Pain Management in Pregnancy: Multimodal Approaches

The role of pharmacological interventions in managing urological complications during pregnancy and childbirth: A review

Pregnancy leads to a number of structural and functional changes in the urinary system, which makes females susceptible to urological complications. This review aims to discuss the epidemiology, complications and prevention and management of urinary tract infections (UTIs), kidney stones and bladder dysfunction in pregnancy. UTIs are the most common urological problem presenting in 10% of pregnant women; Escherichia coli is the most common causative organism. If left untreated, UTIs lead to acute pyelonephritis which occurs in about 2% of pregnant women and which has serious consequences for both the mother and the baby. Kidney stones, although rare, are hazardous, occurring in 1 in 200 to 1 in 1500 pregnancies, and may cause obstructive uropathy, and aggravation of "labor-like" pain. Urological complications are frequent in pregnancy; bladder dysfunction alone has been documented to affect 50% of the pregnant women. Urological complications can have severe consequences when not properly managed including preterm labor and renal dysfunction. In order to have the best pharmacological care, safe use of antibiotics for UTIs is needed along with other measures for kidney stones. This review highlights the importance of a team approach to patient management to optimize outcome and touches briefly on some of the ethical dilemmas that may be encountered when drug therapy in pregnancy is being considered. Therefore, it is feasible to enhance the health of women and the fetus during this period through patient focused care and innovative interventions.

Self-medication among pregnant women in comparison to the general population: a scoping review of the main characteristics

Objective

An in-depth evaluation of the published evidence is needed on self-medication, specifically the evidence focusing on vulnerable groups, such as pregnant women. This scoping review aims to provide an overview of the differences in self-medication prevalence and study characteristics among different groups, while identifying gaps in the literature.

Methods

A literature search was performed in PubMed and Web of Science, including articles published in the last 10 years for the pregnant women group (PWG) and the general population group (GPG). Data on study design, self-medication prevalence, medications used, and other variables were collected, tabulated, and summarized.

Results

From 2888 screened articles, 75 were considered including 108,559 individuals. The self-medication (SM) in the PWG ranged from 2.6 to 72.4% and most studies had an SM prevalence between 21 and 50% and in the GPG, 32 from 50 studies had a SM prevalence higher than 50%. The reviewed studies varied considerably in methodology, requiring careful interpretation. While most of the studies assessed self-medication during the entire pregnancy, self-medication definition was often inconsistent between studies. Acetaminophen was the most used medication and headache was the most frequent symptom leading to self-medication initiation in the PWG.

Conclusions

Self-medication among pregnant women showed a lower prevalence when compared to the general population. The medications used and symptoms reported were similar between groups. However, methodological differences must be carefully considered. Pregnant women should carefully follow their physicians' advice before initiating self-medication to avoid preventable maternal and fetal adverse effects.

Association Between Pain During Pregnancy and Postpartum Depressive Symptoms in Adolescent and Adult Women

ISSUE

Postpartum depressive symptoms may be more prevalent and/or severe in vulnerable populations.

BACKGROUND

Postpartum depression represents a serious mental health problem associated with maternal suffering. Despite the relevance and clinical implications of investigating pain during pregnancy and the association with postpartum depression, there is limited research on this topic.

AIM

We evaluated the association between pain during pregnancy and postpartum depression symptoms in adolescent and adult women.

METHODS

This study included 86 pregnant women (42 adolescents aged 13 to 18 years and 44 adults aged 23 to 28 years) from Trairi region, Northeastern Brazil. The evaluation of pain intensity and postpartum depression symptoms was conducted using the validated instruments of the Pelvic Pain Assessment Form and Edinburgh Postnatal Depression Scale (EPDS), respectively. Mann-Whitney and Kruskal-Wallis tests compared depressive symptoms in relation to pain status.

FINDINGS

Overall, pregnant women reporting moderate to intense pain presented more depressive symptoms, with emphasis to "deep pain with intercourse" (p = .09), "burning vaginal pain after sex" (p = .01), "pelvic pain lasting hours or days after intercourse" (p = .06), and "pain with urination" (p = .09). When stratified by age group, significant associations were found only for the adolescents.

DISCUSSION

Our results suggest that women reporting pain in different daily situations have higher EPDS scores.

CONCLUSION

Pain during pregnancy is associated with postpartum depression symptoms, mainly among adolescents. Adequate screening and pain management during pregnancy may improve women's quality of life.

Exploring the Experience of Pain and Pain Management for Pregnant and Postpartum Veterans with Chronic Musculoskeletal Pain

BACKGROUND

To examine how veterans experience and treat pain during the perinatal period, we conducted a qualitative study to explore the experiences of pain, pain management, and facilitators and barriers to treatment among perinatal veterans.

