For women who suffer from chronic pain and want to become pregnant, preparations should begin long before conception. Since many of the medications used to treat chronic pain can affect early fetal development, making sure you don’t get pregnant before you are ready is important.
“As we know, half of all pregnancies are not planned,” says Shona Ray-Griffith, MD, co-director of the Women’s Mental Health Program at the University of Arkansas for Medical Health Sciences in Little Rock. “If you have chronic pain, you need to have an ongoing discussion about contraception with your physician. When you start to think about having a child, you and your physician can then begin to discuss how best to manage your pain and keep the fetus safe.”
Work out who will manage what
The decision about who will be managing chronic pain during and after the pregnancy should be made before conception. Whether you will be seeing an obstetrician (OB), your family doctor or another provider, ask about his or her experience in dealing with moms on chronic pain medication.
Explore your doctor’s access to higher-level experts such as maternal-fetal medicine or high-risk obstetricians should the need arise. You and your local doctors may want to consider referral to one of these specialists from the first preconception visit forward.
Many women with chronic pain see more than one physician even before they add an OB. If you have rheumatoid arthritis, you may already be seeing a rheumatologist and a pain specialist. It is important that both you and the doctors understand early on who will be responsible for what part of your care.
“Mothers-to-be have to be active collaborators in their care and can’t assume that all of their doctors are talking to each other in real time,” says W. Clay Jackson, MD, DipTH, a clinical associate professor of family medicine and psychiatry at the University of Tennessee in Memphis. “I suggest they leave every appointment with a written note to be given to the other practitioners as they see them. This ensures that your doctors all know what the others are doing and thinking.”
Be sure to know other questions to ask before getting pregnant.
• What kinds of pain should I expect during the pregnancy?
• How should I address them?
• When should I bring them to the attention of a doctor?
The biggest concern when contemplating pregnancy is the medications you are taking. Many of the drugs used to control pain can have a negative impact on the fetus, especially during the first trimester. You and your doctor will have to determine which medicines you may need to quit or cut back on prior to conception.
Your health-care providers may eliminate the use of nonsteroidal anti-inflammatory drugs (NSAIDs), including naproxen (Naprosyn), ibuprofen (Motrin) and others. Acetaminophen (Tylenol and others) is the only medicine of this class that is recommended for use throughout the pregnancy.
“This discussion is largely a cost/benefit analysis,” says Ray-Griffith. “You have to weigh the benefits to you of pain control through the medications against the risks to the baby as well as the risks and benefits to both of you of going untreated.”
The source of pain and mom’s ability to function with it is another variable. For example, concerns are different for a person whose migraine headache requires medication once or twice a month than for one who is on medications all the time to prevent more frequent, disabling headaches.
The cause of pain is another talking point with your physicians. For example, pre-existing low back pain may get worse as the pregnancy progresses. However, other pain-inducing diseases may actually get better. “In pregnancy, the woman’s immune system becomes less aggressive so that it doesn’t attack the 50 percent of the fetus that is made up of foreign genetics,” says Jackson, who also is president of the Academy of Integrative Pain Management. “Inflammatory diseases such as rheumatoid arthritis and lupus may actually get better until delivery.”
After you are pregnant, any new pain should be brought to your doctors’ attention. Even if you had pain in the past, you can’t assume that a similar sensation is not from a new cause. The important point is that any change in symptoms or the appearance of a new one needs to be discussed.
Pregnancy itself can cause pain, most often in the back. Causes include:
• weight gain between 25 and 35 pounds, which puts extra tension on the spine;
• posture changes, which shift your center of gravity and cause you to move differently;
• release of the hormone relaxin, which relaxes ligaments, loosens joints to help along the birth and causes the ligaments that support the spine to loosen, which can result in instability and pain;
• separation along the center seam of the two sheets of muscle that run from the ribs to the pubic bone, which can occur as the uterus expands along with the growing fetus and make back pain worse; and
• emotional stress, which can cause muscle tension and spasms in the back that are often felt as pain.
“If a woman already has back problems, the pregnancy is often going to exacerbate them,” says Roger Mignosa, DO, in private practice at the Osteopathic Center San Diego. “Correcting alignment and posture issues both before and during the pregnancy can help lessen the pregnancy-related pain triggers.”
Consulting with an osteopathic physician for osteopathic manipulation is one way to go. Using a chiropractor or massage therapist are other avenues for muscle or skeletal realignment before you become pregnant.
