Prevalence and predictors of chronic pain after labor and delivery

Saffron (Crocus sativus) and its constituents for pain management: A review of current evidence

Pain can become a chronic and deliberating experience with a significant burden. In preclinical and clinical studies, Saffron (Crocus sativus L.) has shown analgesic activities. Considering the unsatisfactory results of current therapeutic management for chronic pain conditions, we aimed to review saffron's analgesic activity and underlying mechanisms. Saffron showed antinociceptive activities in formalin-, carrageenan-, and capsaicin-induced experimental pain models. Saffron analgesic activities affected several targets, including ion channels of nociceptors; the adrenergic system and central histaminic system; inhibition of inflammatory pathways, apoptotic pathways, and oxidative stress; regulation of NO pathway, and the endocannabinoid system. Clinical studies showed analgesia of Saffron in rheumatoid arthritis, after-pain following childbirth, dysmenorrhea, and fibromyalgia. Our literature review showed that saffron can be beneficial as an adjunct therapy to commonly used analgesics in practice, particularly in chronic pain conditions.

The Use of Capacitive and Resistive Energy Transfer in Postpartum Pain Management in Women after Perineal Trauma

Perineal pain occurs in 97% of women with episiotomy or first- and second-degree perineal tears on the first day after delivery. The study aimed to assess the impact of capacitive and resistive energy transfer (TECAR) on perineal pain and discomfort in the first two postpartum days. The prospective randomized double-blind study was performed with the pain and discomfort assessment using the Visual Analogue Scale at baseline and after both TECAR interventions. Characteristics data, delivery information, and the number of painkillers taken were collected. The assumed significance level was α < 0.05. The study included 121 women with a mean age of 30.7 ± 4.2 years and a median BMI of 26.1 kg/m2 (24.1; 28.9). Pain reduction at rest, when walking, and discomfort reduction when walking were significantly higher in the TECAR group compared to the sham group (p < 0.05). After the first TECAR intervention, significant reduction in all measured parameters was observed in the study group (p < 0.03), whereas in the control group, it was observed in pain and discomfort while sitting (p < 0.04). The amount of ibuprofen taken on the second day was significantly reduced in the study group compared to the first day (p = 0.004). TECAR has been shown to provide more immediate and significant reduction in perineal pain and discomfort.

The effect of pelvic floor muscle exercises applied during pregnancy on genito-pelvic pain level in postpartum period

INTRODUCTION AND HYPOTHESIS

The goal of the study is to determine the effect of pelvic floor muscle exercises on genito-pelvic pain levels during the postpartum period.

METHODS

The data of the study, which was carried out in a randomized controlled experimental design, were collected in the antenatal policlinic of a public hospital from June-December 2019. There were 60 pregnant women in the experimental and control groups. Pelvic floor muscle exercises were applied to the pregnant women in the experimental group from the 30th week of gestation to the 6th week postpartum. The control group was not given pelvic floor muscle exercise training, and only data collection forms were filled in. During the study, the Descriptive Form, Verbal Category Scale, Pelvic Floor Distress Inventory-20, and Labour and Postpartum Information Form were given to the pregnant women in both groups.

RESULTS

After pregnant women in the experimental group performed pelvic floor muscle exercises, pain levels were significantly lower than in the control group (p < 0.01). Pelvic Floor Distress Inventory-20 total score and sub-dimension scores of the experimental group were statistically significantly lower than in the control group (p < 0.01). In addition, a statistically significant difference was found (p < 0.01) in the postpartum 72 h findings of the experimental group in which pelvic floor muscle exercises were applied compared to the control group.

CONCLUSIONS

According to the result of the study, as the gestational weeks progress, the genito-pelvic pain increases. Pelvic floor muscle exercises applied during pregnancy prevent the development and progression of pelvic floor disorders in both the antenatal and postnatal periods.

TRIAL REGISTRATION

NCT05343520.

Wound Infusion of 0.35% Levobupivacaine Reduces Mechanical Secondary Hyperalgesia and Opioid Consumption After Cesarean Delivery. A Prospective, Randomized, Triple-Blind, Placebo-Controlled Trial

BACKGROUND

Some patients still report moderate-to-severe postoperative pain after cesarean delivery. Local anesthetic wound infusion improves acute pain and might act on peripheral and central sensitization mechanisms; however, no studies have proved this hypothesis. We evaluated the potential benefits of continuous wound infusion of levobupivacaine after cesarean delivery on secondary hyperalgesia (primary end point) and primary hyperalgesia, pain relief, persistent pain, and inflammatory and metabolic stress response.

METHODS

Healthy women scheduled for elective cesarean delivery participated in this prospective, randomized, triple-blind, placebo-controlled trial (NCT01458431). All patients received spinal anesthesia with 0.5% hyperbaric bupivacaine with fentanyl and a multiholed wound catheter placed under the fascia. Women were randomized to receive continuous wound infusion (0.35% levobupivacaine 7 mL/h for 48 hours; group L) or an equal volume of saline (group S). Secondary hyperalgesia to punctate mechanical stimuli was evaluated using dynamic tests, and primary hyperalgesia was evaluated using an electronic von Frey anesthesiometer; both were assessed at 24, 48, and 72 hours. The following variables were collected: intensity of postoperative parietal and visceral pain at rest and on movement rated on a visual analog scale >72 hours, time to first bolus of patient-controlled analgesia (PCA), cumulative dose of rescue morphine (PCA) and acetaminophen, ability to sleep and sleep quality, and patient satisfaction. Persistent postoperative pain was evaluated during a telephone interview at 1, 3, 6, and 12 months after surgery. C-reactive protein, acid glycoprotein, preprandial glucose, insulin, cortisol, prolactin, growth hormone, and interleukin-6 were measured before cesarean delivery and at 8, 24, and 48 hours. Adverse events and patient outcomes were recorded.

