What medication is suitable for a pregnant patient with a history of trauma?

Medication Management for Pregnant Patients with Trauma History

Psychological Medications for Trauma-Triggered Pregnancy

For pregnant patients experiencing pregnancy as a trauma trigger, selective serotonin reuptake inhibitors (SSRIs) such as sertraline can be used throughout pregnancy, while cognitive-behavioral therapy should be the primary intervention to address trauma responses and develop healthy coping mechanisms. 1

First-Line Psychological Interventions

• Cognitive-behavioral therapy is the recommended first-line treatment to address trauma responses and develop healthy coping mechanisms in pregnant patients with trauma history 1
• Approach-oriented coping strategies should be actively encouraged, as they predict reduced depressive symptoms postpartum 1
• Avoidant coping mechanisms must be actively discouraged, as greater avoidant coping is associated with increased psychological distress and potentially higher risk of preterm birth 1

Pharmacological Options for Comorbid Depression/Anxiety

• Sertraline is compatible for use throughout pregnancy when psychological symptoms require pharmacological intervention 2, 3
• Hydroxychloroquine, azathioprine/6-mercaptopurine, colchicine, and sulfasalazine are strongly recommended as compatible for use throughout pregnancy for patients with rheumatic conditions 2
• Low-dose glucocorticoids (≤10 mg daily of prednisone or nonfluorinated equivalent) may be continued during pregnancy if clinically indicated 2

Medications to Avoid

• Methotrexate, mycophenolate mofetil, cyclophosphamide, and thalidomide must be discontinued within 3 months prior to conception due to known teratogenic effects 2
• For women treated with leflunomide, cholestyramine washout is strongly recommended if there are detectable serum levels of metabolite prior to or as soon as pregnancy is confirmed 2

Pain Management Following Physical Trauma During Pregnancy

Acute Trauma Pain Management

• Intravenous acetaminophen 1000mg every 6 hours is the first-line treatment for acute trauma pain in pregnancy, with regular scheduled dosing more effective than as-needed administration 4
• NSAIDs may be added cautiously for severe pain in the first two trimesters if no contraindications exist, but NSAIDs are strongly contraindicated in the third trimester due to risk of premature closure of the ductus arteriosus 2, 4
• Nonselective NSAIDs are conditionally recommended over cyclooxygenase 2-specific inhibitors in the first 2 trimesters due to lack of safety data on COX-2 inhibitors 2

Opioid Use in Pregnancy

• Opioids should be reserved for breakthrough pain only, using the lowest effective dose for the shortest duration as part of multimodal analgesia 4
• Tramadol may be considered as an intermediate option before stronger opioids 4
• Women with opioid use disorder should remain on prescribed medication-assisted treatment throughout pregnancy, as it increases adherence to prenatal care 1

Neuropathic Pain Management

• Nonfluorinated glucocorticoids should be used when needed, but substitution of steroid-sparing pregnancy-compatible immunosuppressive therapy is desirable when high-dose or prolonged use is required 2
• Higher doses of nonfluorinated glucocorticoids should be tapered to <20 mg daily of prednisone, adding a pregnancy-compatible glucocorticoid-sparing agent if necessary 2

Trauma-Specific Obstetric Medications

Rh Immunization Prevention

• Anti-D immunoglobulin must be given to all Rh-negative pregnant trauma patients to prevent alloimmunization 2, 5
• In Rh-negative pregnant trauma patients, quantification of maternal-fetal hemorrhage by tests such as Kleihauer-Betke should be done to determine the need for additional doses of anti-D immunoglobulin 5
• O-negative blood should be transfused when needed until cross-matched blood becomes available to avoid Rh alloimmunization 5

Eclampsia/Pre-eclampsia Management

• Magnesium sulphate is recommended as first-line treatment in women having had an episode of eclampsia following trauma 2

Antibiotic Prophylaxis

• Antibiotic prophylaxis is NOT indicated for closed fractures or simple abrasions from blunt trauma in pregnant patients 4
• For open fractures, cefazolin alone provides adequate coverage for Gustilo-Anderson Type I or II injuries 4
• Systemic antibiotics are NOT indicated for simple abrasions without signs of infection 4

Critical Resuscitation Medications

Cardiac Arrest Medications

• For refractory ventricular fibrillation and tachycardia, amiodarone 300 mg rapid infusion should be administered with 150-mg doses repeated as needed 2
• Epinephrine 1 mg IV/IO every 3 to 5 minutes is reasonable to administer during cardiac arrest 2
• In the setting of cardiac arrest, no medication should be withheld because of concerns about fetal teratogenicity 2
• Medication doses do not require alteration to accommodate the physiological changes of pregnancy 2

Vasopressor Use

• Vasopressors should be used only for intractable hypotension that is unresponsive to fluid resuscitation due to their adverse effect on uteroplacental perfusion 5

Oxygen Therapy

• Oxygen supplementation should be given to maintain maternal oxygen saturation >95% to ensure adequate fetal oxygenation 5
• Pregnant women suffering major trauma or severe hypoxaemia should be started on high-concentration oxygen via a non-rebreathing reservoir mask 2
• For mild/moderate analgesia during transportation, Entonox may be administered, though it should be avoided if possible in patients at risk of hypercapnic respiratory failure 2

Common Pitfalls to Avoid

• Do not defer or delay radiographic studies including abdominal CT due to concerns regarding fetal radiation exposure when indicated for maternal evaluation 5
• Do not perform systematic episiotomy outside specialized structures for the sole purpose of reducing risk of anal sphincter injury 2
• Do not inflate the abdominal portion of military anti-shock trousers on a pregnant woman as this may reduce placental perfusion 5
• Do not use cricoid pressure routinely during resuscitation, as it may impede ventilation and laryngoscopy 2