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OB
CMECNECPE

Managing Pain in the Postpartum Period: Recommendations Using the Multimodal Approach

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Learning Objectives and CME/Disclosure Information

This activity is intended for healthcare providers delivering care to women and their families.

After completing this activity, the participant should be better able to:

1. Discuss the ACOG recommendations for use of pain medications following vaginal and cesarean delivery
2. Apply the ACOG recommendations regarding pain medication in women who are breastfeeding

Estimated time to complete activity: 0.25 hours

Faculty:

Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires instructors, planners, managers and other individuals who are in a position to control the content of this activity to disclose any real or apparent conflict of interest (COI) they may have as related to the content of this activity. All identified COI are thoroughly vetted and resolved according to PIM policy. PIM is committed to providing its learners with high quality CME activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of a commercial interest.

Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.

Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.

Method of Participation and Request for Credit

Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from July 6 2018 through July 6 2021, participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education

Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Pharmacy Education

Postgraduate Institute for Medicine designates this continuing education activity for 0.25 contact hour(s) (0.25 CEUs) of the Accreditation Council for Pharmacy Education. (Universal Activity Number – JA4008162-9999-18-286-H01-P)

Type of Activity: Knowledge

Continuing Nursing Education

The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.

Designated for 0.2 contact hours of pharmacotherapy credit for Advance Practice Registered Nurses.

Read Disclaimer & Fine Print

SUMMARY:  

ACOG has published a Committee Opinion on the management of postpartum pain, and the document has been endorsed by ABM, ACNM, AWHONN, SMFM, SOGC, and SOAP.  The recommendations focus on the use of a  “stepwise, multimodal combinations of agents (ie, the use of two or more pain medications that have different mechanisms of action)”

  • Vaginal Birth
  • Cesarean Section
  • Breastfeeding
  • FDA Warning Against Tramadol or Codeine
  • Opioid Use Disorder

Vaginal Birth 

Medications

  • NSAIDs may be superior to acetaminophen (evidence ‘not strong’)  
  • Acetaminophen (given together with NSAID) is preferred next step if NSAID insufficient  
    • Maximum daily acetaminophen dose is 3g to 4g  
  • Milder opioid if necessary  
    • Scheduled vs ‘as needed’ is preferable  
    • Some milder opioid formulations are combined with 325 mg acetaminophen 
  • Stronger opioid analgesics (eg, intravenous morphine, hydromorphone, fentanyl) should be considered if  
    • Pain uncontrolled after above multimodal approach  
    • “Absolutely” needed for pain control  

Breast Conditions 

  • Breast engorgement 
    • Cold packs  
    • Breastfeeding more often  
    • Antiinflammatory analgesics 
  • Nipple pain  
    • Review proper latching  
    • No evidence as to benefit of topical ointments/lotions  
    • Breast milk + breast shield may be effective 
  • Persistent breast pain 
    • Assess additional causes including maternal factors (e.g., mastitis/other infections and infant factors (e.g., ankyloglossia)  

Uterine Cramping

  • More common in multips and associated with nursing  
    • Heating pads  
    • NSAIDs (work better than acetaminophen) 
    • Opioids benefit unclear  

Perineal Pain

  • Consider 
    • Oral analgesics 
    • Topical anesthetics 
    • Nonpharmacologic agents such as cold packs 

Hemorrhoids

  • Multiple agents, but studies have not confirmed effectiveness 
    • Astringents | Steroid | Anesthetic creams
    • Avoid overuse of steroid creams

Cesarean Section  

Medications

  • Neuraxial opioids provide good pain relief  
  • As effects wear off, additional pain medication may be required  
    • Acetaminophen 
    • NSAIDs 
    • Dexamethasone as a single preoperative dose  
    • Opioids 
    • Combination opioid formulations with acetaminophen or NSAID 
    • Local anesthesia
      • Wound infiltration
      • Transversus abdominis plane block
  • Oral opioids preferred vs parenteral