RESULTS

Seventy women were included. In group L, the area of secondary hyperalgesia was significantly reduced (43.4 [18.5-80] vs 68.4 [39.0-136] cm2 and 45.1 [0.9-89.8] vs 67.3 [31.3-175] cm2 at 24 and 48 hours, respectively; group:time interaction P value < .001), the mechanical pain threshold was significantly higher at 24 hours (633 [441-802] vs 417 [300-572] g.mm-2; P = .001), and morphine consumption was significantly lower at 24 hours (4 [2-11] vs 11[6-23]; P = .003) compared with group S. Levobupivacaine had no effect on persistent postoperative pain at 1, 3, 6, and 12 months. Plasma insulin levels in the immediate postoperative period and at 8, 24, and 48 hours were significantly lower in group L (P < .001). There were no significant differences in other biochemical parameters of inflammatory and endocrine-metabolic response.

CONCLUSIONS

Levobupivacaine wound infusion provides adequate analgesia and might be an effective antihyperalgesic adjunct.

Assessment of pain and maternal complications after normal vaginal delivery

Management of postpartum perineal pain is essential because untreated pain can interfere with the motherhood experience and might result in various complications. The study aimed to assess postpartum perineal and postpartum pain intensity, pharmacological management and maternal complications after normal vaginal delivery. A prospective observational study was conducted in Obstetrics and Gynaecology among 300 women who underwent normal vaginal delivery. The severity and intensity of the perineal pain in subjects were relatively high, i.e. severe on Day 1, moderate to mild pain on Day 2 and mild pain on Day 3. The overall postpartum pain was mild on all 3 d. Non-steroidal anti-inflammatory drugs (NSAIDs) and analgesic combination drugs were prescribed the most for pain management, which significantly impacted pain reduction. All participants involved in the study had a postpartum haemorrhage and was the most common complication. The study concludes that there was a significant reduction in the overall intensity of pain from Day 1 to Day 3.IMPACT STATEMENTWhat is already known on this subject? Vaginal delivery is a multidimensional process that causes inflammation of cervical tissue and tears in the birth canal, leading to pain perception. Previous studies reported increased pain intensity on the first day after childbirth and a gradual decrease as the days pass.What do the results of this study add? The well-accepted pain scales, such as faces rating scale (FRS) and verbal numeric scale (VNS) were appropriate for assessing the intensity of perineal pain. Self-developed and validated postpartum pain assessment questionnaire (PPAQ) was beneficial for the assessment of postpartum pain. NSAIDs and analgesics combination was effective in managing the pain.What are the implications of these findings for clinical practice and/future research? Accurate pain assessment is essential for humanising patient care since it helps make a correct plan for required intervention, and its evaluation can help provide appropriate medications and reduce complications. Self-developed and validated PPAQ is easy to use and can be used in clinical studies to assess postpartum pain.

A retrospective audit of pain assessment and management post-caesarean section at New Somerset Hospital in Cape Town, South Africa

Background

The most common major surgical procedure performed worldwide is the caesarean section (CS). Effective pain management is a priority for women undergoing this procedure, to reduce the incidence of persistent pain (a risk factor for postpartum depression), as well as optimise maternal-neonatal bonding and the successful establishment of breastfeeding. Multimodal analgesia is the gold standard for post-CS analgesia. At present, no perioperative pain management protocols could be identified for the management of patients presenting for CS at regional hospitals in South Africa. This audit aimed to review the folders of patients who underwent CS, with particular reference to perioperative pain management guidelines for CS.

Methods

A descriptive, retrospective, cross-sectional audit was conducted. Three hundred folders (10% of the annual number of caesarean procedures performed) from New Somerset Hospital, a regional hospital in Cape Town, South Africa were reviewed.

Results

The women were a mean age of 30 years (standard deviation [s.d.]: 6.2). Median gravidity was 3 (interquartile range [IQR]: 2–3) and parity was 1 (IQR: 1–2); 52% had previously undergone a CS. In 93.3% cases, spinal anaesthesia was employed for CS. Pain assessment was poor, with only 55 (18%) patients having their pain assessed on the day of the operation. Analgesia was prescribed in over 98% of the patients, however, medication was only administered as prescribed in 32.6%. Non-steroidal anti-inflammatory drugs (NSAIDs) were prescribed in < 5% of cases. None of the patients received a patient-controlled analgesia (PCA), transversus abdominis plane (TAP) block, or wound infusion catheter as supplementary strategies.

Conclusion

Pain management for post-CS patient at this hospital is lacking. There is the need for the implementation of a structured assessment tool to improve administration of analgesics in these patients. In addition, the reasons for the omission of NSAIDs from the analgesia regimen requires investigation. Hospital requires post-CS pain protocols to guide management especially in resource-limited settings.

