Cohort who had information on acetaminophen use during the first trimester of pregnancy. We used the National Hospital Registry to identify 3784 (4.3%) children from the cohort diagnosed with 5847 congenital abnormalities.

RESULTS

Children exposed to acetaminophen during the first trimester of pregnancy (n = 26,424) did not have an increased prevalence of congenital abnormalities (hazard ratio = 1.01, 0.93-1.08) compared with nonexposed children (n = 61,718). No association was found between congenital abnormalities and duration of use during the first trimester. Increased prevalence was not observed for specific abnormalities, except for "medial cysts, fistula, sinus" (congenital abnormalities of the ear, face, and neck, ICD-10 code Q18.8, n = 43) with an adjusted hazard ratio of 2.15 (1.17-3.95).

CONCLUSION

Acetaminophen is not associated with an increased prevalence of congenital abnormalities overall or with any specific group of major abnormalities.

A randomized study of the effects of preoperative ketorolac on general anaesthesia for caesarean section

BACKGROUND

Ketorolac may attenuate the maternal stress response to tracheal intubation, while avoiding opioid-induced neonatal depression. We aimed to evaluate the haemodynamic and hormonal effects of prophylactic ketorolac on surgical stress and analgesia after caesarean delivery.

METHODS

After ethical approval, 90 patients scheduled for elective caesarean delivery were randomly allocated receive either ketorolac 15 mg i.v. bolus 20 min before induction, followed by an infusion of 7.5 mg/h (n=45), or saline placebo (n=45). Anaesthesia was maintained with 50% nitrous oxide in oxygen with 0.5% isoflurane. Haemodynamic variables, plasma cortisol concentrations, uterine relaxation, need for supplementary doses of oxytocin, peri-operative blood loss, haematocrit, Apgar scores at 1 and 5 min, postoperative pain scores at rest and movement, and tramadol consumption were recorded.

RESULTS

After induction, patients receiving ketorolac had a smaller increase in heart rate, systolic and mean arterial blood pressure (P<0.001) and lower plasma cortisol concentrations, (32.2+/-7.61 vs. 45+/-15.1 microg/dL, P<0.05), lower pain scores at rest and movement for the first two postoperative hours (P<0.001) and a longer time to first request for analgesia. Fewer patients in the ketorolac group received tramadol in the four hours after surgery (7 (15.6%) vs. 14 (31.1%), P=0.004). There were no differences between groups in peri-operative blood loss, vomiting or Apgar scores. There was no echocardiographic evidence of premature closure of the ductus arteriosus in the newborns.

CONCLUSION

Prophylactic ketorolac is safe and effective in attenuating the maternal stress response to intubation and improves the quality of analgesia after caesarean delivery.

Analgesic and antacid properties of i.m. tramadol given before Caesarean section under general anaesthesia

BACKGROUND

Intramuscular (i.m.) tramadol increases gastric pH during anaesthesia similar to famotidine. We investigated the antacid analgesic value of a single dose of i.m. tramadol given 1 h before elective Caesarean section performed under general anaesthesia.

METHODS

Sixty ASA I parturients undergoing elective Caesarean section were included in a randomized double-blind study. The patients were randomly allocated to receive i.m. tramadol 100 mg (n=30) or famotidine 20 mg (n=30) 1 h before general anaesthesia.

RESULTS

At the beginning and the end of anaesthesia, patients receiving tramadol had a median gastric fluid pH of 6.4, which was not significantly different from those treated with famotidine (median 6.3). The infant well-being, as judged by Apgar score, cord blood gas analysis, and neurobehavioural assessment showed no significant difference between the two groups. Nalbuphine consumption in the first 24 h after operation was reduced by 35% in the tramadol group. Pain intensity score on sitting and sedation were significantly greater in famotidine group up to 24 h after surgery. There was no significant difference in incidence and severity of nausea and vomiting between the two groups.

CONCLUSION

A single i.m. dose of tramadol is useful pre-treatment to minimize the risk of acid aspiration during operation, and in improving pain relief during 24 h after surgery.

