Pregnancy and Chronic Pain: Expert Advice to Help You Thrive

Pregnancy comes with changes, challenges, and some aches and pain, too. But if you become pregnant when you've got a chronic pain condition, discomfort may reach a whole new level. With a baby on board, treatments that have worked in the past may have to be changed or shelved. Here's what to know about pregnancy and chronic pain.

pregnant womanFor pregnant women with chronic pain, the choice of medication is complicated.
On the path toward parenthood, swollen ankles, back aches, and the pain of labor and delivery are pretty much par for the course. But if you suffer from migraine headaches, fibromyalgia, rheumatoid arthritis, or other conditions that cause pain throughout the body, we're talking a whole different level of distress.

Here, research and expert advice to help you understand how pregnancy is impacted by chronic pain, how pregnancy affects pain management, and what types of pain relief you can expect.

Exploring the Choices

About 20% of adults over the age of 18 experience chronic pain, according to a report from the Centers for Disease Control and Prevention. Women are affected more than men, particularly as they age, and menopause tends to increase chronic pain. But women in their child-bearing years also face challenges.

When you're pregnant, the choice of pain medication is complicated by potential side effects that can impact your well-being and the baby's, too. Even common over-the-counter choices can have dramatic consequences for an unborn child.

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Research finds, for example, that the more acetaminophen an expectant mother takes during pregnancy, the greater the baby’s risk of attention-deficit hyperactive disorder (ADHD) and autism spectrum disorder (ASD). NSAIDS (non-steroidal anti-inflammatory drugs such as ibuprofen) have been associated with serious malformations, particularly if taken during certain times during pregnancy.

Some researchers advise that “NSAIDs should be given in pregnancy only if the maternal benefits outweigh the potential fetal risks, at the lowest effective dose and for the shortest duration possible.” Other experts conclude that “Paracetamol and nonsteroidal anti-inflammatory drugs are appropriate for mild to moderate pain, but NSAIDs should be avoided in the third trimester due to established risks.”

What About Cannabis?

Now that cannabis has been legalized for medical and recreational purposes in many states, more women are using it during pregnancy. Approximately 7% of pregnant women report using cannabis, with levels rising as high as 12% during the first trimester. Is this a promising option for managing chronic pain conditions?

The state of Colorado, which saw a jump in usage after cannabis was legalized there, became a real-life experiment. As cannabis use increased, birth defects in the state increased as well, even after accounting for other factors. Another study followed 500 women who had been cared for during pregnancy by urban university medical centers.

Those who used cannabis were 12 times more likely to have a stillbirth or miscarriage than women who used only tobacco or neither substance.

Research links marijuana use during pregnancy with increased risk. A study published in May 2019 by researchers from the University of California, Berkeley, and the Environmental Protection Agency, found that exposure to cannabis in a mother’s womb can alter the child’s brain development and genetic expression. These changes are associated with ASD, ADHD, schizophrenia, addiction, and other psychiatric diseases.

“The period of fetal development is extremely sensitive to environmental cues and chemicals,” said one of the study’s authors, Andres Cardenas, PhD, MPH. “Chemicals present in cannabis—even if consumed in other forms—can cross the placenta and blood-brain barrier, reaching the fetus and brain where most of these compounds are active.”

Some doctors, troubled by the outcomes, have proposed a new diagnosis called “Fetal Cannabis Spectrum Disorder.” Dr. Cardenas pointed out a recent study that found “a relative increase of 50% for risk of developing ASD among children of mothers reporting cannabis use in their pregnancies compared to non-exposed children. A smaller increase in risk in ADHD was also observed.”

Dr. Cardenas recommends talking to your OB-GYN or primary health care provider before starting or stopping any medications during your pregnancy or while trying to become pregnant. “They can help you navigate this decision,” he says.

Pregnancy and Chronic Conditions

Some pregnant women with chronic pain experience less pain during pregnancy but that happy scenario is nearly impossible to predict. Hormones, which influence how you feel and how you experience pain, are just one of the many factors in play here. Another complicating factor is that the balance of hormones shifts comfort and pain sensations frequently during those nine months.

