Tuesday, 31 March 2015

the effects of neuropathic pain and fibromyalgia on pregnancy, and pain treatment safety

Recently I've been researching the effects of neuropathic pain and fibromyalgia on pregnancy. As by now I'm 16 weeks pregnant and we've let all our friends and family know of our coming excitement. I think its then a little over due to write about it here.

Since I am finding that having Fibromyalgia and having a baby, is fast becoming the ultimate challenge. In order to keep the baby health it is an incredible balancing act, you need to make sure your drugs are safe as the first trimester is most important to the baby's brain and development. But, also that the pain is not going undertreated as it causes stress on your body and your baby. After seeing 3 Dr.'s and 2 pharmacists, in the first few weeks, I found that the Lyrica was unsafe to stay on, however will not do damage, if I went off of it slowly, and over course of a few weeks. (Luckily I was only 3weeks when we found out) However, the Noretritylne is said to be ok, by some and argued as dangerous by others. What a foreign thought to think another human being, is alive and growing within me. 

Thus first hurdle I encountered was going off of the medications that my Pain Specialist deemed unsafe, which the very thought of terrified me. I was off of the Lyrica (300mg) and Nortriptyline (40mg) within the first couple of weeks luckily for us we found out early enough. The Specialist switched me onto cyclobenzaprine (40mg) to help with the pain at night so I could hopefully sleep better. My average pain went from a 7/10 to a 9/10 almost immediately after stopping my medications which is quite a leap, as not only the level of pain changed but also the amount of pain. As the neuropathic pains were mostly being limited from existence through the Nortriptyline. Now without it there to stop them from coming they are coming back with a vengeance, daily growing stronger. The fibro pain was limited by the Lyrica, which without it now similarly grows stronger. After 10 weeks the cyclobenzaprine is rendered useless as its ability to help has weakened as the pain comes flooding back.

The lifestyle effects of the pain are dramatic as can be expected as the morning sickness mingles with chronic fatigue and mendling into the pain symptoms creates what feels like a perfect storm. After seeing multiple specialists they all agree that the drugs are not worth the risk to the baby and I sadly agree as its hard for me to admit that anything would be worth a risk to another life that I am responsible for.

This weeks been the hardest, as I've now surpassed the max allowable classes and go into tricky territory as courses end in three and a bit weeks and I will finally graduate with a BA in Crisis Counselling. Grad seems like a light at the end of the tunnel and my director has assured me that if I need more grace on missing classes I do have extenuating health circumstances that should suffice as reasoning. I worry nonetheless which is only to my detriment as stress exaggerates the pain levels to my brain. The stress from outside areas like family issues and school issues have had me throwing up non-stop this last week, not to mention in embarrassing places as I lack control over more bodily functions. I am learning that with a pain disorder that is triggered by stress I need to protect my baby through having stronger firmer boundaries with others. As if I lose too much more weight they will want to put me on IV's, not cool.  

At 16 weeks pregnant life grows more trying as my pain levels threaten any attempts towards finishing my research papers, classes, and finals; not to mention un-packing from our move, and wifely duties. I sometimes find myself crying on bathroom floor, because I just can't take all the pain, all the time. The latest Dr I saw was a neurologist about the neuropathic trigeminal pains , and he advised that I "grin and bear it, as theres nothing we can do for you until after the birth".

Further research turns up similar findings, "that women with fibromyalgia had more symptoms of pain during pregnancy than women who did not have fibromyalgia. Also, fibromyalgia symptoms seemed to be exacerbated during pregnancy. As pregnant women with fibromyalgia may experience significant pain, fatigue, and psychological stress, especially in the first three months". It's the fourth month and I struggle to maintain my basic daily routines, when I eat the motion of moving my hand to my mouth hurts. There is bone pain in my knuckles, through to my elbow and random neuropathic pain shoots through my veins shocking my system and causing me to jump. The most troubling part of all the pain is that no one understands, or comprehends the extent of it as I do. I know when I explain it to them, they have some brief or vague form of understanding but it is worlds apart from where I stand or fall depending on the day. The research on pain medications and their uses in pregnancy while promising seem also misleading as the College of Family Physicians of Canada state on their website that,
"Commonly prescribed pain medications appear to be relatively safe to use during pregnancy. None of the analgesics has been found to increase the risk of major malformations, although caution should be used when prescribing them in late pregnancy. Because of fear about use of drugs during pregnancy, some pregnant women would rather suffer than treat their pain. Consequently, it is possible that such women are at risk of undertreatment, or no treatment, for painful conditions. Chronic, severe pain that is ineffectively treated is associated with hypertension, anxiety, and depression—none of which is conducive to a healthy pregnancy.1,2"