Are labor pain and birth experience associated with persistent pain and postpartum depression? A prospective cohort study

Background and aims A considerable research-literature focuses on pain during labor and associations with postpartum persistent pain and depression, with findings pointing in various directions. The aim of this study was to examine the role of labor pain and overall birth experience in the development of pain and depression 8 weeks after delivery. Methods The study sample was drawn from the Akershus Birth Cohort. Data from multiple sources were used, including the hospital's birth record (n = 4,391), questionnaire data from gestational week 17 of pregnancy (n = 3,752), 8 weeks postpartum (n = 2,217), and two questions about pain and birth experience asked within 48 h after delivery (n = 1,221). The Edinburgh Postnatal Depression Scale was used to measure postpartum depression, a single question was used to measure persistent pain 8 weeks postpartum, while pain and birth experience were measured by numeric rating scales. A history of pre-pregnant depression and chronic pain were measured through self-report questions in gestational week 17. A total of 645 women had complete data from all sources. We applied multiple imputation techniques to handle missing responses on the two questions about pain and birth experience. Results The results showed that neither labor pain nor birth experience were associated with persistent pain 8 weeks postpartum, whereas pain before pregnancy (OR 3.70; 95% CI 2.71-5.04) and a history of depression (OR 2.31; 95% CI 1.85-2.88) were statistically significant predictors of persistent pain. A negative birth experience was significantly (OR 1.16; 95% CI 1.04-1.29) associated with postpartum depression, whereas labor pain intensity was not. A history of depression (OR 3.95; 95% CI 2.92-5.34) and pre-pregnancy pain (OR 2.03; 95% CI 1.37-3.01) were important predictors of postpartum depression 8 weeks after delivery. Conclusions and implications Whilst the relationship between labor pain intensity and postpartum pain and depression remain unclear, our results do imply the need to screen for previous depression and chronic pain conditions in pregnant women, as well as consider preventive measures in those who screen positive.

Neuropathic component of postoperative pain for predicting post-caesarean chronic pain at three months. A prospective observational study

BACKGROUND

Recent investigations have showed that caesarean section (CS) might be a cause of chronic pain, with a consequent decrease in quality of life.

METHODS

Prospective observational study in a Spanish tertiary hospital. Main Outcome measure was to assess early neuropathic characteristics of pain (DN2 score ≥ 3) one week after CS as a potential risk factor for post-caesarean section chronic pain (PCSCP) at three months. Secondary outcome was to identify other risk factors. 610 consecutive consenting patients undergoing CS were interviewed preoperatively, at discharge from recovery room and 24h postoperatively. Telephone follow-up interviews were conducted one week, three months and twelve months following surgery.

RESULTS

We analysed 597 consecutive patients. The incidence of PCSCP at three and twelve postoperative months were 6.2% and 1% respectively. Subjects with NRS score superior to five on movement one week after CS presented higher incidence of PCSCP (NRS superior to five: 19 (52,2%); NRS equal or lower to five: 172 (30,9%); p=0,009). On multivariate analysis neuropathic pain one week after CS was associated with a higher risk of PCSCP (AOR: 1.63 (95% CI: 1.26-2.11; p<0.001). Other identified risk factors for PCSCP were: uterine exteriorization during CS (AOR: 3.89 (95% CI 1.25-12.10; p=0.019) and a lower gestational age (AOR: 0.87 (95% CI: 0.78-0.96; p=0.008).

CONCLUSIONS

Incidence of PCSCP at three and twelve postoperative months was low, 6.2% and 1% respectively. Early neuropathic characteristics of pain after one week measured by neuropathic pain questionnaire, consisting of two questions (DN2) ≥ 3/7 could be used to identify patients at risk for chronic post-surgical pain and develop preventive strategies.

Research Recommendations on the Effects of Postpartum Depression and Pain on Infant Care and Development

Postpartum depression is one of the most common complications of childbirth, and another is pain. A growing body of research shows that the severity and duration of postpartum pain can increase a woman's risk for postpartum depression. Postpartum depression and pain negatively affect maternal well-being, and postpartum depression has been associated with adverse outcomes in children. However, there is a dearth of information about the effects of postpartum depression and pain on infant care and development. The objectives of this commentary were to highlight the need to address this gap in the literature, offer a preliminary conceptual model to advance the field, and ignite new lines of inquiry to inform infant care and development.

The impact of a transversus abdominis plane block including clonidine vs. intrathecal morphine on nausea and vomiting after caesarean section: A randomised controlled trial

BACKGROUND

Intrathecal morphine (ITM) is a widely used technique for postcaesarean section analgesia but entails a high risk of postoperative nausea and vomiting (PONV). The transversus abdominis plane (TAP) block is an alternative.

OBJECTIVE

We tested the hypothesis that a TAP block including clonidine reduces the incidence of PONV after caesarean section when compared with ITM.

DESIGN

A randomised, controlled, double-blinded study.

SETTING

Geneva University Hospitals, Switzerland, from October 2013 to February 2017.

PATIENTS

A total of 182 patients undergoing elective caesarean section were studied. Reasons for noninclusion were complicated pregnancy, contraindication to spinal anaesthesia or TAP block, extreme weight or height, allergy to any medication or previous median abdominal incision.

INTERVENTIONS

Patients were allocated randomly to one of two groups (quadruple blinded): 100 μg of morphine added to the spinal local anaesthetic or a bilateral TAP block with 20 ml of ropivacaine 0.375% + 75 μg of clonidine on each side.

MAIN OUTCOME MEASURES

The primary outcome measure was the total number of patients presenting with PONV at 24 h. Secondary aims were to compare other adverse effects (pruritus, respiratory depression, hypotension, bradycardia, sedation), analgesic efficacy and the quality of postoperative recovery.

