Showing posts with label pregnancy. Show all posts
Showing posts with label pregnancy. Show all posts

Wednesday, 28 October 2015

Preeclampsia

Preeclampsia was something that until last month all I'd known about it was that the writers of downton abbey used it to kill off my favorite character. I know it's naive to think about now but, I didn't consider it being something that people still died from, or much less still encountered before now. I didn't read up on it in my pregnancy books, because it didn't seem like something worth worrying over, it seemed like more of a myth...That is until I went to the monthly doctor visit and was told my blood pressure was too high and to report to the hospital maternity wing for observation and testing.

The Dr. told me that day, that at the hospital they'd be monitoring for preeclampsia, and knowing that it could be fatal, I was concerned. But still, I thought it was probably nothing, perhaps my blood pressure was off that day, or the under-treated neuropathic pain, or fibromyalgia, had spiked it somehow. As I sat in triage the nurses put on the baby monitor on my stomach for baby's heart beat to indicate stress and the contraction monitor to see how my uterus was doing. After 20 minutes of monitoring and other tests it showed that my blood pressure was elevated above what it should be. Yet my blood test results were good and although there was protein found, it wasn't necessary to keep me. I was told to just monitor my blood pressure at home and come back in two days for more observation and tests.

I went home feeling like I'd dodged a bullet. Although I felt worse over the next two days and my blood pressure was wonky, I thought that I'd just go in early to mention it to the Dr and then be reassured it was nothing and go to the wedding we had planned to attend. After mentioning the pain in my ribs,  the little spots I saw through my slightly more blurred vision, the Dr ran more tests and they showed elevated levels of a variety of preeclampsia markers. The Dr. decided to keep me for observation and so began the catch and release program, through which I went from 34 weeks pregnant to delivering my son at 36 weeks. Those two weeks I spent mostly in and rarely out of the hospital being monitored and tested daily as my levels rose and symptoms worsened. It was when I stopped keeping sips of water down and my liver enzymes rose that the Drs decided to induce me as my preeclampsia was explained as being too dangerous to keep monitoring. After being induced I was in labor for 5 hours and gave birth to my son, who after a few seconds after being put on my stomach wasn't breathing and was rushed to the NICU. The next two hours were more terrifying than anything I could have imagined I was told he was having trouble breathing and that I needed to pass the placenta, be stabilized, and stitched up before I could see him. I tried to will my body to be better, to summon any last bit of energy I had just to be able to see him and see that he was okay. It mattered very little to me, if I was stable or stitched up I had to know he'd be okay, nothing else mattered. My mind raced as to why no one had come to say he was okay yet.  My husband had gone with him to the NICU and the nurses were dead set on keeping me in my room and in my bed. My mind raced as to what went wrong, what had I done wrong, but the Dr.s and nurses couldn't say if it had been anyone's fault as there is no known cause for preeclampsia. It wasn't a reassuring or supportive environment as it had been before the birth, afterward it felt cold and prison like. The early warmth and joy that came with the observation part our catch and release time, had now come to an abrupt end and I felt alone, guilty, and scared like I never had before.

We were kept a few days as my son needed the CPAP to breath the first 24hrs, and visitors came and went. I just wanted to be alone secretly feeling a mixture of emotions but mainly that birth was traumatic and scary; confused as to why people thought it was glorious. When my milk supply did eventually show up to the party it was lacking greatly and so my son had to be started on formula right away. It felt like a failure of motherhood times two. The NICU nurses were kind to me and I felt somewhat safer and calmer sitting by the incubator where I could see him breathing and make sure he was okay. When visitors came I felt more like a circus act than a joyous mother. This was not what I had imagined motherhood to be like, this was terrifying and overwhelming. In the moments alone with my son I felt immeasurable joy, as I saw him and held him. Watching every movement not wanting to miss out on a second. The time passed and we were both cleared by Dr.'s to go home, I was excited and mostly because I thought we'd finally get to be alone together just him and I. Suddenly new challenges awaited us and I had no idea what was in store.

~Elysia B       

Tuesday, 28 July 2015

Pain medications in third trimester

As the third trimester approached I began to struggle as I was completely off of any and all pain medications. Trying to see how long I could go without them as in the third trimester it is suggested to try first to go on bed-rest and not have any medications as it's the best for the baby. My pain specialist has noted that understandably, I may need to go back on medications as pain causes stress to the body which is also bad for the baby. Thus, weighing all the research about my options, nortriptyline while unsafe in the first and second trimesters is now an option to go back to or doxepin. Yet, the least effective and least damaging would still be the Flexril and Extra Strength or T3 strengths of Tylenol as a combo. I've decided that at least with a low dose of nortriptyline (75mg) at least I know it will be effective, as the flexril/tylenol in the 1st and 2nd trimester was a joke, and trying something new like doxepin that's so closely related to the nortriptyline is a risk simply not worth taking at this stage.