METHODS

We identified veterans who received care at any of the 15 Veterans Health Administration (VHA) facilities across the United States and were enrolled in an ongoing cohort study. All participants gave birth to a newborn between March 2016 and June 2021 and met the inclusion criteria for having a prepregnancy pain-related musculoskeletal condition. We completed interviews with 30 veterans between November 2021 and January 2022. We used a framework approach to our qualitative analysis.

RESULTS

Veterans in our sample were, on average, 31 years of age, married (80%), and white (47%). The most common type of pain diagnoses were back pain (93%) and joint disorders (73%). We identified the following major themes: 1) veteran experiences of pain during pregnancy, 2) challenges to pain care during the perinatal period, and 3) veteran recommendations for VHA perinatal pain care. Experiences of pain during pregnancy varied and several barriers to pain care were identified. Veterans suggested several ways the VHA could improve pain care during the perinatal period, including more training for VHA providers on perinatal pain care and greater complementary and integrative health coverage.

CONCLUSIONS

Understanding the unique needs of pregnant veterans with chronic pain is important to provide high-quality care during the perinatal period. Veterans who participated in this study highlighted several areas where the VHA could improve pain management during pregnancy and postpartum.

A 26 years old primigravida woman presented with abdominal cutaneous entrapment syndrome: a case report

BACKGROUND

Abdominal cutaneous nerve entrapment syndrome (ACNES) is characterized by severe, mostly refractory, chronic pain due to the entrapment of the cutaneous branches of the lower torso intercostal nerves at the lateral edge of the rectus abdominis muscle. ACNES is rare compared to other pregnancy-related peripheral neuropathies and is often overlooked as a differential diagnosis for abdominal pain, despite the diagnosis relying primarily on patient history and physical examination. Emergency physicians and other medical personnel's lack of exposure to such cases results in unnecessary laboratory requests, repeated visits, and increased fear and tension for the patient.

CASE PRESENTATION

A 26-year-old primigravida on her second trimester of pregnancy presented to our Emergency department with persistent localized right upper quadrant abdominal pain. Despite repeated visit to the nearby hospital, no diagnosis was settled and the pain persisted. At our ED after a thorough history, physical examination and diagnostic test no abnormality was found. Finally Abdominal cutaneous nerve entrapment syndrome (ACNES) was considered and a mixture of 1 ml 2% lidocaine with adrenaline and 1 ml dexamethasone (4 mg) was infiltrated into the fascial plane in a fanning fashion into the most tender area using a modified technique and the patient reported significant improvement in pain.

CONCLUSION

Abdominal cutaneous nerve entrapment syndrome (ACNES) is a cause of abdominal pain in pregnancy that is often overlooked. The objective of this study is to describe a rare case of ACNES in a 26-year-old primigravida woman who presented to a low-resource emergency department to assist patient management.

Challenges and Strategies in Administering Anesthesia to Pregnant Patients With Malaria: A Comprehensive Review

Malaria remains a significant global health challenge, particularly in sub-Saharan Africa, where its impact on pregnant women and their fetuses is profound. The disease's complex interaction with pregnancy introduces unique challenges in anesthesia management, necessitating a thorough understanding of both malaria and its implications for anesthetic care. This review aims to explore the multifaceted issues associated with anesthesia for pregnant patients with malaria, examining the impact of the disease on pregnancy and the specific considerations required for effective anesthetic management. A comprehensive review of the current literature was conducted, focusing on the physiological effects of malaria on pregnancy, its complications, and the related anesthetic challenges. The review synthesizes findings from clinical studies, case reports, and expert guidelines to provide an overview of best practices and strategies. Malaria in pregnant women can lead to severe complications such as maternal anemia, placental insufficiency, and preterm labor, all of which complicate anesthetic management. The review identifies key considerations for anesthesia, including the choice of anesthetic techniques, drug interactions, and fluid management. Specific challenges include managing anemia, ensuring adequate hemodynamic stability, and mitigating potential risks associated with malaria medications. Effective anesthesia management in pregnant patients with malaria requires a nuanced approach that addresses both the disease's effects and the physiological changes of pregnancy. This review underscores the need for tailored anesthetic strategies and highlights areas for further research to enhance patient safety and outcomes. Recommendations are provided to guide clinicians in optimizing care for this vulnerable population.

Anesthetic Challenges in a Pregnancy Case With Congenital Kyphoscoliosis

Kyphoscoliosis is a well-known spinal deformity. The abnormal curvature in both the coronal and sagittal planes presents unique challenges during pregnancy. This case discusses the management of a 27-year-old primigravida with thoracolumbar kyphoscoliosis, who underwent an emergency cesarean section at 39.3 weeks of gestation. An interdisciplinary team consisting of an obstetrician, pulmonologist, orthopedic surgeon, anesthesiologist, and physiotherapist collaborated in her care. In such cases, successful outcomes require a tailored approach that prioritizes maternal-fetal well-being and minimizes potential complications associated with complex spinal deformity during pregnancy and childbirth.