RESULTS

At 24 h, there was no significant difference between ITM and TAP groups in the total number of patients presenting with PONV: 17/92 patients (18.5%, 95% confidence interval 11.1 to 27.9) and 27/88 patients (30.7%, 95% confidence interval 21.3 to 41.4) in TAP and ITM groups, respectively (P = 0.065). Pain scores at 6 h and cumulative morphine consumption at 24 h were lower in the ITM group (P < 0.0001 for morphine consumption at 24 h). The incidence of hypotension was higher in the TAP group (54.3 vs. 29.2%, P = 0.0006). Maternal satisfaction was high and not different between groups.

CONCLUSION

A TAP block with clonidine and local anaesthetic does not reduce significantly the incidence of PONV compared with ITM. We confirm the superiority of ITM on acute postcaesarean section analgesia compared with a TAP block, even with clonidine as an adjunct.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01931215.

The influence of preoperative epidural labor analgesia on postoperative pain in parturients undergoing emergency cesarean section : A retrospective analysis

BACKGROUND

Intense noxious input from the periphery may result in central sensitization and hyperexcitability, thus accentuating subsequent postoperative pain. Parturients who undergo emergency cesarean section (C-sec) after experiencing labor pain often develop labor pain-induced sensitization.

OBJECTIVE

This retrospective study evaluated whether parturients without epidural labor analgesia (ELA) who underwent emergency C‑sec, experienced more severe postoperative pain and required more rescue analgesics during the postoperative period.

METHODS

The institution's medical database was searched for parturients who underwent emergency C‑sec under spinal anesthesia for any reason between January 2013 and December 2016. Those who underwent elective C‑sec under spinal anesthesia were included as the reference arm. Parturients were divided into three groups: ELA, no-ELA and elective. Characteristics of patients and perioperative outcomes were evaluated. As primary outcomes, numerical rating scale (NRS) for postoperative pain (0-10) was recorded up to 96 h postoperatively, and use of rescue analgesics was evaluated at 6, 24, and 48 h postoperatively.

RESULTS

In the ELA, no-ELA, and elective groups, 61, 73, and 88 parturients, respectively, were ultimately enrolled. The NRS for pain were similar among the three groups, except at 6 h postoperatively. Parturients in the no-ELA group demonstrated significantly higher NRS at 6 h postoperatively than those in the ELA group (P = 0.01).More patients in the no-ELA group required rescue analgesics than in the ELA (P = 0.001) and elective groups (P < 0.001) at 6-24 h postoperatively. Moreover, the proportion of patients requiring rescue analgesics ≥2 times was also significantly higher in the no-ELA group (vs. the ELA group, P = 0.004; vs. the elective group, P < 0.001).

CONCLUSION

Parturients undergoing emergency C‑sec without ELA management during labor experienced greater postoperative pain and a greater use of rescue analgesics during the postoperative period. The findings suggest that administration of ELA before emergency C‑sec may act as pre-emptive analgesia against postoperative pain.

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.

Procedure-Specific Pain Intensity Four Days After Day Surgery and the Relationship with Preoperative Pain: A Prospective Cohort Study

Background

Identification of painful procedures is essential for the development of procedure-specific pain-treatment schedules. The aim of this study was firstly, to analyze the prevalence of acute postsurgical pain (APSP) after various types of day surgery on the fourth postoperative day, and secondly, to assess the predictive value of preoperative pain for the development of APSP after different types of surgical procedures.

Methods

From November 2008 to April 2010, patients scheduled for elective day surgery were enrolled in this prospective cohort study. Data were collected one week preoperatively and four days postoperatively. The 11-point Numeric Rating Scale (NRS) was used for pain measurement. Moderate pain was defined as an NRS 4 to 5, and severe pain as an NRS > 5. The predictive value of preoperative pain for development of APSP was analyzed using a univariate logistic regression, stratified for the surgical procedure.

Results

From a total of 1123 included patients, 182 patients experienced moderate pain (16.3%) and 136 patients experienced severe pain (12.1%) on the fourth postoperative day. A large procedure-specific variability in APSP was observed, with shoulder, anal and dental surgery associated with the highest pain levels. Overall, preoperative pain significantly predicted postoperative pain on the fourth day (OR 4.45). This predictive value showed a procedure-specific variation and was not noted after various well-defined procedures.

Conclusions

The prevalence of moderate to severe APSP was high four days after day surgery and showed a significant procedure-specific variation. Furthermore, there was a strong relationship between preoperative and postoperative pain, likewise characterized by a significant procedure-specific variation.

The relationship between labor pain management, cortisol level and risk of postpartum depression development: a prospective nonrandomized observational monocentric trial

Postpartum depression (PPD) is the main psychological status disorder and women suffering from postpartum depression often need long-term psychological and socio-economic rehabilitation. The study is dedicated to the evaluation of the role of labor pain management using epidural analgesia in natural delivery on stress level in labor and frequency of postnatal depression.

Materials and methods

210 women were investigated and divided into two groups. In the first group for labor pain management in natural delivery, patient-controlled epidural analgesia was used (bolus - 10.0 - 0.08% ropivacaine hydrochloride, lockout - 30 min, limit - 120 ml/6 h) with a background of continuous-flow infusion of local anesthetic 0.08% ropivacaine hydrocluoride solution. Patients in the second group had no pain relief in delivery. The stress level was evaluated using blood plasma cortisol level in the early stages of labor, 6 hours and 3 days after delivery. The assessment of depression development was carried out step-by-step: Before the delivery, 6 hours after, 3 days and 6 weeks after the delivery.

