From the Guidelines
For a pregnant patient (12 weeks) with post-operative pain following exploratory laparotomy and salpingoophorectomy who has not responded to Tylenol and has already received oxycodone 10mg and morphine 4mg, I recommend administering additional opioid analgesia, such as another dose of IV morphine 2-4mg or oral oxycodone 5-10mg, depending on the severity of pain and time since last dose, as supported by the most recent guidelines 1.
Key Considerations
- Opioids are generally considered acceptable for short-term use during pregnancy when the benefits outweigh the risks, as noted in the American Journal of Obstetrics and Gynecology 1.
- The patient's pregnancy status requires careful consideration, but adequate pain control is important following major abdominal surgery.
- Non-opioid alternatives like NSAIDs should be avoided in pregnancy when possible, especially in the first trimester, due to potential risks.
- Multimodal analgesia incorporating scheduled acetaminophen (if not contraindicated) alongside as-needed opioids may provide better pain control while minimizing opioid requirements.
Recommendations
- Ensure appropriate monitoring for respiratory depression and other side effects when administering additional opioid analgesia.
- Consult with obstetrics regarding ongoing pain management for this pregnant surgical patient.
- Consider a multimodal approach to pain management, including non-pharmacologic approaches and non-opioid analgesics, as recommended in the most recent guidelines 1.
Additional Options
- Intrathecal morphine 50–100 μg or diamorphine 300 μg may be considered as an alternative to systemic opioids, as suggested in the Anaesthesia journal 1.
- Prescribe paracetamol and a non-steroidal anti-inflammatory drug (NSAID) administered after delivery and continued regularly postoperatively, if not contraindicated.
- Administer a single dose of intravenous (i.v.) dexamethasone after delivery in the absence of contraindications, as recommended in the Anaesthesia journal 1.
From the Research
Patient's Current Situation
- The patient is 12 weeks pregnant and has undergone an exlap/salpingoophorectomy today.
- She is experiencing pain and has already been given Tylenol, which did not help.
- She has also received a one-time 10mg oxycodone and IV morphine 4mg earlier today.
Considerations for Pain Management
- According to 2, acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) are first-line treatment options for most patients with acute mild to moderate pain.
- However, the patient has already been given Tylenol (acetaminophen) without relief, and her pregnancy status may affect the choice of pain management options.
- 3 and 4 discuss the importance of balancing pain management with the risks associated with opioid use in pregnant patients, particularly those with opioid use disorder.
Potential Next Steps
- Consider alternative pain management options, such as NSAIDs, as recommended by 2.
- However, the use of NSAIDs in pregnancy should be approached with caution, and the patient's individual circumstances should be taken into account.
- 5 suggests the use of multimodal analgesic therapy, including acetaminophen and NSAIDs, as a primary approach to pain management, with opioids used only as needed.
- The patient's recent use of oxycodone and morphine should also be considered when determining the next steps for pain management, as discussed in 3 and 4.