Musculoskeletal Pain During Pregnancy Among Veterans: Associations With Health and Health Care Utilization

INTRODUCTION

Musculoskeletal (MSK) pain is more likely to be diagnosed in veterans compared with the general population; however, MSK pain during pregnancy has not been studied in veterans. This study examined health and health care use differences between pregnant veterans with and without MSK pain (MSK-).

METHODS

Veterans who delivered a newborn before June 1, 2021, were identified from an existing cohort (n = 1,181). Survey and Veterans Health Administration (VA) electronic health record data were obtained on participants. Veterans meeting inclusion criteria were identified as those with MSK pain (MSK+) and were compared with MSK- participants. We examined differences between primary outcomes of VA health care engagement (including mental health diagnoses, health care visits, receipt of prescription opioids, and complementary and integrative health use) and secondary outcomes (including postpartum variables) between MSK pain groups. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were calculated.

RESULTS

There were 172 veterans (14.6%) who met MSK pain eligibility criteria. In adjusted models, MSK+ veterans were more likely to be diagnosed with major depressive disorder (aOR, 1.76; 95% CI, 1.22-2.53) and post-traumatic stress disorder (aOR, 1.79; 95% CI, 1.21-2.64) during pregnancy compared with MSK- veterans. The use of VA mental health care (aOR, 1.52; 95% CI, 1.09-2.12) and the odds of receiving an opioid prescription during pregnancy (aOR, 2.76; 95% CI, 1.53-5.00) was higher in MSK+ veterans compared with MSK- veterans. Only a small proportion (3.6%) of our entire cohort used complementary and integrative health approaches during pregnancy. MSK+ veterans were more likely to deliver by cesarean section compared with MSK- veterans (36% vs. 26%).

CONCLUSIONS

MSK+ veterans were more likely to be diagnosed with mental health conditions and to use VA mental health care during pregnancy compared with MSK- veterans. Because veterans receive their obstetrical care in the community, understanding the unique needs of pregnant MSK+ veterans in comparison with MSK- veterans is important to provide comprehensive care during the perinatal period.

Redefining Maternal Wellness: The Role of Antenatal Exercises in Musculoskeletal Issues Among Primigravida Mothers

During pregnancy, there are notable alterations in biomechanics, hormones, and vascular functioning, which frequently result in a range of musculoskeletal ailments, including back pain, leg cramps, and pelvic girdle discomfort. The significance of pregnancy-related musculoskeletal problems on women's daily functioning and general well-being is highlighted by their widespread occurrence worldwide, necessitating heightened focus and implementation of effective therapeutic approaches. The main aims of this study were to assess the effectiveness of prenatal exercises in musculoskeletal discomfort and investigate the association between post-intervention levels of discomfort and certain demographic factors. A quantitative technique was used in this study, utilizing a pre-experimental design conducted for three months. A total of 60 primigravida mothers were selected as participants through purposive sampling. The study was conducted in a Maternity Tertiary Care Center located in Tamil Nadu. The intervention encompassed the provision of antenatal exercises, specifically focusing on abdominal tightness, pelvic tilting, and foot and ankle movements. The researcher demonstrated the exercises for 20 minutes, and afterward, mothers were asked to perform the activities themselves. The process was monitored and observed for two weeks. The findings were statistically significant, suggesting a noteworthy decrease in musculoskeletal disorders following the implementation of the intervention. The statistical analysis revealed a significant degree of significance (P = 0.001), confirming the efficacy of the exercises. Before the implementation of the intervention, a significant proportion of mothers, namely, 45 (75%) reported experiencing moderate back pain. However, following the intervention, this percentage notably fell to 33.34% (20). The incidence of moderate pelvic pain decreased from 80% (48) to 30% (18), and a comparable pattern was observed in the reduction of leg cramps. Additionally, the research identified significant associations between the improvements and a range of demographic and obstetric factors, including the level of education, occupation, family structure, age at marriage, and weight of the mother. The results highlight the significance of incorporating antenatal exercises as a regular component of prenatal care to minimize musculoskeletal discomfort, hence promoting the overall health and well-being of expectant mothers.