Results

The baby blues frequency 6 hours after the delivery in the group where the pain relief was conducted was 29.91%, with cortisol level below and equal to 2310.91 nmol/l. In the group with no pain relief 6 hours after delivery, baby blues was found in 15.53% of puerperas (p < 0.05) and the cortisol level was 2673.82 nmol/l (p < 0.05). Six weeks after the birth, postpartum depression was diagnosed in 4.67% of women who received epidural analgesia during delivery, in comparison to 6.79% with no pain relief during delivery. However, the difference was not statistically significant (p < 0.05).

Conclusions

The use of epidural analgesia leads to a significant reduction of pain syndrome and stress response during natural delivery, increases the risk of baby blues in the early postnatal period, but slightly influences the frequency of postpartum depression.

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.

Aplastic anemia during pregnancy: a review of obstetric and anesthetic considerations

Aplastic anemia is a hematologic condition occasionally presenting during pregnancy. This pathological process is associated with significant maternal and neonatal morbidity and mortality. Obstetric and anesthetic management is challenging, and treatment requires a coordinated effort by an interdisciplinary team, in order to provide safe care to these patients. In this review, we describe the current state of the literature as it applies to the complexity of aplastic anemia in pregnancy, focusing on pathophysiologic aspects of the disease in pregnancy, as well as relevant obstetric and anesthetic considerations necessary to treat this challenging problem. A multidisciplinary-team approach to the management of aplastic anemia in pregnancy is necessary to coordinate prenatal care, optimize maternofetal outcomes, and plan peripartum interventions. Conservative transfusion management is critical to prevent alloimmunization. Although a safe threshold-platelet count for neuraxial anesthesia has not been established, selection of anesthetic technique must be evaluated on a case-to-case basis.

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.

Prevalence and Predictors of Chronic Pain in Pregnancy and Postpartum

OBJECTIVE

A clinically relevant number of patients report pain 1 year after vaginal delivery or Caesarean delivery. Study objectives were to identify the incidence of peripartum pain; determine whether pre-existing pain, pregnancy pain, or pain 2 weeks postpartum predicts pain at 3 months; and to identify whether delivery mode, epidural analgesia use, or delivery complications predict non-genito-pelvic pain postpartum.

METHODS

Primiparous women at 30 to 36 weeks GA with an uncomplicated singleton pregnancy were recruited from a large perinatal clinic. Participants completed questionnaires on sociodemographics and non-genito-pelvic pain. Questionnaires were completed in the perinatal clinic and then electronically 2 weeks and 3 months postpartum.

RESULTS

Of the 133 women included, 50 patients (38%) had a chronic pain condition or pain prior to pregnancy, whereas 73 patients (55%) reported pain in pregnancy. Pain was present 2 weeks postpartum in 57 patients (43%) and 3 months postpartum in 33 patients (25%). Patients with pre-existing pain were more likely to experience pain 2 weeks postpartum (P = 0.006), and patients with pain 2 weeks postpartum were more likely to have pain 3 months postpartum (P = 0.005). Women who had a Caesarean delivery (P < 0.001) were more likely to have non-genito-pelvic pain at 2 weeks but not 3 months postpartum.

CONCLUSIONS

Women with pain 2 weeks postpartum were significantly more likely to have pain at 3 months. Further investigation is required to determine whether pre-existing pain, pain in pregnancy, or pain at 2 weeks postpartum can adequately predict the likelihood of chronic pain.

Clinical profile of persistent genito-pelvic postpartum pain

OBJECTIVE*: the primary aim was to describe the pain characteristics of persistent genito-pelvic postpartum pain (PPP) and compare these characteristics by mode of delivery. The secondary aim was to incorporate psychosocial variables into the conceptualization of PPP by exploring the relationship among postpartum depressive symptoms, fatigue, and PPP.

DESIGN

cross-sectional study design.

SETTING

online survey.

PARTICIPANTS

106 women recruited from the community who gave birth within twelve months prior to completing the survey.

MEASUREMENTS AND FINDINGS

questionnaire regarding sociodemographic information, pregnancy and childbirth variables, depressive symptoms (Edinburgh Postnatal Depression Scale), and fatigue (Fatigue Symptom Checklist). Women who were ≥3 months postpartum and indicated they were still experiencing any genito-pelvic pain from childbirth were provided questions about their current pain experience. Twenty-seven (25.5%) women were between 3-12 months postpartum and currently experiencing PPP. The intensity of pain was mild, and had multiple locations and triggers. Compared to women whose acute pain resolved after childbirth, women with PPP were more likely to have had a Caesarean section (15.2% versus 33.3%). Other birth-related (i.e., epidural/spinal anesthesia use during vaginal birth) and psychosocial variables (income) also differentiated women with PPP from women whose gentio-pelvic pain resolved. Postpartum fatigue independently predicted PPP (Odds ratio = 4.7), while postpartum depressive symptoms did not.

KEY CONCLUSIONS

PPP was quite prevalent in this sample, and while the intensity of pain was on average, mild, the pain was widespread in terms of location and triggers. Multiple biopsychosocial factors differentiated women with persistent postpartum pain from those women whose pain resolved.

IMPLICATIONS FOR PRACTICE

PPP is a common health concern for new mothers in the first year postpartum, and may be best addressed by health care professionals using a multidimensional approach, which focuses on the psychosocial aspects of pain.

Best Practices in Management of Postpartum Pain

Pain has been documented as a major concern for women in the postpartum period. Management of postpartum pain, however, is a relatively neglected area of clinical research. As a result, evidence to support interventions to alleviate the discomforts associated with childbirth is sparse. This paucity of research on postpartum pain management is particularly surprising given that in the United States alone nearly 4 million women give birth each year. Inadequate pain relief in the hours to months following childbirth can interfere with maternal-newborn bonding and feeding and, by impeding mobility, can increase the risk of postpartum complications. In addition, pain that is not adequately managed may increase the risk of chronic pain that lasts beyond the postpartum period. In this article, the more common causes of pain following childbirth are reviewed and recommendations for pain management based on available evidence are outlined. Considerations for pain management in lactating women and for hospital discharge are discussed.

Pelvic pain after childbirth: a longitudinal population study

In this longitudinal population study, the aims were to study associations of mode of delivery with new onset of pelvic pain and changes in pelvic pain scores up to 7 to 18 months after childbirth. We included 20,248 participants enrolled in the Norwegian Mother and Child Cohort Study (1999-2008) without preexisting pelvic pain in pregnancy. Data were obtained by 4 self-administered questionnaires and linked to the Medical Birth Registry of Norway. A total of 4.5% of the women reported new onset of pelvic pain 0 to 3 months postpartum. Compared to unassisted vaginal delivery, operative vaginal delivery was associated with increased odds of pelvic pain (adjusted odds ratio [OR]: 1.30; 95% confidence interval [CI]: 1.06-1.59). Planned and emergency cesarean deliveries were associated with reduced odds of pelvic pain (adjusted OR: 0.48; 95% CI: 0.31-0.74 and adjusted OR: 0.65; 95% CI: 0.49-0.87, respectively). Planned cesarean delivery, young maternal age, and low Symptom Checklist-8 scores were associated with low pelvic pain scores after childbirth. A history of pain was the only factor associated with increased pelvic pain scores over time (P = 0.047). We conclude that new onset of pelvic pain after childbirth was not commonly reported, particularly following cesarean delivery. Overall, pelvic pain scores were rather low at all time points and women with a history of pain reported increased pelvic pain scores over time. Hence, clinicians should follow up women with pelvic pain after a difficult childbirth experience, particularly if they have a history of pain.

Prevalence and risk factors for chronic pain following cesarean section: a prospective study

BACKGROUND

Chronic post-surgical pain (CPSP) remains a major clinical problem which may be associated with impaired activities of daily life and decreased health-related quality of life. Although cesarean section is one of the most commonly performed operations, chronic pain after cesarean delivery has not been well-studied. The purpose of this prospective study was to assess the incidence and risk factors of chronic pain at 3, 6 and 12 months after cesarean delivery.

METHODS

We prospectively investigated preoperative demographic and psychological factors, intraoperative clinical factors, and acute postoperative pain in a cohort of 527 women undergoing cesarean section. The women were interviewed and completed pain questionnaires after 3, 6 and 12 months. Questions were about pain intensity, frequency, and location, as well as medical treatment and impact on daily living.

RESULTS

The incidence of CPSP at 3, 6 and 12 months after cesarean section was 18.3 %, 11.3 % and 6.8 %, respectively. Most of the women with CPSP experienced mild pain at rest. The incidence of moderate and severe pain on movement was high at 3 month, and then has a significant decrease at 6 and 12 months. CPSP had a negative influence on the activities of daily living. Independent predictors of CPSP at 3 months included higher average pain intensity on movement within 24 h postoperatively, preoperative depression, and longer duration of surgery. At 6 months, more severe pain during movement within 24 h of surgery and preoperative depression were predictive of pain persistence. And 12 months after surgery, only higher average pain score on movement within 24 h following cesarean section was found to be significant associated with CPSP. The three models all showed moderate discrimination and good calibration for the prediction of CPSP at 3, 6 and 12 months postoperatively.

CONCLUSIONS

CPSP was not rare in women undergoing cesarean section. Patients with more intense of acute postoperative pain on movement, preoperative depression, and longer surgical time had greater risk for CPSP following surgery.

Birthing postures and birth canal lacerations

OBJECTIVE

This study was performed to assess the differences in the birth canal lacerations following the lateral and fours posture deliveries compared with those following the supine posture deliveries.

METHODS

We examined the birth canal lacerations of our "low risk" pregnant women under the midwife-led delivery care at Japanese Red Cross Katsushika Maternity Hospital between April 2006 and March 2015.

RESULTS

There were 3826, 1754 and 719 women who delivered with supine, lateral and fours postures. The rate of no laceration in the women who delivered with lateral posture was significant lower than that in the women who delivered with supine posture (OR 0.630, 95% CI 0.56-0.71, p < 0.01); however, the incidence of perineal laceration in the women who delivered with lateral posture was significant lower than that in the women who delivered with supine posture (OR 0.856, 95% CI 0.76-0.90, p < 0.01). The incidence of perineal laceration of third- or fourth-degree in the women who delivered with fours posture was significant higher than that in the women who delivered with supine posture (OR 2.28, 95% CI 1.2-4.2, p < 0.01).

CONCLUSION

The current results may be to help for self-determination of birthing postures in prenatal women.