Opioids

  • Parenteral opioids if  
    • Cannot take oral medication or persistent pain 
    • Persistent pain  
      • Use patient-controlled if possible  
  • Opioid risks and adverse events include  
    • Worsening constipation  
    • Significant drowsiness  

Note: Gabapentin  

  • Not recommended due to lack of evidence  
  • ACOG does state that gabapentin can be considered in addition to other medications if there is “a history of chronic pain or pain not relieved by standard treatment protocols”

Discharge Medications and Opioids  

  • Legitimate concern that opioids are over-prescribed, however women should be discharged with appropriate pain control  
  • ACOG recommends Individualized therapy, with shared decision making  
    • No specific number of pills and/or duration of treatment  

KEY POINTS:  

Breastfeeding 

NSAIDs 

  • Oral NSAIDs found in low concentrations in breast milk 
  • Ibuprofen first-line for postpartum pain
    • low concentrations found in breastmilk  

Ketorolac  

  • ACOG states that ketorolac has a role in a multimodal treatment plan when indicated, particularly after cesarean  
  • Drug label cautions use during breastfeeding
    • Concentrations in breast milk are low in the first few days postpartum  

Opioids  

  • Transfer from mother to breast milk  
  • Some individuals may be ‘ultra-rapid metabolizers’ of opioids due to genetic changes (called polymorphisms)
    • Cytochrome P450 2D6 (encoded by the CYP2D6 gene) is the enzyme that breaks down codeine and tramadol
      • Minor changes in DNA sequence can significantly alter drug metabolism
    • ‘Ultra-rapid’ genotype results in potent metabolites that are stronger than initial drug
    • If more potent metabolites do transfer to the infant, excessive newborn sedation or even death can occur  
  • Oxycodone and hydrocodone also may be a target for ‘ultra-rapid metabolizers’ 
    • Hydromorphone metabolism is not affected by these genetic polymorphisms 
  • Morphine use should be limited as the drug appears in breast milk   
  • ACOG recommends monitor infants of mothers who are prescribed opioids and are breastfeeding

FDA Warning Against Tramadol or Codeine  

  • FDA does not recommend tramadol or codeine in nursing women (see ‘Related ObG Topics’, below)  
    • No evidence for tramadol, but similar to codeine with respect to metabolism pathways 
    • ACOG recommends that this recommendation should “not interfere with pain control or disrupt breastfeeding”  
    • Discuss risks/benefits with patients, provide patient education and counseling especially about non-opioid alternatives

Opioid Use Disorder 

  • Provide additional support  
  • Use validated screening tools 
    • 4 Ps, NIDA Quick Screen, and CRAFFT questionnaires at first prenatal visit  
    • Continue opioid agonist pharmacotherapy through pregnancy and postpartum 
    • Monitor for relapse and screen for depression in postpartum period

Learn More – Primary Sources:  

ACOG Committee Opinion 742: Postpartum Pain Management

ACOG Committee Opinion 711: Opioid Use and Opioid Use Disorder in Pregnancy

CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016

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Related ObG Topics:

FDA Restricts Codeine and Tramadol in Children and Breastfeeding Mothers – ACOG SMFM ABM Respond 
Screening for Perinatal Depression
Do Non-Opioids Work as Well as Opioids for Acute Extremity Pain? 

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Computer System Requirements

OBG Project CME requires a modern web browser (Internet Explorer 10+, Mozilla Firefox, Apple Safari, Google Chrome, Microsoft Edge). Certain educational activities may require additional software to view multimedia, presentation, or printable versions of their content. These activities will be marked as such and will provide links to the required software. That software may be: Adobe Flash, Apple QuickTime, Adobe Acrobat, Microsoft PowerPoint, Windows Media Player, or Real Networks Real One Player.

Disclosure of Unlabeled Use

This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.

The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

Disclaimer

Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.

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