Arnold-Chiari Malformations in Pregnancy and Labor: Challenges and Management Strategies

Arnold-Chiari malformations (ACMs) present unique challenges in pregnancy and labor, requiring a comprehensive understanding and multidisciplinary approach to care. This review article provides an overview of ACMs, including their definition, classification, and prevalence. The challenges in diagnosing ACMs during pregnancy, the available imaging modalities, and screening recommendations are discussed. The impact of ACMs on maternal health, fetal development, and the management strategies employed during pregnancy and labor are explored. Emphasis is placed on the importance of a multidisciplinary approach involving neurologists, obstetricians, and other specialists. Medical management options for symptom relief, surgical interventions, and anesthetic considerations during labor and delivery are also addressed. The importance of postpartum care, breastfeeding considerations, and long-term follow-up for women with ACMs who desire future pregnancies are highlighted. Finally, areas for further research and advancements in ACM management are identified. By improving our understanding and management of ACMs in pregnancy and labor, healthcare professionals can optimize care and improve outcomes for mothers and babies affected by this condition.

Low back pain in a sample of Syrian pregnant women: A cross-sectional study

Introduction

Low back pain related to pregnancy occurs in 60%-70% of pregnancies, at any time during pregnancy. During pregnancy, many factors such as weight gain, and others are the causes of the back pain. In Syria, due to the circumstances of the war, many pregnant women may be exposed to increase the risk of lower back pain, so this study will determine the prevalence of lower back pain among pregnant women and its potential risk factors. We aimed to evaluate the prevalence of low back pain in pregnant women and to assess the risk factors related to it.

Methods

A cross-sectional, observational study was conducted between May 2020 and December 2022 at Obstetrics and Gynecology University Hospital in Damascus, Syria. Pregnant women aged over 18 years were selected from the outpatient clinic. Participants, after signing the informed consent, fill out the survey, which included the following parameters: age, weight, height, body mass index (BMI), education, parity, shoe type, weekly walking hours, occupation, low back pain, in which semester, radiation, onset, alleviating and aggravating factors, disability, and pain in previous pregnancies. We used Excel 2010, and the Statistical Package for the Social Sciences version 23.0. p < 0.05 was considered statistically significant, and we used the Chi-square test (χ 2 test), t student test to test the basal differences between groups.

Results

A number of 551 pregnant participants were included and low back pain prevalence was 62%. There was a statistically significant relation between low back pain and each of the following: Obesity, weekly walking hours, pain in previous pregnancies, and occupation.

Conclusion

Low back pain is prevalent during pregnancy and the most important risk factors include obesity and pain in previous pregnancies whereas walking and employment are protective measures to prevent low back pain.

COVID-19 and liver injury: Pathophysiology, risk factors, outcome and management in special populations

The coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus-2 is an ongoing health concern. In addition to affecting the respiratory system, COVID-19 can potentially damage other systems in the body, leading to extra-pulmonary manifestations. Hepatic manifestations are among the common consequences of COVID-19. Although the precise mechanism of liver injury is still questionable, several mechanisms have been hypothesized, including direct viral effect, cytokine storm, hypoxic-ischemic injury, hypoxia-reperfusion injury, ferroptosis, and hepatotoxic medications. Risk factors of COVID-19-induced liver injury include severe COVID-19 infection, male gender, advanced age, obesity, and underlying diseases. The presentations of liver involvement comprise abnormalities in liver enzymes and radiologic findings, which can be utilized to predict the prognosis. Increased gamma-glutamyltransferase, aspartate aminotransferase, and alanine aminotransferase levels with hypoalbuminemia can indicate severe liver injury and anticipate the need for intensive care units’ hospitalization. In imaging, a lower liver-to-spleen ratio and liver computed tomography attenuation may indicate a more severe illness. Furthermore, chronic liver disease patients are at a higher risk for severe disease and death from COVID-19. Nonalcoholic fatty liver disease had the highest risk of advanced COVID-19 disease and death, followed by metabolic-associated fatty liver disease and cirrhosis. In addition to COVID-19-induced liver injury, the pandemic has also altered the epidemiology and pattern of some hepatic diseases, such as alcoholic liver disease and hepatitis B. Therefore, it warrants special vigilance and awareness by healthcare professionals to screen and treat COVID-19-associated liver injury accordingly.

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.

Vasovagal Reactions during Interventional Pain Management Procedures—A Review of Pathophysiology, Incidence, Risk Factors, Prevention, and Management

Vasovagal reactions are a benign but common outcome of interventional pain management procedures that can negatively impact patient care, including aborted procedures and fear of future procedures that would otherwise help the patient. Research has been done on the incidence, risk factors, and management of vasovagal reactions resulting from such procedures, but less is known about how to prevent these reactions from occurring. In this paper, we present a literature review of the pathophysiology, incidence, risk factors, prevention, and management of vasovagal reactions during interventional pain management procedures, with an emphasis on the relative lack of research and conflicting advice on preventive measures. We found that moderate sedation and anxiolytics have been used prophylactically to prevent vasovagal reactions, but their side-effect profiles prevent them from being used commonly. Less studied is the prophylactic administration of antimuscarinics and IV fluids, despite the potential benefit of these measures and relatively low side-effect profile. We explore these topics here and offer advice for future research to fill the gaps in our knowledge.