Pregnancy and Sickle Cell Disease

With advances in management, men and women with sickle cell disease are enjoying an improved quality of life well into adulthood, when they may elect to plan a family. Pregnancy has been associated with exacerbation of sickle cell disease and may place women, especially those with sickle cell anemia (HbSS), at an additional risk for obstetric complications. Appropriate management by health care providers familiar with sickle cell diseases and high-risk obstetric care can result in a successful pregnancy for most women with sickle cell disease.

Migraine during pregnancy: options for therapy

Migraine is common during pregnancy, but fortunately this combination of conditions obviously exists for only a finite period. The greatest frequency of migraine attacks occurs during the first trimester. Accurate diagnosis is a sine qua non in this setting as in any headache patient. It is in the first trimester that the fetus is at greatest risk from abortifacient and teratogenic drugs, and when very early pregnancy may be undiagnosed. Ergot alkaloids (including methysergide) should be avoided during pregnancy because of their teratogenicity, and most other drug classes should be used only when unavoidable. The use of prophylactic agents during pregnancy should be the exception, not the rule, and preferably only during the second and third trimesters; propranolol is probably safest in this situation. De novo headache during pregnancy usually requires expert review of the patient. Treatment tactics for uncomplicated migraine in pregnancy depend on the concurrent clinical situation. Paracetamol (acetaminophen) is the mainstay for the patient whose typical attacks continue into the first trimester. If paracetamol is insufficient, then partial agonist opioids may be used if typical migraine attacks persist in the second and third trimesters (which is uncommon). 'Chronic migraine' in pregnancy, i.e. >or=15 headache days per month, is rare, and is the greatest therapeutic challenge. Co-morbidities such as depression or epilepsy require specialised approaches. The complexities associated with these tactics are discussed in this article, and it is emphasised that none has the specific approval of regulatory authorities. Heightened pharmacovigilance will better inform the future pregnant migraineur. However, this type of information is less likely to be available for novel classes of neuropharmacological agents than for existing ones.

Buprenorphine and Norbuprenorphine Concentrations in Human Breast Milk Samples Determined by Liquid Chromatography-Tandem Mass Spectrometry

Buprenorphine (BUP) is considered to be safe during pregnancy. However, the extent of BUP transfer into breast milk has not been investigated thoroughly. Because the drug concentration in the milk is 1 of the determinants in the assessment of the exposure risk, a rapid and sensitive LC-MS/MS method has been developed and evaluated to measure BUP and norbuprenorphine (norBUP) concentrations in milk. A solid-phase and 2 liquid-liquid extraction procedures have been compared. The lower limits of detection and quantification were 0.05 ng/mL and 0.18 ng/mL for BUP and 0.05 ng/mL and 0.20 ng/mL for norBUP, respectively, using a sample volume of 0.5 mL milk. BUP and norBUP concentrations determined from 10 random breast milk samples collected over 4 successive days from a lactating woman during buprenorphine maintenance therapy ranged from 1.0 to 14.7 and 0.6 to 6.3 ng/mL, respectively. Drug exposure of the infant may be considered to be low. Further investigations may seek to extend these preliminary findings to evaluate an infant's level of BUP exposure through breast milk.

Intrathecal Morphine for Analgesia After Postpartum Bilateral Tubal Ligation

Postpartum bilateral tubal ligation (PPBTL) causes postoperative pain. We designed this study to determine the efficacy of 50 microg intrathecal morphine for analgesia after PPBTL. Sixty-five women received spinal anesthesia with 12.75 mg hyperbaric bupivacaine, 20 microg of fentanyl, and either 50 microg of morphine (morphine group) or 0.05 mL of saline (control group). Postoperative analgesia was provided with regular naproxen 500 mg and oxycodone 5 mg/acetaminophen 325 mg mixture as needed. Overall, satisfaction was higher (P=0.003) and pain was less intense at rest (P=0.008) and on movement (P <0.0001) in the morphine group. There was no significant overall difference in nausea, pruritus, or sedation scores, but vomiting occurred more frequently in the morphine group (21.4% versus 3.5%; P=0.052). In post hoc comparisons, pain at rest within the morphine group was significantly less at 4 h (P=0.006), pain on movement was significantly less at 4 h (P=0.002) and 12 h (P=0.0004), and pruritus was significantly more frequent at 12 h (P=0.002) compared with the control group. Oxycodone 5 mg/acetaminophen 325 mg mixture consumption was significantly smaller (P=0.006) and the time to first request of analgesia was significantly longer (P=0.006) in the morphine group. We conclude that the addition of 50 microg of morphine to intrathecal hyperbaric bupivacaine and fentanyl provides improved postoperative analgesia in women undergoing PPBTL.