However, all things considered I feel like I could manage the fibromyalgia in stride through on bed-rest but what I'm noticing to be most unbearable is the neuropathic pains. The fibromyalgia is predictable as I know where it will hurt, I know it will gradually flare and regularly hurt at increasing levels but the neuropathic is unpredictable. It comes randomly to differing locations and stays for differing durations, it's unpredictable and unbearable. I continue to look healthy and fine on the outside, as my appearance has never reflected the inside pain and sometimes, its quite upsetting as it makes me feel incongruent. Regardless of my pain level that ranges from 8/10-10/10 I reflect nothing on the outside; The surface level that everyone else sees feels like a lie, as it reflects a calm happy face when my insides have a war raging on. When the pain gets too bad to bear I calmly leave the room and go sit in the washroom where I don't need to smile and sometimes if I'm honest, I can't help but cry because its too much to bear alone. But, I suppose that's just life with this type of disorder, when it gets to heavy you take a time-out, leak out some tears, take a couple deep breathes, and eventually pull yourself together and return to life. Is there a better way?

Some people go all natural and unmedicated they swear by smoothie concoctions, natural health products, and vitamin supplements. All of which may help a mild case and may be good for fibromyalgia management, I have yet to discover one that helps my case of it. Yet I wonder what natural things are there for neuropathic pain?

  • B12 injection or supplements are said to help with general pain, also Zinc deficiency can cause pain. I've had the B12 injections during flares in pregnancy but it hasn't helped in any significant way. 
  • Neuropathy: The Northern California Chapter of the Neuropathy Association has published a guide to complementary and alternative treatments for neuropathy. Among the treatments listed are alpha-lipoic acid (a universal antioxidant), Bowen therapy (a type of massage) and IVIG (intravenous immunoglobulin therapy), as well as many folk remedies such as borage oil, primrose oil and nettle footbaths. Though there is little scientific evidence supporting these treatments, they are recommended anecdotally by members of NCCNA support groups. Be sure to always discuss alternative treatments with your doctor before experimenting with complementary therapies. 

What cures random electric shocks and sharp stabbing pain? Can we naturally cure this extreme? There are plenty of Dr.'s that continue to tell me how great it is that I'm pregnant as they say, "often pregnancy cures lupus, and fibromyalgia" they talk of pregnancy as a wonder drug in and of itself, that miraclously solves diseases that they can not explain. Does science really back up this claim I wonder?

The title above links to an article that was written by Dana Levy who notes how, "pregnancy and autoimmunity are a potentially hazardous combination. But with the right guidance and therapy, these women can become healthy mothers." As a question and answer with two Dr.'s (Michael Lockshin, MD, professor of medicine and obstetrics-gynecology at the Weill Medical College of Cornell University in New York City, and Laurence Mack, MD, an obstetrician/gynecologist with a special interest in high-risk obstetrics in Massapequa, N.Y. ) The article is a helpful resource for women with autoimmune disorders to understand the risks and benefits to pregnancy. As it relates to medication issues I have copied the question and answers directly below:

Q: Can a woman continue to take medication for an autoimmune condition while pregnant?

Dr. Lockshin: When women ask if it’s safe to stay on their medications, I say “I don’t know,” because there is no information available. Many medications have not been examined in pregnancy because drug companies don’t want to give experimental drugs to pregnant women. Often, the only data available are from animals. That said, cyclophosphamide and methotrexate are absolutely forbidden during pregnancy. Additionally, women should not use anti-inflammatory drugs in the latter stages of pregnancy because these agents can damage the baby’s heart and kidneys. In early pregnancy, however, these drugs are probably fine. We’re quite comfortable prescribing drugs like prednisone. With rheumatic diseases, we frequently prescribe hydroxychloroquine. 

Thyroid medications and insulin are also safe. There is some uncertainty about immunosuppressant drugs, but by and large, it is probably better for a woman to continue such medication and not risk a flare than to discontinue it. One of the worst scenarios occurs when a woman finds out she’s pregnant and stops her medications cold, only to have the disease explode.

Dr. Mack: We give pregnant women steroids, but we don’t like to prescribe high doses except in bursts. The strategy entails giving a burst and getting the autoimmune flare under control. Steroids should not be given on a chronic basis in high doses before 16 weeks’ gestation because they can cause congenital anomalies.

~Elysia B 

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


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

Opioids

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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