In conducting my research for this book, along with my personal experiences as a
registered nurse for over 25 years and a nurse practitioner in pain management for
over 20, caring for patients with chronic and acute pain during pregnancy, I discovered a real need in the community to provide a practical education guide for the
advanced practice registered nurse, bedside and clinic nurse, and Midwife. My
objective is to provide the reader with the most up-to-date clinical information
available on assessment and management of pain during pregnancy, applying a nurturing and holistic approach to the patient. An overview to the scope of the need,
including a discussion on the use of opioids and the incidence of opioid use disorder
will be covered. Things that you can do to help your patient in preparation for a
healthy pregnancy will be reviewed, including optimization of diet, nutrition, ftness, mental health, and stabilization of chronic pain conditions. A few of the most
common pain conditions that can present or worsen with pregnancy will be evaluated, including low back pain, pelvic girdle pain, migraine, and fbromyalgia .
Introduction to Pain in Pregnancy
Pain is as common to being human as breathing. Pain is a physiologic response to
the exposure of noxious stimuli that is built into our DNA .
. Pain is protective; the
“pain response” is what helps us escape or remove ourselves from potential further
harm or even death.
Our current understanding as to the pathophysiology of pain is
broken down into four distinct phases: transduction, transmission, perception, and
modulation (Fig. 1.1).
It is through these phases that pain is experienced
Transduction occurs at the point of tissue insult, where primary afferent neurons are
activated by a noxious stimulus, such as a burn. Transmission occurs when the nerve
impulses are transmitted from the periphery (site of injury) to the dorsal horn of the
spinal cord Perception occurs as part of the ascending pain pathway, when the
nerve impulse ascends to the regions of the brain responsible for pain perception
(somatosensory cortex, insular cortex, prefrontal cortex, anterior cingulate cortex,
thalamus, amygdala, nucleus accumbens). Finally, modulation occurs in parallel to
the activation of the ascending and descending pathways. Where within the periphery, the spinal cord, and in the brain, chemical changes are occurring in the nervous
system to bring about homeostasis and reduce the noxious impact of the pain
To best set the stage for a robust discussion about pain in pregnancy, we will
spend some time here defning some basic concepts in pain. Pain is generally defned
as being acute or chronic. Acute pain is pain that is anticipated, generally has a
known cause, and is short-lived .
Chronic pain is maintained pain that general outlasts its protective beneft, often has multiple causes, is associated with much emotional suffering and disability, is ongoing or recurrent, and continues beyond the
anticipated time of tissue healing (3–6 months)
. A newer term that has been .
Background and Medication Overview
In 2011, the Institute of Medicine (IOM) released a report on pain, estimating that
100 million adults in the United States live with chronic pain conditions, and it is
the most common cause of long-term disability.
. The Global Burden of Disease
Study 2016 reaffrmed that the high prominence of pain and pain-related diseases
as the leading cause of disability and disease burden worldwide .
. Studies have
shown that women compared with men experience a greater burden of disease and
functional disability when it comes to chronic pain .
[3, 4]. In the United States, the
latest fgures report upward of six million pregnancies for 2010, refecting that
pregnant women represented approximately 5% of the total US population .
Sedgh and colleagues reported the global pregnancy rate in 2012 to be upward of
213 million pregnancies .
. There is no doubt that both pain and pregnancy are
prevalent in our society. Although the precise/exact incidence/prevalence of
chronic pain in pregnant women is unknown.
, it is estimated to be signifcant.
One study of 156 pregnant women who presented to the Women’s Mental Health
Program at the University of Arkansas for Medical Sciences for an initial evaluation from July 2013 to June 2016 showed chronic pain conditions were reported
by 44 (28.2%). The most common chronic pain complaints included neck and/or
back pain (34.1%) and headaches (31.8%) .
. Bateman and colleagues, in their
article published in 2014, looking at patterns of opioid utilization in pregnancy in
the United States, found that in a cohort of over 500,000 pregnant women, 14%
flled a prescription for an opioid at least once during their pregnancy, and 6%
received opioids throughout all trimesters
. A study published in the Journal of
Obstetrics and Gynecology reported an opioid prescribing rate of 20% in over a
million pregnant women surveyed