Migraine and Pregnancy

If you had migraine headaches before pregnancy you're probably concerned they'll get worse during gestation. “Migraine is more than twice as likely to occur during the first three days of menstruation and more than three times as likely to be severe,” says Ryotaro Ishii, MD, PhD, a visiting scientist in the Neurology Department of the Mayo Clinic in Arizona.

Dr. Ishii and his colleagues surveyed 607 women with an average age of 37. Fear of migraine headaches during pregnancy drove nearly 20% of these women to avoid becoming pregnant in the first place. Many of these women also worried that migraine medications would hurt their child’s development.

Yet, surprisingly, Dr. Ishii says women who struggle with chronic migraine can do well during pregnancy. He cited three promising studies. In the first, between half to three-fourths of migraine sufferers reported a marked improvement during pregnancy, with a significant reduction in the frequency and intensity of their migraine attacks. In the second study, women with menstrual migraine showed improvement during the second half of pregnancy. In the third, a large Italian study, 67% of menstrual migraine cases without aura disappeared during pregnancy.

When migraine medications are necessary during pregnancy, safety must be considered, Dr. Ishii explains. “The preventive medication of migraine with the best evidence for safety during pregnancy is propranolol, which has a long history of safe use despite being classified (formerly) in category C by the FDA,“ he says.

For pregnant women who do need acute migraine treatment, these “can typically be limited and used in a stratified way,” says Dr. Ishii. For example, peripheral nerve blocks with lidocaine or ropivacaine are considered safe, and during the second trimester only, certain NSAIDs are also considered safe.

In addition, “Non-invasive devices have a benign safety profile and many providers feel comfortable using them during pregnancy. Safety of these devices has not been formally studied, however” he says.

If you're considering pregnancy, Dr. Ishii says it's important to make changes to ensure you're living a healthy lifestyle and doing all you can to control your pain without medication. Receiving sufficient rest, eating a healthy diet, being properly hydrated, and staying physically active are absolutely essential components of a healthy pregnancy.

Rheumatic Conditions and Pregnancy

If you have fibromyalgia, rheumatoid arthritis (RA), psoriatic arthritis (PsA), or other rheumatic conditions check out the 2020 Guidelines for the Management of Reproductive Health in Rheumatic and Musculoskeletal Diseases (RMD), recently released by The American College of Rheumatology.

This first-ever, comprehensive guide to reproductive health in RMD patients features over 130 recommendations and suggestions for good practices. Useful for the full spectrum of RMD patients, it also considers diagnoses that require more detailed recommendations such as systemic lupus erythematosus (SLE), antiphospholipid syndrome (APS), and antiphospholipid antibody (aPL).

“Many rheumatology professionals have limited familiarity with current OB-GYN practices and so the guideline presents background knowledge that clarifies and supports the recommendations,” says lead author Lisa Sammaritano, MD, Director of the Rheumatology Reproductive Health Program at the Barbara Volcker Center for Women and Rheumatic Disease and Professor of Clinical Medicine at Weill Cornell Medicine Hospital for Special Surgery.

“Patients should discuss reproductive health issues with their rheumatologists as well as their OB-GYN, early and often,” said Dr. Sammaritano. She offered these key takeaways for patients:

  • Some rheumatology medications are teratogenic (cause birth defects) and need to be changed prior to pregnancy.
  • Some women already have disease-related damage that makes pregnancy unsafe, and risks can increase if their disease is poorly controlled.
  • Use the safest and most effective contraception available, since unplanned pregnancy increases risk. “Long-acting reversible contraception such as IUDs or progestin are most effective and most RMD patients can and should consider these,” she said.
  • Identifying and managing specific pregnancy risk factors, such as aPL and anti-Ro/SS-A antibodies, usually leads to better pregnancy outcomes and is strongly encouraged.
  • In most cases, fertility therapies such as IVF and egg freezing are available to women who have RMD, although adjustments in therapy may be suggested.

Dr. Sammaritano said that the guideline also includes some recommendations that might surprise patients and their rheumatologists. For example, it recommends continuation of TNF-inhibitor therapies through at least the early part of pregnancy and says biologic therapies (monoclonal antibody therapies) may be used throughout breastfeeding.

Special Considerations During Pregnancy

If your pain isn’t well managed during pregnancy, the strain can cause you to develop depression and high blood pressure. These conditions, in turn, can impact your ability to care for your infant. Managing pain during pregnancy is a true balancing act. How to get the best outcome for both mother and child?

Opioids and Pregnancy

Opioids are among the most powerful tools for chronic pain management. Unfortunately, they are also ripe for abuse. One study suggests that between 8 and 12% of people who receive prescription opioid medications go on to develop an opioid addiction disorder.

During pregnancy, opioids carry special risks, especially during the third trimester when there is higher probability of neonatal abstinence syndrome. What should you do if you are currently on opioid therapy and hoping to become pregnant? Is it wise to taper off the medication, despite the potential difficulty? Are there good pain management alternatives that protect both mother and child up to and during delivery?

These are complicated questions that require individual answers and consultation with a doctor. But a recent study out of Yale suggested that maintenance therapy with methadone or buprenorphine is the preferred approach to opioid use disorder (OUD) during pregnancy.

“When women with chronic pain are planning to get pregnant, there needs to be a definitive plan of how to minimize opioids and also a plan for postpartum on how to regulate them due to breastfeeding and alertness when taking care of a newborn,” says Jessica Shepherd, MD, MBA, a clinician and member of the Healthy Women Women’s Health Advisory Council.

“Often, a referral for treatment of pregnant women with opioid use and opioid use disorder can improve maternal and infant outcomes,” she explains.  Dr. Shepherd encourages developing a pain management plan that highlights alternative therapies, including exercise, physical therapy, and non-opioid pharmacologic treatments. Standard of care guidelines recommend that opiate prescriptions be limited to the shortest reasonable course, even after birth.

Ideally, women who struggle with opioid addiction during pregnancy can get support from a multidisciplinary team that includes experts in obstetrics, addiction, social work, anesthesia, pediatrics, and behavioral health. Treatment always needs to be sensitive to any underlying social, psychological, and emotional factors as well as trauma and its role in addiction.

Curbing Pain with Food Choices

Women with chronic migraines sometimes discover that when they eliminate certain foods, they begin to feel better. For example, Michelle J., suffered tremendously from chronic migraines until she began following advice in The Migraine Miracle: A Sugar-Free, Gluten-Free, Ancestral Diet to Reduce Inflammation and Relieve Your Headaches for Good by Josh Turknett, MD. “This book has given me my life back,” Michelle says. During pregnancy she adjusted the approach by upping her carb intake somewhat, and after giving birth resumed the same nutritional approach to keep chronic pain at bay.

Fibromyalgia has been linked to nutritional deficiencies – specifically of amino acids, magnesium, selenium, vitamins B and D. These deficiencies can result from an inadequate diet, but in other cases the body gets the nutrients but cannot digest them properly. This problem has been observed, for example, in cases of toxic mercury exposure or gluten sensitivity.

Good nutrition can also be beneficial to rheumatoid arthritis. Researchers took a close look at the biochemistry behind dietary approaches and confirmed that specific foods are indeed beneficial. These include fruits (blueberries, grapefruits, apples, and others), whole grains (oatmeal, wheat, rice, and others), spices (ginger and turmeric), yogurt, green tea, olive oil, and other foods with tangible anti-inflammation properties. They conclude that consuming anti-inflammatory foods may reduce and delay progression of rheumatoid arthritis and potentially allow a decrease in drug therapy.

Researchers and medical experts continue to uncover how day-to-day food choices influence conditions that cause chronic pain. Making these positive lifestyle changes can reduce the prospect of pain during pregnancy and beyond.

Updated on: 11/13/20
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