Medication use during pregnancy among women with congenital physical disabilities

BACKGROUND

Medication use during pregnancy is common, with up to 90% of pregnant women taking at least one medication. Women with congenital physical disabilities often report co-occurring conditions during pregnancy that may warrant pharmaceutical treatment, however, research is limited. We aim to describe medication use during pregnancy including: pain, psychotropic, and antibacterial medication, among women with and without congenital physical disabilities.

METHODS

We used data from the Slone Birth Defects Study (1976-2015), a case-control study that collected information on pre-pregnancy health conditions and exposures among participating mothers. Women with congenital physical disabilities (n = 132) included women with spina bifida, cerebral palsy, muscular dystrophy, limb deficiencies, and other skeletal/connective tissue conditions and were matched by interview year and study site to women without congenital physical disabilities (n = 528). Proportions and difference in proportions for each medication were compared between groups. Simple proportions were also calculated for duration and multiple medication use variables.

RESULTS

Women with congenital physical disabilities more frequently reported use of pain (acetaminophen and opioids), psychotropic (antidepressants), and antibacterial medications during pregnancy. Women with congenital physical disabilities used pain and psychotropic medications for longer, frequent durations, and more frequently reported haven taken multiple medications during pregnancy.

CONCLUSION

Women with congenital physical disabilities report higher medication use during pregnancy compared to women without physical disabilities. Patterns may be attributable to co-occurring conditions or increased risk of pregnancy complications in this population. Further research is needed to describe the patterns of medication use for clinical decisions regarding treatment of pregnant women with disabilities.

Maternal pain during pregnancy dose-dependently predicts postpartum depression: The Japan Environment and Children's Study

BACKGROUND

Postpartum depression (PPD) affects women during the first year after delivery. This study investigated the association between prenatal pain (maternal pain during pregnancy) and PPD.

METHODS

Data were analyzed from the Japan Environment and Children's Study (JECS), a nationwide prospective birth cohort study. Information on prenatal pain was collected twice during pregnancy through self-administered questionnaires. PPD symptoms were assessed using the Edinburgh Postnatal Depression Scale at one month postpartum. Poisson regression analyses were performed to investigate the association between prenatal pain and PPD, with other putative risk factors adjusted in the model.

RESULTS

Among 84,801 study subjects, 11,535 (13.6%) were screened as positive for PPD. In the present study, the occurrence of prenatal pain was 69.6 and 84.0% at the first trimester and the second/third trimester, respectively. A positive relationship between any degree of pain and PPD in both the first and the second/third trimester was observed. A significant linear dose-dependent association was also found (Ptrend < 0.001) when the subjects were divided by the severity of pain. Using participants without any pain at either point as a reference, those with persistent pain both at the first and the second/third trimesters showed the highest risk for PPD: aRR = 1.95 (95%CI: 1.76-2.15; p < 0.001).

LIMITATIONS

No detailed information regarding the type or site of prenatal pain was available in the JECS questionnaires, neither did data concerning delivery and postpartum pain.

CONCLUSIONS

The study results suggest that prenatal pain is a dose-dependent risk factor for the development of PPD.

Transcutaneous Electrical Nerve Stimulation: An Overview

Pain and its management hold a central place in health care. The pain associated with pregnancy and giving birth is unique in that it is a normal, physiologic phenomenon that is affected by cultural mores, personal experience, and internalized sensations. There are numerous nonpharmacologic tools available to treat discomfort during pregnancy and childbirth. Some methods of nonpharmacologic relief are underutilized, due to the lack of knowledge of the evidence. Childbirth educators, doulas, nurses, and midwives are a prime source of knowledge for birthing families to learn a variety of comfort techniques during pregnancy and labor. The purpose of this article is to discuss the use of transcutaneous electrical nerve stimulation (TENS) as a nonpharmacologic comfort technique.

Maintenance of physical activity level, functioning and health after non-pharmacological treatment of pelvic girdle pain with either transcutaneous electrical nerve stimulation or acupuncture: a randomised controlled trial

OBJECTIVE

To investigate if there are differences between acupuncture and transcutaneous electrical nerve stimulation (TENS) as treatment for pelvic girdle pain (PGP) in pregnancy in order to manage pain and thus maintain health and functioning in daily activities and physical activity (PA).

DESIGN

Randomised controlled trial.

SETTING AND PARTICIPANTS

Pregnant women (n=113) with clinically verified PGP in gestational weeks 12-28, recruited from maternity healthcare centres, randomised (1:1) into two groups.

EXCLUSION CRITERIA

any obstetrical complication, systemic disease or previous disorder that could contradict tests or treatment.