However, in my experience with the current doctors I see, from GP's to Specialist's all either refuse to help treat the pain or warn against with only the hope of a very weak prescription to help me cope. While the research states how a variety of pain medications are safe to use, Dr.s often view them as to large a risk. While there are some drugs that are very dangerous to take when pregnant and that is why I choose to go off of mine, I understand that there are also those that have been proven to be acceptable with caution. Drugs should only be given if the potential benefit outweighs the potential risk. Thus my pain specialist has switched me from the cyclobenzaprine to Tramacete which he has assessed as safe at the lowest dose and will be worth the minor risk of taking. The College of Family Physicians of Canada further defines safe drugs in pregnancy below:


Acetaminophen, a nonsalicylate similar to aspirin in analgesic potency, has demonstrated efficacy and apparent safety at all stages of pregnancy in standard therapeutic doses. Its established safety profile for use has been demonstrated in a recent study of thousands of pregnant women, without increasing risks of congenital anomalies or other adverse pregnancy outcomes.3 

Nonsteroidal anti-inflammatory drugs

Nonsalicylate NSAIDs are known to relieve pain through peripheral inhibition of cyclooxygenase and hence inhibition of prostaglandin synthetase. They include drugs such as ibuprofen, naproxen, and ketorolac. To date, studies have failed to show consistent evidence of increased teratogenic effects in either humans or animals following therapeutic doses during the first trimester. However, even short-term use of NSAIDs in late pregnancy is associated with a substantial increase in the risk of premature ductal closure.7


These agents include morphine-like agonists (eg, morphine, hydromorphone, hydrocodone, codeine, and oxycodone), meperidine-like agonists, and synthetic opioid analogues (eg, tramadol). Reproductive studies describing the use of narcotic analgesics in human pregnancies are limited, and there are no prospective, comparative studies. However, these drugs have been used in therapeutic doses by pregnant women for many years and have not been linked to elevated risk of major or minor malformations. The Collaborative Perinatal Project identified 448 morphine exposures at various stages of pregnancy and found no evidence of increased teratogenic effects.8 The Michigan Medicaid study reported 332 newborns exposed to hydrocodone, 281 exposed to oxycodone, and 7640 exposed to codeine, all in the first trimester. The rate of major birth defects was 4.6% for the oxycodone-exposed group; 4.9% for the codeine-exposed group (consistent with the general population risk); and 7.2% for the hydrocodone group, which could have been influenced by confounding factors (ie, maternal disease severity and concurrent drug use).9 A case-control study of 141 infants with cardiac malformations did not report an association with the use of codeine in the first trimester of pregnancy.10 Neonatal withdrawal has been observed with use of codeine in late pregnancy, even with therapeutic doses in nonaddicted mothers.11,12
Acetaminophen, NSAIDs, Opioids, Benzodiazepines, Steroids, Antidepressants 
Categories: Ibuprofen (B), indomethacin(B), ketorolac(C), naproxen(B), aspirin(D)
Note that, Pregnancy categories listed above are for first and second trimesters. All NSAIDs are category D in the third trimester. However, there is No role for use of these drugs that is safe in routine pain control during pregnancy. And, If NSAIDs must be used, the duration should be limited to 48 hours or less. 

Meds for Migraines: 
Caffeine, Sumatriptan, Beta Blockers, Ergot Alkaloids, Local Anesthetics, Anticonvulsants

When it comes to the use of Opiods:
If used for prolonged periods during pregnancy, can induce neonatal opioid dependence – withdrawal can range from mild (irritability) to severe (seizures) and is called Neonatal Abstinence Syndrome

Hope some of this research helps others :)
~Elysia B 


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