Transfer of celecoxib into human milk

The aim of this study was to investigate the transfer of celecoxib into human milk. In one group of 3 breastfeeding patients on celecoxib at steady state, milk levels were determined at set intervals over 24 hours. Plasma levels were determined in 2 of their infants, age 17 and 22 months. In a second group of 2 subjects, intravenous lines were placed and a single 200-mg dose of celecoxib was followed by multiple paired plasma and milk samples over 8 hours. The mean milk-to-plasma ratio for celecoxib was 0.23 (95% confidence interval [CI]: 0.15-0.31). The average concentration of celecoxib in milk during the 8-hour dosing interval was 66 microg/L (95% CI: 41-89). The absolute infant dose averaged 9.8 microg/kg/d (95% CI: 6.2-13.4); the mean relative infant dose was 0.30%. Therefore, the average clinical dose transferred to the infant daily would be approximately 0.3% of the weight-adjusted maternal dose. The authors suggest that the use of celecoxib in breastfeeding mothers at these doses is very unlikely to cause untoward effects in breastfed infants.

Pharmacokinetics and transplacental transfer of lidocaine and its metabolite for perineal analgesic assistance to pregnant women

BACKGROUND

Obstetrical analgesia continues to be challenging to science in the search for safe and effective methods that will permit the use of these procedures allied to improved obstetrical and perinatal results.

OBJECTIVE

The objective of the present study was to investigate the pharmacokinetics and the placental transfer of lidocaine and its metabolite in parturients whose pregnancies were resolved by the vaginal route under perineal analgesia.

PATIENTS AND METHODS

The study was conducted on 23 pregnant women who received perineal analgesia with 20 ml 2% lidocaine (400 mg) during the expulsive period of labor. Maternal venous blood samples were obtained from 0 min to 360 min after drug administration, and umbilical venous blood was obtained at delivery. Lidocaine and monoethylglycinexylidide (MEGX) were determined using high-performance liquid chromatography. The fetal/maternal ratios of the drugs were determined on the basis of maternal and fetal concentrations at delivery.

RESULTS

Maximum lidocaine concentrations at the median times of 15 min were 3.22 microg/ml. The pharmacokinetic parameters were: half-life t1/2alpha 24.0 min, area under the curve (AUC)0-infinity 460.2 microg/min per ml, t1/2beta 180.0 min, clearance 12.2 ml/min per kg and volume distribution 3.1 l/kg. The fetal/maternal ratio for lidocaine at delivery was 0.46, with the latency time between drug administration and delivery being 11.0 min. Maximum MEGX concentrations at the median time of 90 min were 229.0 ng/ml. The t1/2 for MEGX was 240 min, and AUC0-infinity was 82.4 microg min/ml.

CONCLUSION

Lidocaine administered by the perineal route presented a tmax of 15 min, significantly lower than when the drug was administered peridurally, revealing that the time between administration and the occurrence of the analgesic effect was shorter. The study demonstrated placental transfer of lidocaine at ratios of about 50% for lidocaine at the time of delivery. The MEGX placental transfer demonstrated fetal concentration higher than the maternal at the time of delivery.

Pregnancy and lactation

Pregnancy results in physiologic changes in almost all organ systems in the body mediated mainly by female sex hormones. Physiologic changes of pregnancy influence the dental management of women during pregnancy. Understanding these normal changes is essential for providing quality care for pregnant women. This review article briefly discusses the cardiovascular, respiratory, gastrointestinal, urogenital, endocrine, and oral physiologic changes that occur during normal gestation. A summary of current scientific knowledge of ionizing radiation is presented. Information about the compatibility, complications, and excretion of the common drugs during pregnancy is provided. Drugs and their usage during breast-feeding are also discussed. Guidelines for the management of a pregnant patient in the dental office are summarized.

Effects on the fetus and newborn of maternal analgesia and anesthesia: a review

PURPOSE

To review the effects of maternal anesthesia and analgesia on the fetus and newborn.

METHODS

An on-line computerized search of Medline, Embase, and the Cochrane Collaboration via PubMed was conducted. English language articles were selected. The bibliographies of relevant articles and additional material from other published sources were retrieved and reviewed.

PRINCIPAL FINDINGS

No one test clearly separates the effects on the fetus/newborn, if any, of maternally administered medication during labour and delivery, or during surgery for non-obstetric indications. Supposition in this regard is limited in part by methodology previously used to study the transplacental passage of various drugs. This work needs to be repeated using a human model. Routine maternal supplemental oxygen administration is being questioned in light of research showing that free radical generation and oxidative stress are implicated as the underlying mechanisms in several neonatal conditions. Maternal hypotension is associated with neonatal acidemia and base excess correlates with neonatal outcome. Common postpartum analgesics transfer minimally into breast milk. Maternal or fetal surgery conducted during pregnancy necessitates modification of both anesthetic and surgical approaches. The key to resuscitation of the fetus is resuscitation of the mother: intra-uterine maneuvers, including perimortem Cesarean section, aim to reverse treatable causes of fetal asphyxia, restore fetal oxygenation, and correct fetal acidosis.

CONCLUSIONS

The well-being of the infant is a major criterion for evaluating the anesthetic management of pregnant women. Many tools exist to assist with this determination for the fetus, whereas few are available to evaluate the newborn.

Questions and Answers from the F.I.X. Ketorolac Continuous Infusion Pregnancy and Newer NSAIDs Article Review: Medication Errors and Adverse Drug Events in Pediatric Inpatients

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The effect of intravenous ketorolac on opioid requirement and pain after cesarean delivery

Nonsteroidal antiinflammatory drugs, including ketorolac, are widely used for postoperative analgesia. This randomized, double-blinded trial compared IV ketorolac or saline combined with meperidine patient-controlled epidural analgesia (PCEA) after cesarean delivery. Fifty healthy parturients scheduled for elective cesarean delivery under combined spinal-epidural anesthesia received PCEA plus either IV ketorolac (Group K) or saline (Group C) for 24 h. The ketorolac dose was modified, after six patients had been studied, based on new product information recommending a maximum of 120 mg ketorolac over 24 h. Group K (n = 24) and Group C (n = 20) were demographically similar. During the first 24 h, Group K used significantly less meperidine (P < 0.05). Postoperative pain at rest and with movement, and patient satisfaction, did not differ significantly between groups, except that worst pain at 12 h was less in Group K (P < 0.005). The two groups were similar with respect to patient recovery and side effects. IV ketorolac, as an adjunct to PCEA after cesarean delivery, produced a meperidine dose-sparing effect of approximately 30%, but did not significantly improve pain relief, reduce opioid-related side effects, or change patient outcome.

Breastfeeding and over-the-counter medications

A breastfeeding mother is confronted with a wide variety of over-the-counter products, necessitating careful guidance from her health care professional. This article presents a discussion and comprehensive tables that cover, by category, over-the-counter medications that nursing mothers may need to take. These tables should greatly assist the health care professional in the important task of counseling the nursing mother about the proper use of over-the-counter medications. This information will enable health care professionals to interpret information on the topic of over-the-counter medications and breastfeeding; list medications, in specific over-the-counter categories, that are usually safe to take while breastfeeding; recommend over-the-counter medications of choice for a breastfeeding mother; and generally counsel a breastfeeding mother who is taking or expects to take over-the-counter medications.

Drug use during pregnancy and lactation

This article reviews the basic principles of pharmacology and teratogenicity of drugs for the pregnant and lactating woman and summarizes the Food and Drug Administration, American College of Obstetrics and Gynecology, and American Academy of Pediatrics classifications. These categories were devised for caregivers of both women and their babies. The authors propose a two/three letter category system to assist those who, like family physicians, must care for women while pregnant and while lactating. Common problems from everyday practice are reviewed, with an emphasis on the important drugs to use and avoid in a wide variety of everyday clinical settings to help the busy primary care physician in making decisions about medications in pregnancy and lactation.