Postoperative persistent chronic pain: what do we know about prevention, risk factors, and treatment

BACKGROUND AND OBJECTIVES

Postoperative persistent chronic pain (POCP) is a serious health problem, disabling, undermining the quality of life of affected patients. Although more studies and research have addressed the possible mechanisms of the evolution from acute pain to chronic postoperatively, there are still no consistent data about the risk factors and prevention. This article aims to bring what is in the panorama of the current literature available.

CONTENT

This review describes the definition, risk factors, and mechanisms of POCD, its prevention and treatment. The main drugs and techniques are exposed comprehensively.

CONCLUSION

Postoperative persistent chronic pain is a complex and still unclear etiology entity, which interferes heavily in the life of the subject. Neuropathic pain resulting from surgical trauma is still the most common expression of this entity. Techniques to prevent nerve injury are recommended and should be used whenever possible. Despite efforts to understand and select risk patients, the management and prevention of this syndrome remain challenging and inappropriate.

A retrospective study on persistent pain after childbirth in the Netherlands

Reported prevalence rates of persistent postpartum pain (PPP) range from less than 1% to almost 20%. The aim of this study was to examine the prevalence of PPP in a Dutch cohort and to evaluate a possible causal role for specific risk factors on the development of chronic pain after childbirth. A questionnaire was sent to 960 postpartum women approximately 2 years after delivery. Primary outcome was pain that arose from childbirth at follow-up, and secondary outcomes included quality of life (QoL) and Hospital Anxiety and Depression Scale scores. Tested risk factors included mode of labor analgesia, history of negative effect, history of chronic pain, delivery route, parity, and ethnicity. A total of 495 (51.6%) women participated. At a mean time of 2.3 postpartum years, 7.3% of women reported any pain and 6.1% reported significant pain related to the delivery. Compared to spontaneous delivery, cesarean delivery provided protection against persistent pain (odds ratio, 0.12; 95% CI, 0.01–0.63, P<0.05). None of the other risk factors, including remifentanil use for labor pain, were of influence on the prevalence of persistent pain. Women with PPP experienced greater negative effects and had lower QoL scores compared to women without pain. In this cohort of Dutch patients, PPP is a serious problem with a great impact on the physical and mental health of women.

Development of chronic pain after episiotomy

OBJECTIVE

To analyze the incidence of chronic pain 5 months after episiotomy, as well as potential prognostic factors.

METHODS

A prospective cohort observational study was conducted on pregnant women age≥18 years who had undergone an episiotomy. The presence of pain was evaluated in the area of episiotomy at 24 and 48 h of delivery using a structured face-to-face questionnaire, and by telephone questionnaire at 5 months. The primary endpoint was the presence of persistent pain at 5 months. A record was made of the presence of pain at delivery, and its intensity, the presence or absence of epidural analgesia, instrumental delivery, perineal tear, and pain when episiotomy was performed, as well as the presence of dyspareunia and urinary incontinence at 5 months post-episiotomy.

RESULTS

A total of 87 parturient patients were included, of whom 78 completed the study. Of the patients who completed the study, 12.8% reported chronic episiotomy pain. Epidural analgesia was associated with a higher incidence of instrumental delivery and less pain at the time of episiotomy and expulsion (P<.0005, P<.02, and P<.01, respectively). Chronic pain is associated with operative delivery (P<.017), and with the presence of pain at rest at 24 and 48 h (P<.01), of wound complications (P<.026), and of dyspareunia (P<.001).

CONCLUSION

An incidence of 12.8% of women developing chronic pain after delivery with episiotomy suggests a health problem. More studies are needed to confirm our results.

[Single-dose intraincisional levobupivacaine infiltration in caesarean postoperative analgesia: a placebo-controlled double-blind randomized trial]

OBJECTIVES

The efficacy of single-dose intraincisional infiltration with levobupivacaine in postoperative analgesia and chronic pain after caesarean sections is unknown.

STUDY

A placebo-controlled double-blind randomized trial.

PATIENTS AND METHODS

After ethical approval, and written inform consent, 140 women scheduled for a caesarean section were randomly assigned and received 30mL of levobupivacaine 0.5% (L group) or saline (placebo-P group) into their wound. The primary endpoint was morphine consumption (using intravenous morphine patient-controlled analgesia) for the first 24h after surgery. At 1h to 48h, side effects, pain at rest and pain 2months later were recorded.

RESULTS

All included patients had similar demographic and surgical characteristics. The morphine consumption was significantly lower in the L group at h6, h8 and h12 (considering both total intake and each request). At h4, the mean total morphine consumption was 25 (12) mg in the L group versus 31 (14) mg in the P group (P=0.05). Time until discharge and side effects including nausea-vomiting (14 vs 20%), wound scar complications (6 vs 8%) and chronic pain after 2months (25% in both groups complained of small pain, and 75% no pain) were similar between the two groups (P>0.05).

CONCLUSION

Single-dose local infiltration of levobupivacaine 0.5% reduced opioid requirement at 12h, with no difference after 24h. www.clinicaltrials.com, number: NCT00621907.

Evaluation of experimental pain tests to predict labour pain and epidural analgesic consumption

BACKGROUND

The aim of this study was to determine whether experimental pain tests (EPTs) using heat, pressure, and i.v. cannulation before induction of labour reliably predict epidural analgesic use and pain intensity during labour.

METHODS

Fifty healthy women with singleton, term pregnancies admitted for scheduled induction of labour comprised the study population for this prospective case-controlled study. Heat and pressure threshold, tolerance, and suprathreshold VAS pain ratings were determined using a Medoc thermal sensory analyser and Somedic pressure algometer, respectively, after admission before induction of labour. Verbal pain scores (VPS 0-10) were determined during peripheral 18 G i.v. placement. Response outcomes included time to epidural request, pain at epidural, labour pain [area under the curve (AUC) and worse score], and epidural local anaesthetic use. Bivariate analysis followed by forward-backward multiple regression modelling was performed to determine relationships between EPTs and labour pain response measures.

RESULTS

Heat tolerance was significantly correlated with worst labour pain (r=0.33, P=0.025) and pain with i.v. cannulation was correlated with time to epidural request (r=0.33, P=0.025). Multiple linear regression analysis found that labour pain AUC could be predicted with suprathreshold heat VAS, heat tolerance, and pressure tolerance (R(2)=0.26; P=0.007). There were strong correlations among the various pre-labour QSTs.

CONCLUSIONS

Pre-labour EPTs were not very reliable at predicting the labour pain experience. Consistent with postoperative studies, suprathreshold and tolerance tests appear more useful than the threshold for predicting labour pain responses. Pain rating during i.v. cannulation (an easy, rapid, point-of-care test) showed some utility as an EPT.

Can anaesthetic technique effect postoperative outcome?

PURPOSE OF REVIEW

Conventional wisdom maintains that multiple aspects of surgical technique and management may affect postoperative outcome, while anaesthetic technique has little long-term effect on patient outcomes. There is accumulating evidence that, on the contrary, anaesthetic management may in fact exert a number of longer-term effects in postoperative outcome. Here, we review the most topical aspects of anaesthetic management which may potentially influence later postoperative outcomes.

RECENT FINDINGS

There is strong evidence that administration of supplemental oxygen and the avoidance of perioperative hypothermia, allogeneic blood transfusion, hyperglycaemia or large swings in blood glucose levels reduces postoperative infection rates. There is also some evidence that the use of regional anaesthesia techniques reduces chronic postsurgical pain and that avoidance of nitrous oxide reduces the long-term risk of myocardial infarction. Current evidence is equivocal regarding the effects of anaesthesia techniques and cancer recurrence. The instigation of perioperative beta-blockade in noncardiac surgery may not reduce perioperative adverse events or improve postoperative cardiovascular risk.

SUMMARY

Further prospective, large-scale human trials with long-term follow-up are required to clarify the association between anaesthesia and cancer recurrence, neurotoxicity and the developing brain and long-term postoperative cognitive dysfunction in the elderly.

Preoperative scar hyperalgesia is associated with post-operative pain in women undergoing a repeat Caesarean delivery

BACKGROUND

Over 1.4 million Caesarean deliveries are performed annually in the United States, out of which 30% are elective repeat procedures. Post-operative hyperalgesia is associated with an increased risk for persistent post-surgical pain; however, there are no data on whether residual scar hyperalgesia (SHA) from a previous Caesarean delivery (CD) persists until the next delivery. We hypothesized that residual SHA may be present in a substantial proportion of women and is associated with increased post-operative pain.

METHODS

One hundred and sixty-three women scheduled for a repeat CD under spinal anaesthesia were enrolled into the study. Mechanical temporal summation (mTS) and SHA index were measured preoperatively. SHA was considered present when the index was >0. Post-operative pain scores at 12, 24 and 48 h and wound hyperalgesia (WHA) at 48 h were recorded.

RESULTS

SHA was present in 67 women 41% with a median SHA index of 0.42 (Q (25)  = 0.25; Q (75)  = 1.1, range 0.03-4.25). Women with SHA had overall higher post-operative pain scores and SHA was correlated with preoperative mTS (r = 0.164, p < 0.05), post-operative pain severity (r = 0.25, p < 0.002) and WHA at 48 h (r = 0.608, p < 0.001). Severe pain (visual analogue pain scale-S48 ≥ 7, n = 20) was predicted with a sensitivity and specificity of 60% and 62%, respectively. Positive predictive value was 18% and negative predictive value was 92%.

CONCLUSIONS

Preoperative SHA is present in 41% of women scheduled for repeat CD and is associated with increased mTS and post-operative pain. Screening for preoperative SHA may predict women at risk for increased post-operative pain, and guide post-operative analgesia to include anti-hyperalgesic drugs.

Pain cognitions as predictors of the request for pain relief during the first stage of labor: a prospective study

BACKGROUND

It is thought that pain cognitions determine coping behavior and success in adapting to labor. The aim of this study was to examine whether pain cognitions assessed by the labor pain coping and cognition list (LPCCL) predict the request for pain relief during the first stage of labor and which pain cognition is the strongest predictor of a request for pain relief over and above, and independent of, other pain cognitions.

METHODS

Participants in this prospective study were 177 low-risk nulliparous pregnant women. Data were collected on two different occasions. The numerical pain intensity scale (NPS)-anticipated and the LPCCL were administered at 34-36 weeks' gestation followed by the NPS-during labor.

RESULTS

Catastrophizing and external pain control predicted the request for pain relief during labor after adjustment for relevant demographic and clinical characteristics, respectively (adjusted odds ratio [OR] 2.61 [95% CI 1.45-4.68] and adjusted OR 1.90 [95% CI 1.16-3.10]). Catastrophizing was found to be the strongest and independent predictor among the pain cognitions while controlling for significant background variables (adjusted OR 2.61 p-value < 0.001).

CONCLUSION

Catastrophizing seems to have a substantial impact on the request for pain relief in low-risk pregnant women.