INTERVENTIONS

The intervention consisted of either 10 acupuncture sessions (two sessions per week) provided by a physiotherapist or daily home-based TENS during 5 weeks.

PRIMARY OUTCOME VARIABLES

Disability (Oswestry Disability Index), functioning (Patient Specific Functional Scale), work ability (Work Ability Index) and PA-level according to general recommendations.

SECONDARY OUTCOME VARIABLES

Functioning related to PGP (Pelvic Girdle Questionnaire), evening pain intensity (Numeric Rating Scale, NRS), concern about pain (NRS), health (EuroQoL 5-dimension), symptoms of depression/catastrophising (Edinburgh Postnatal Depression Scale/Coping Strategies Questionnaire).

RESULTS

No mean differences were detected between the groups. Both groups managed to preserve their functioning and PA level at follow-up. This may be due to significantly (p<0.05) reduced within groups evening pain intensity; acupuncture -0.96 (95% CI -1.91 to -0.01; p=0.049), TENS -1.29 (95% CI -2.13 to -0.44; p=0.003) and concern about pain; acupuncture -1.44 (95% CI -2.31 to -0.57; p=0.0012), TENS -1.99 (95% CI -2.81 to -1.17; p<0.0001). The acupuncture group showed an improvement in functioning at follow-up; 0.82 (95% CI 0.01 to 1.63; p=0.048) CONCLUSION: Treating PGP with acupuncture or TENS resulted in maintenance of functioning and physical activity and also less pain and concern about pain. Either intervention could be recommended as a non-pharmacological alternative for pain relief and may enable pregnant women to stay active.

TRIAL REGISTRATION NUMBER

12726. https://www.researchweb.org/is/sverige/project/127261.

A hierarchical procedure to select intrauterine and extrauterine factors for methodological validation of preterm birth risk estimation

BACKGROUND

Etiopathogenesis of preterm birth (PTB) is multifactorial, with a universe of risk factors interplaying between the mother and the environment. It is of utmost importance to identify the most informative factors in order to estimate the degree of PTB risk and trace an individualized profile. The aims of the present study were: 1) to identify all acknowledged risk factors for PTB and to select the most informative ones for defining an accurate model of risk prediction; 2) to verify predictive accuracy of the model and 3) to identify group profiles according to the degree of PTB risk based on the most informative factors.

METHODS

The Maternal Frailty Inventory (MaFra) was created based on a systematic review of the literature including 174 identified intrauterine (IU) and extrauterine (EU) factors. A sample of 111 pregnant women previously categorized in low or high risk for PTB below 37 weeks, according to ACOG guidelines, underwent the MaFra Inventory. First, univariate logistic regression enabled p-value ordering and the Akaike Information Criterion (AIC) selected the model including the most informative MaFra factors. Second, random forest classifier verified the overall predictive accuracy of the model. Third, fuzzy c-means clustering assigned group membership based on the most informative MaFra factors.

RESULTS

The most informative and parsimonious model selected through AIC included Placenta Previa, Pregnancy Induced Hypertension, Antibiotics, Cervix Length, Physical Exercise, Fetal Growth, Maternal Anxiety, Preeclampsia, Antihypertensives. The random forest classifier including only the most informative IU and EU factors achieved an overall accuracy of 81.08% and an AUC of 0.8122. The cluster analysis identified three groups of typical pregnant women, profiled on the basis of the most informative IU and EU risk factors from a lower to a higher degree of PTB risk, which paralleled time of birth delivery.

CONCLUSIONS

This study establishes a generalized methodology for building-up an evidence-based holistic risk assessment for PTB to be used in clinical practice. Relevant and essential factors were selected and were able to provide an accurate estimation of degree of PTB risk based on the most informative constellation of IU and EU factors.

Diagnostic value of high-frequency ultrasound in carpal tunnel syndrome during pregnancy: A case-control study

Background: Carpal tunnel syndrome (CTS) is the most prevalent entrapment syndrome in the upper limbs, for which pregnancy is a known risk factor. CTS diagnosis is confirmed via nerve conduction studies (NCSs), which sometimes is expensive, and the electrical stimulation makes it an unpleasant diagnostic modality, especially for pregnant subjects. Recently, high-frequency ultrasonography (HF-USG) is known as a diagnostic method. This study is concerned with determining the diagnostic value of this modality for CTS among pregnant women. Methods: This cross-sectional case-control study was conducted with 40 CTS cases and 40 matched controls. The HF-USG of wrists was performed bilaterally on all participants with a focus on the median nerve cross-sectional area (MNCSA) at the carpal tunnel (CT) inlet. Results: Mean MNCSA was statistically different between the CTS group (11.71 ± 1.86 mm2, range: 8 to 18 mm2) and the control group (6.75 ± 1.38 mm2, range: 4 to 11 mm2) (P < 0.001). The receiver operating characteristic (ROC) curve was drawn, and the cross-sectional area (CSA) cut-off point of 8.5 mm2 showed sensitivity and specificity of 98% and 93%, respectively. The positive predictive value (PPV) and the negative predictive value (NPV) were 95% and 98%, respectively, with the mentioned point as the diagnostic threshold. Conclusion: HF-USG of the median nerve can be utilized as a preferable alternative to NCS (the current gold standard diagnostic method) in pregnant women, due to its convenience and lower cost, or at least, it can be used as a screening tool among pregnant women with suspicious symptoms.

Association of Gestational Opioid Exposure and Risk of Major and Minor Congenital Malformations

IMPORTANCE

The rapid increase of opioid-related overdoses and deaths has become a public health concern in the US. Use of prescription opioids in pregnant women has increased; results from teratogenicity studies remain controversial.

OBJECTIVE

To evaluate the association between maternal prescription opioid use (excluding opioid use disorders) during pregnancy and the incidence of congenital malformations.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective population-based cohort study evaluated linked Rhode Island Medicaid claims and vital statistics data of live births from January 1, 2008, to December 31, 2016. Data analysis was conducted from May 1, 2019, to May 31, 2020. Women who had a live birth during the study period, but no cancer or opioid use disorder, were followed up from 3 months before pregnancy to the end of pregnancy.

EXPOSURES

Data on the mother's prescription opioid exposure were obtained through pharmacy claims and exposure was defined as dispensing of at least 1 prescription opioid during the first, second, or third trimester.

MAIN OUTCOMES AND MEASURES

The primary outcome was overall major or minor congenital malformations, defined as 1 or more major or minor congenital malformation. Secondary outcomes were defined as 10 specific categories of congenital malformations classified by organ systems using International Classification of Diseases diagnosis codes.

RESULTS

Of 12 424 included pregnancies, 891 mothers (7.2%) received prescription opioids during pregnancy and 3153 infants (25.4%) were diagnosed with major or minor congenital malformations. Comparing prescription opioid exposure vs nonexposure, no excess risk was observed for major birth defects in infants with opioid exposure in trimester 1 (adjusted relative risk [aRR], 1.40; 95% CI, 0.84-2.34), and higher risks were found for overall minor birth defects in trimester 3 (aRR, 1.26; 95% CI, 1.04-1.53) and minor birth defects in the musculoskeletal system in trimester 2 (aRR, 1.50; 95% CI, 1.10-2.03) and trimester 3 (aRR, 1.65; 95% CI, 1.23-2.22). Significant dose responses in selected minor malformations and effects of specific opioids were also identified. Hydrocodone in trimester 2 (aRR, 3.01; 95% CI, 1.80-5.03) and oxycodone in trimester 3 (aRR, 2.43; 95% CI, 1.37-4.02) were associated with plagiocephaly, polydactyly, and other specified congenital deformities of the hip.

CONCLUSIONS AND RELEVANCE

The findings of this study suggest a higher risk of minor congenital malformations associated with use of prenatal prescription opioids in trimester 3, which seems to be dose-dependent. Further investigation is needed to establish causality and explore the physiologic plausibility of the association.

Community-based non-pharmacological interventions for improving pain, disability and quality of life in pregnant women with musculoskeletal conditions: protocol for a systematic review with meta-analyses

INTRODUCTION

Twenty five per cent of pregnant women with musculoskeletal pain have disabling symptoms that negatively influence quality of life. Studies have reported varying effects of non-pharmacological interventions including exercise, manipulation and pelvic belts for pregnant women with musculoskeletal problems. The overall effectiveness and acceptability of these interventions is uncertain due to lack of synthesised evidence. This protocol is for the first systematic review of community-based non-pharmacological interventions for improving pain, disability and quality of life in pregnant women with musculoskeletal conditions from studies published until August 2020.

METHODS AND ANALYSIS

A detailed search of PubMed, CINAHL, CENTRAL, Global Index Medicus, African Index Medicus, African Journal Online, Western Pacific Region Index Medicus, Latin American and Caribbean Centre on Health Science Information, Index Medicus for South-East Asia Region, IRIS (WHO digital publications), British Library for Development Studies and Google Scholar. Additional studies will be located from the reference list of identified studies and relevant systematic reviews. The databases will be searched from inception to August 2020. Appraisal of study quality will be performed with the Mixed Methods Appraisal Tool. Data will be synthesised using a mixed-studies synthesis design-the convergent synthesis. The description of interventions in all study designs will be summarised narratively. Meta-analyses will be used to statistically summarise the effectiveness of interventions in randomised controlled trials and the factors that influence these. Other quantitative studies will be summarised narratively to answer the objectives. Thematic synthesis will be used to summarise results of qualitative studies. The outcomes of interest include pain, disability and quality of life. This paper is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols 2015 guidelines.

