Fentanyl in Pregnacy

[Sublime]

Had a pt. who was approx. 33 weeks pregnant the other day who rolled her vehicle. Her only complaint was 10/10 shoulder pain. Seeing as it was a long transport time to the trauma center and the bumpy roads... I decided to give her some fentanyl.

Gave her two doses of 50 mcg, about 20 mins apart. I was looking through our protocols and in the back where it lists our drug info, a contraindication for fentanyl is pregnancy. Hadn't seen this before. As far as I was concerned it was a Class C, and at the time I thought the benefit outweighed the risks. What do you guys think?

 

[Anjel]

It is a class C.

From what I have read, the only time it becomes a problem is with continuous use.

Give just the one time I am sure it didn't hurt the baby.

 

[usalsfyre]

The two biggest issues with narc use in pregnancy are fetal dependence (unlikely to occur from one time dosing) and fetal depression post-delivery (only a concern if the administration was shortly before delivery). You should be fine, but in the future Nubain and Stadol are preferred because they are less likely to cross the placental barrier.

 

[Anjel]

My two options are fentanyl and morphine.

I am assuming fentanyl would be more appropriate?

 

[lightsandsirens5]

Nubain? Blahhhhh......

But anyhow, I'd think fentynal should be pretty safe and like anjel said, it is class c. That being said, if your protocol books contraindicate it, don't go running around giving it! The protocols is what the supe looks at and what you get retained or let go over.

Kind of an aside, but I'd think fentynal is better in pregnancy than morphine because it is, I'm and of itself, hemodynamically stable as compared to morphine. Right?

 

[Veneficus]

That being said, if your protocol books contraindicate it, don't go running around giving it! The protocols is what the supe looks at and what you get retained or let go over.

Easily solved with an order from med control.

Unless the woman wa sin labor, two doses of fent is not something I would get overly worried or worked up over.

 

[lightsandsirens5]

This is true....

Was going to put that. Not sure how it didn't end up in there. Long night...going to sleep now. Can I get some fentynal? I'm not pregnant, I promise.

 

[mycrofft]

Almost EVERY drug has, on its informational inclosure from the manufacturer, a note about it not being known to be safe with pregnancy, or that it is NOT safe with pregnancy.

Unless you are a neonatologist, perhaps a call to medical control or separate protocols for pregnancy are in order? Because a pain med is of a certain schedule or class has no bearing upon pregnancy, right? (Although if delivery is not imminent and it is really needed, then less danger. Just don't have an unheralded premature delivery after you give her that dose).

There are many other meds used besides pain meds, there are non-pain meds given off label to address pain, some of which CAN have deleterious effects on fetus or on the mother. Not only is this good info to inform your practice, it is good data for the receiving facility to know (Is the pt taking any meds not currently prescribed, or is anyone "loaning" her some of their meds? OTC's? Herbals?).

 

[Aidey]

Easily solved with an order from med control.

Unless the woman wa sin labor, two doses of fent is not something I would get overly worried or worked up over.

The last time I called for order for fentanyl I was told to give 25mcg. In a stage 4 cancer pt. I've heard too many similar stories to think that calling about pain meds is going to result in a meaningful resolution.

 

[abckidsmom]

The last time I called for order for fentanyl I was told to give 25mcg. In a stage 4 cancer pt. I've heard too many similar stories to think that calling about pain meds is going to result in a meaningful resolution.

My plan with regards to managing pain is to carefully stay within the realm of common sense and ask forgiveness, not permission.

 

[Aidey]

I may or may not have chosen to interpret it it as 25mcg at a time. I wasn't even calling for dosing orders, I was calling for route orders.

 

[Veneficus]

The last time I called for order for fentanyl I was told to give 25mcg. In a stage 4 cancer pt. I've heard too many similar stories to think that calling about pain meds is going to result in a meaningful resolution.

I always like to just make it a polite command.

"I am going to give him X if you don't mind?"

I think it probably has to do with the system.

I have gotten some orders way off the page, but I usually had at least a working relationship with those I called.

 

[KellyBracket]

There was a vigorous discussion on JEMS Connect a little while ago (Question about pharmacological pain management in the pregnant trauma patient) about the same topic - it doesn't go out of style!

There's a vacuum of evidence, but the medical consensus is that episodic pain control during pregnancy is safe, and should be considered an expectation, in the ED or by EMS.

For instance, in the "bible" of emergency medicine, Rosens's Emergency Medicine, the author of the chapter on the acute pelvic pain in women states that:

In both critical and noncritical patients, early administration of analgesia is advisable, both for patient comfort and to improve the yield of examinations. Intravenous opioids, such as morphine, are rapid and effective, titratable, and safe in pregnancy.

UpToDate also notes, in the entry on "Management of pregnant women undergoing nonobstetric surgery," that:

Propofol, midazolam, or fentanyl can be administered in small incremental doses.

As for the references backing up those statements - there are none!

 

[Veneficus]

The only thing I could find in Miller's Anesthesia stated pregnant women require less local and general anesthetics.

They cited a couple of studies on MAC of inhaled anesthetics, but nothing else.

I don't have online access to William's Obstetrics, so I will look when I get home in there.

 

[jwk]

We use fentanyl frequently in pregnant patients for labor, delivery, and non-OB surgery.

Pregnancy categories are generally based on anecdotal evidence, rarely on controlled studies. You can't do a double blind study with a new drug just to see what affect it might have on a pregnant woman and their developing fetus.

The interesting example for us in anesthesia is propofol vs pentothal. Pentothal is Category C, but was pretty much the sole drug used for induction of general anesthesia for C-Sections for decades. There was huge resistance to using propofol for C-Sections the first 20 years of it's existence, because pentothal had been "proven safe" over the years. Propofol is Category B, in theory a safer drug to use during pregnancy. Some places started using propofol instead of pentothal, but there was still huge resistance in many centers. A couple years ago, thanks to the capital punishment debate of all things, pentothal became unavailable in the US. Now everyone just uses propofol and doesn't give it a second thought.

 

[Aidey]

Is there any information about the use in different trimesters? My very very limited understanding of embryology has given me the impression that some meds that are safe later in pregnancy are not as safe in the first trimester.

 

[mycrofft]

Facepalming at myself...maybe

Did anyone think of maybe local cold application at the scene and enroute? Are there any protocols? What would you do after calling 911 from home but before they get there to ease someone's shoulder pain?
Oh, and isn't that shoulder pretty close to the NECK, ennervated by sensory nerves from the NECK...(oh-oh, here's another "black hole").:unsure: