Chapter 39 - Pain Management During Pregnancy and Lactation

Abstract

Pain syndromes, including low back pain, pelvic girdle pain, and carpal tunnel syndrome, are common during pregnancy and lactation. Initial treatment with nonpharmacologic interventions should be considered, if appropriate. Medications taken by the mother can cause fetal exposure via placental transfer or neonatal exposure via transfer into breastmilk. Drug transfer across the placenta and effects of exposure to medications on the developing fetus depend on the gestational age; effects range from malformations and intrauterine fetal death during early pregnancy to neurodevelopmental teratogenicity and acute intoxication in late pregnancy. Many medications used to treat pain are secreted in breastmilk, but most are secreted in small quantities and after first-pass metabolism cause minimal neonatal effects. The Food and Drug Administration attempts to provide guidance on drug safety in pregnancy and lactation, but large studies on fetal and neonatal effects of exposure to pain medications in pregnancy and lactation are scarce or lacking. In summary, the maternal benefit and fetal/neonatal exposure risk should be assessed for all pharmacologic interventions after failure of initial nonpharmacologic interventions to relieve pain symptoms. The lowest effective dose, shortest duration of therapy, and use of older drugs with an established safety profile should be used.