ETHICS AND DISSEMINATION

Ethical clearance is not required. Findings will be presented at conferences and published in peer-reviewed journals.

PROSPERO REGISTRATION NUMBER

CRD42020189535.

Clinical management of the pregnant patient undergoing non-obstetric surgery: Review of guidelines

The management principles of non-obstetric surgery during pregnancy are important concepts for all health care providers to be cognizant of. The goals of non-obstetric surgery are to ensure maternal safety, maintain the pregnancy, and ensure fetal well-being. In this regard, organogenesis occurs roughly between days 7-57 and thus, certain medications have a higher incidence of fetal teratogenicity in this first trimester. Some examples of common surgeries performed urgently or emergently include appendectomies, ovarian detorsions, bowel obstruction, trauma, and cholecystectomies. The choice of anesthetic technique and the selection of appropriate anesthetic drugs should be guided by indication for surgery, the nature of the surgery, and the site of the surgical procedure. Many of the concerns for any patients undergoing urgent or emergent surgery must be considered by anesthesia providers along with steps to ensure the fetus has the best outcome.

Trends in Use of Acupuncture During Pregnancy for the Military Health System, 2006-2016

Objective: Acupuncture is recognized as safe for use in pregnancy when correctly performed and has been provided at military healthcare facilities since 2005. Previous research identified a number of pregnant patients receiving acupuncture within the Military Health System (MHS). This study was conducted to describe trends in usage from 2006 to 2016 including patient and provider characteristics. Materials and Methods: This study utilized TRICARE claims from the MHS Data Repository (MDR). Analysis was performed through the MDR for women ages 18 years and older, who had acupuncture treatments at military treatment facilities related to pregnancy, from 2006 to 2016. Descriptive statistics were collected on patient demographics, clinic types and provider specialties, major diagnostic categories associated with acupuncture, number of visits per patient, and utilization over time. Results: Less than 0.3% of pregnant women in the MHS received acupuncture. The greatest usage was among patients who were white, ages 25-34, dependents of active duty personnel, and in the Army service. The most common diagnoses were for musculoskeletal system and connective tissue disorders (41.9%). Approximately 79% of care was delivered by physicians. The trend over time rose from 11 visits in 2006 to 130 visits in 2016. Conclusions: Provision of acupuncture in pregnancy grew ∼12-fold between 2006 and 2016, although usage remains low overall. This greater proportion of physician-provided care in pregnant women versus the general patient population may reflect a cautionary attitude toward use in pregnancy. This research is expected to inform discussions for people seeking to increase access to acupuncture during pregnancy.

Spinal Cord Stimulation in Pregnant Patients: Current Perspectives of Indications, Complications, and Results in Pain Control: A Systematic Review

Spinal cord stimulation (SCS) has been described as a valuable neuromodulator procedure in the management of chronic medically untreated neuropathic pain. Although the use of this technique has been published in many papers, a question still remains regarding its applicability in pregnant patients. The goal of this paper is to discuss the risks, complications, and results as well as the prognosis of SCS in pregnant patients. We performed a systematic review from 1967 to 2018 using the databases MEDLINE, LILACS, SciELO, PubMed, and BIREME, utilizing language as selection criteria. Eighteen studies that met our criteria were found and tabulated. SCS is a reversible and adjustable surgical procedure, which results in patients that demonstrated a significant effect in the reduction of pain intensity in pregnant patients. The etiologies most frequent were complex regional pain and failed back pain syndromes, which together represented 94% of analyzed cases. The technical complications most frequent were lead migration (3%, n = 1). Regarding the risks, the authors did not show significative factors among the categorical variables that can suggest a teratogenicity, while the maternal risks have been associated to the consequences of technical complications due to, among other factors, improvement of abdominal pressure during pregnancy and delivery. Finally, although there are not significative cohorts of pregnant patients, the procedure is still an effective surgical approach of neuropathic pain associated to lower rates of complications and significative improvement in the quality of life of patients during pregnancy.

Pain Management in the Opioid-Dependent Pregnant Woman

Opioid dependence is an epidemic in the United States, and the percentage of pregnant women who are opioid dependent has increased dramatically in the last decade. Pain management, already a concern for intrapartum and postpartum care, is complicated in the context of opioid dependence. This clinical review surveys the literature on pain management in opioid-dependent pregnant women to summarize current consensus and evidence to guide clinical practice. Points of consensus for pain management in opioid-dependent pregnant women include continual opioid maintenance therapy throughout the pregnancy and the postpartum period; adequate management of acute pain; the contraindication of opioid agonist-antagonists for pain management; and the need for interdisciplinary teams using a multimodal approach to provide optimal care to opioid-dependent pregnant women.