Abdominal pain in pregnancy can be benign, but it also can be an indication of life-threatening conditions. Call the doctor managing your pregnancy if you have a severe and persistent pain, spotting or bleeding, fever, chills, a discharge from the vagina, lightheadedness or dizziness, burning or painful urination, or nausea and vomiting.
Complementary and alternative medicine treatments are another area of discussion both before and during pregnancy. Yoga and exercise are usually safe and helpful during pregnancy, although modifications may be needed. Talk to your doctor, yogi or other exercise instructors about changes that may be needed in forms, types and duration.
Massage therapy and acupuncture can continue, although modifications may need to be made as the pregnancy changes the shape of your body. Stress reduction and biofeedback are also helpful.
As with medications, talk with your physicians about continuing use of herbals or supplements both during and after pregnancy. Some can be harmful to the fetus, others are safe to use and for many, no good research has yet been conducted on their safety. While some are still safe to use topically, in a diffuser or outside of the body, ingesting essential oils is discouraged.
You should not do anything directly over the abdomen, such as transcutaneous electrical nerve stimulation (TENS), which uses electric current to stimulate the nerves and block pain.
“Although part of a big bucket, alternative/complementary medicine treatments are very conservative,” says Mignosa. “Light touch, spinal manipulation, acupuncture, nutritional medicine can be beneficial with little chance of harm. Because of restrictions on medication during pregnancy, nonpharmacological pain management is the safest way to ensure a healthy birth. The changes during pregnancy are physical changes and should be addressed with physical solutions.”
As your pregnancy continues, so will your discussions with your doctors. During the second trimester, there are usually no major concerns specifically related to treating mom’s chronic pain. This is when pregnancy-related pain, especially in the lower back, may occur. Because of fluid retention, sciatica or carpal tunnel syndrome may increase.
Third trimester: plan for delivery and after
The third trimester of the pregnancy is when you and your doctors will begin to plan for delivery and the postpartum period. Again, medications are a main concern.
“While we suggest reducing or eliminating the use of opioids even before the pregnancy begins, this isn’t always an option,” says Jackson. “The last trimester is the time to take another look to make sure that you are at the lowest possible dose and see if you could eliminate them completely for a few months.”
The same is true for muscle relaxing medications such as certain benzodiazepines (clonazepam and others) and gabapentin. In all three cases, the newborn may go through a withdrawal syndrome that can be fatal if not managed properly.
After delivery, the concerns about the baby focus on breastfeeding. If you decide to bottle feed, then you are free to return to any pain intervention that is deemed necessary by you and your doctors.
“If you breastfeed, you should talk to your pediatrician about the possibility of your child getting clinically relevant amounts of medication through the breast milk,” says Jackson.
For the mother, the major concern is postpartum depression (PPD). This is the most common complication that women face after giving birth.
“People with chronic pain are at higher risk for depression even before we factor in added risk in the postpartum period,” says Jackson. “This is a volatile time for moms with the stress of handling a newborn and sleep deprivation, which can increase pain symptoms by itself. Moms, doctors and really the entire family should be on the lookout for signs of depression during that time.”
The signs of PPD include:
• depressed mood or sudden, severe swings in mood;
• an inability to bond with the baby;
• loss of appetite or eating much more than usual;
• crying often for no apparent reason;
• withdrawing or refusing to interact with family and friends;
• sleeping very little or too much with overwhelming fatigue or lack of energy;
• increasing irritability and anger; and
• feelings of worthlessness, shame or inadequacy, especially feeling that she is a bad mother.
Thoughts of suicide or harming the baby or herself are medical emergencies and should be evaluated by a psychiatrist or other professional immediately. Symptoms can start up to six months following the pregnancy.
PPD is treatable. It can be controlled with medication and some forms of talk therapy.
Other topics of conversation
Ray-Griffith notes that this is also an important time to discuss re-establishing contraception. As before, the best pregnancy for those with pain conditions is one that is planned.
Re-establishing pre-pregnancy body alignment should also be considered. Some pain could come from poor posture and bad habits picked up related to the changes in gravity as the baby grows.
“The pelvis and sacrum change positions to let the head out of the birth canal,” says Mignosa. “If it doesn’t release and you don’t teach the mom to stabilize, then chronic pain may follow. I have had patients tell me they have had severe pain for the last 10 years. When I asked what was happening then, they often say it was following a pregnancy.”
Challenging but positive experience
Chronic pain can make having a child a little more challenging, but it can still be a positive experience.
“We talk to our mothers about medication and we talk to them about risk,” says Ray-Griffith. “Sometimes we don’t talk enough about how most of these women will deliver happy, healthy and active babies.”