Question about pharmacological pain management in the pregnant trauma patient.

I recently responded to a call in which a pregnant woman went into the back of a tanker truck at a high rate of speed on the interstate. The patient was suffering from what appeared to be a closed femur fracture. The patient was clearly in an enormous amount of pain. She was unrestrained and there was massive front end damage to her vehicle. Amazingly, the femur fracture seemed to be the only thing she had going on, thankfully. The first words out of her mouth when we walked up were, "Give me pain meds." My partner, who was the lead medic for this call decided he did not want to be responsible for inadvertantly harming the fetus with pain medication and refused.

The terrible part was the woman began to argue that it was her baby and her body and we HAD to give her pain meds. Well that didn't fly so well with my partner and he politely rebuked her statement. We attempted traction with a traction splint with no success as the muscle was balled up around the bone and was not going to allow traction without a motorized winch pulling.

Needless to say we got the patient there stable but in pain and the doctor made the decision to give her a conservative dose of 4 mg of morphine. I have been having a difficult time finding any info in Davis' drug guide or any of my usual sources about the effects of pain medication on 3 month old fetuses. Anyone have any ideas? We carry Morphine, fentanyl and toradol.

I'm aware most of these drugs fall into category "C" or unknown risks but I was wondering if anyone could point me in the direction of any studies or even protocols dealing with pain management in difficult situations like this one.

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Methoxyflurane.
Ken,
IMO this Pt should have been given pain meds based on your specific protocol/sops. I am not familier with your specific standing orders so I won't speculate on what your partner should or shouldn't have done.

However, I will say that had it been me, in my agency and with my standing orders, I would probably have given Fentanyl first, with morphine as my 2nd choice. Both are Class C drugs and the benefits to the patient in this instance outweigh the risk.

When in doubt though, there is always a fallback and your partner could have contacted medical control to get further guidance instead of just refusing to provide PN management. However, if the transport time is shorter than the time it would take to get OLMD, then it's better not to delay transport.


Morphine, Fentanyl, Hydrocodone, & Oxymorphone are all Pregnancy Category C.
Meperidine, Methadone, & Oxycodone are all Pregnancy Catagory B.

And for those who don't know, or aren't going to bother looking:

Category B -Animal reproduction studies have failed to demonstrate a risk to the fetus and there are no adequate and well-controlled studies in pregnant women.

Category C - Animal reproduction studies have shown an adverse effect on the fetus and there are no adequate and well-controlled studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks.
Even the doctor at the ER was hesitant to treat pain with the stage of the fetus ( 3 months). I think this was a difficult call all around and it's hard to say what was right. I am normally a huge advocate of pain management in EMS but the risks (harming the fetus) don't seem to outweight the benefits (not being in pain) when all things are considered. Fentanyl is especially tricky because of the lack of studies in populations such as pregnant and geriatric populations. Thanks for the input, guys, food for thought.
First off, I'm envious you have toradol...that's great stuff. Anyway, I would be cautious, but certainly do what I can for the pain. How hard is it to call command on this one?
One factor many don't recognize about med administration and fetal risk is what point in the pregnancy they are and what med you are giving. Almost all meds can have a detrimental effect when given during neural tube closure (approx. week 4). The closer you get to term, the less risks is appreciated. Overall, so few studies have been performed so we really just don't know how drugs effect the fetus. I will leave u w/ this to consider. How many babies are born daily who's mother's drank, smoked, used illicit drugs, etc. and end up being just fine. A controlled dose of an analgesic probably isn't going to have that much of an effect.
I'm surprised at blair4630's comment of "I'm envious you have toradol...that's great stuff." with regards to Toradol. The PDR and other references are pretty consistent in that ,"The analgesic effect of Toradol begins in 30 minutes with maximum effect in 1 to 2 hours after dosing [intravenously] or I'M" I haven't had a lot of direct experience with pre-hospital Toradol (have had it personally for injury & dental) but I can't imagine allowing a patient to wait 30 minutes for an analgesic to start or 60 mins to peak for pain control would be the "best practice". Again what meets the ED needs isn't necessarily directly transferable to the field. Most ERs palnt you in a bed at 30 inches wioth minimal movement, versus being humped on and down stairs, onto a litter into a bouncey ,pot hole curb bashing ambulance transport. Just an old curmudgeon's view
Boston...that was more of a side note than anything else. I would still prefer fentanyl for most trauma related pain such as the case in point. I have seen toradol been quite effective in certain abdominal pain pt.'s of different etiologies where narcotics have failed miserably. More two thoughts in one comment. By the way, what the heck is a curmudgeon?
BostonMedic109 said:
I'm surprised at blair4630's comment of "I'm envious you have toradol...that's great stuff." with regards to Toradol. The PDR and other references are pretty consistent in that ,"The analgesic effect of Toradol begins in 30 minutes with maximum effect in 1 to 2 hours after dosing [intravenously] or I'M" I haven't had a lot of direct experience with pre-hospital Toradol (have had it personally for injury & dental) but I can't imagine allowing a patient to wait 30 minutes for an analgesic to start or 60 mins to peak for pain control would be the "best practice". Again what meets the ED needs isn't necessarily directly transferable to the field. Most ERs palnt you in a bed at 30 inches wioth minimal movement, versus being humped on and down stairs, onto a litter into a bouncey ,pot hole curb bashing ambulance transport. Just an old curmudgeon's view
I may be a little behind the times being over here, but shouldn't a traction splint have been applied first? In femur fx it can usually provide a great deal of relief from the pain, thus allowing little or no pain meds at all? If she was only 3mo. along, the fetus would still be sitting high, and thus no danger with the traction device. That would have been my first idea, knowing the hemodynamics involved with morphine, and always the possible risk when dealing with pregnancies. Of course, I would have also informed the pt the possible dangers, and it becomes a patient informed choice at that point as far as meds go. Protocol dependent, of course.
Nubain is just a synthetic version of morphine so either way you are dealing with effects of morphine being that it still binds with the opiate receptor sites.

To be honest, I haven't ever looked that deep into the issue of narcotic pain management and pregnancy.  I do recall that the last time I wanted to give pain management to a pregnant patient I called online medical control and got shot down, though I'm pretty sure our protocols don't list it as a contraindication.  I'll have to do some more reading on this.

Great thread.

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