Background and purposeThe majority of the reviews and studies on chronic pain in pregnancy have primarily focused on the pharmacological and non-pharmacological treatment options. The purpose of our review was to identify evidence-based clinical research for the evaluation and management of preexisting chronic pain in pregnancy, chronic pain associated with pregnancy, and chronic pain in relation to mode of delivery.MethodsA literature search was undertaken using the search engines PubMed, CINAHL, EBSCOhost, and Web of Science. Search terms used included “chronic pain” AND “pregnant OR pregnancy” OR “pregnancy complications” from inception through August 2016.ResultsThe basis of this review was the 144 articles that met inclusion criteria for this review. Based on our review of the current literature, we recommend 7 guidelines for chronic pain management during and after pregnancy: 1) complete history and physical examination; 2) monitor patients for alcohol, nicotine, and substance use; 3) collaborate with patient to set treatment goals; 4) develop a management plan; 5) for opioids, use lowest effective dose; 6) formulate a pain management plan for labor and delivery; and 7) discuss reproductive health with women with chronic pain.ConclusionThe management of chronic pain associated with pregnancy is understudied. Obstetrical providers primarily manage chronic pain during pregnancy. Some general guidelines are provided for those health care providers until more information is available.

Objective To scrutinize a series of pregnant women treated with electroconvulsive therapy (ECT) at a tertiary treatment center and combine this data with a literature review to refine the treatment guidelines for ECT during pregnancy. Methods A retrospective chart review of mentally ill pregnant patients treated with ECT since the establishment of a formal women’s mental health program. Results A total of eight pregnant women treated with ECT were identified from 01/2012–08/2014. Information was extracted from the medical record from a total of 30 ECT treatments across this group. Subjects received an average of 3.75 ECT treatments (range 1–7). All women were diagnosed with a mood disorder (either unipolar or bipolar), and five of the eight women had suicidal ideation. The treatment team for ECT was consistent across all treatments. Two women experienced significant complications following the initial treatment: 1) an acute episode of complete heart block; and 2) acute onset of mania following ECT. Obstetrical complications included two women with pre-term delivery – one secondary to premature rupture of membranes. No other complications or adverse outcomes were recorded. The five women with suicidal ideation had symptom resolution, and significant symptom improvement was noted in six of the eight women. Conclusions Electroconvulsive therapy is a safe and effective treatment during pregnancy and of particular benefit in the acute treatment of suicidal ideation.

Objective This randomized controlled pilot study examines the differences in response to electroconvulsive therapy as defined by an improvement of depressive symptoms between ketamine and methohexital as the primary anesthetic agent. Side effects and cognitive tolerability were also examined. Methods Subjects undergoing electroconvulsive therapy for unipolar or bipolar depression were randomized to receive ketamine or methohexital as the anesthetic agent. Primary outcome measure includes the Hamilton Rating Scale for Depression (17-item). Secondary outcome measures included Mini-Mental Status Examination (MMSE) and Beck Depression Inventory. All ratings were conducted masked to anesthetic agent. Due to multiple outcome measures obtained over time, mixed models were used to account for the correlations among the measurements within the subjects. Since outcomes were either normally distributed or approximately normally distributed, general linear mixed models were fit with a random intercept specified. Results A total of 21 subjects were enrolled, and 16 were randomized (methohexital, n= 8; ketamine, n=8). The two treatment groups did not differ statistically in any demographic characteristic. No statistical difference was found between the ketamine and methohexital groups for an improvement in depressive symptoms (p=0.6); however, subjects in both groups showed significant improvement in depression overtime (ketamine, p<0.0001; methohexital, p<0.0001). MMSE results did not differ between groups, and fatigue was reported more in subjects receiving ketamine (p=0.03). Conclusion The results of this pilot study are inconclusive as they lack power to support an advantage of ketamine anesthesia compared to methohexital in ameliorating depressive symptoms for electroconvulsive therapy.

Background and Objectives: The factors associated with medication for opioid use disorder (MOUD) treatment retention among pregnant women with opioid use disorder (OUD) are largely unknown. This study sought to characterize factors associated with postpartum treatment retention. Methods: A retrospective chart review from 2014 to 2017 was conducted among women with OUD in pregnancy treated with buprenorphine. Women were assigned to the treatment retention group if they attended an appointment within 10 to 14 weeks postpartum. Others were assigned to the dropout group. The groups were compared using bivariate analysis for sociodemographic variables, obstetrical and neonatal outcomes, clinical and subjective opioid withdrawal symptoms, buprenorphine dosage, urine drug toxicology (UDT) results, and other factors. Results: A total of 64 pregnancies received treatment until delivery, and 47 (73.1%) were retained in treatment by 12 weeks postpartum. The treatment dropout group had lower buprenorphine doses at delivery, a higher percentage of benzodiazepine positive UDT, and number of UDT positive for benzodiazepine in the third trimester. Breastfeeding rates were higher in the treatment retention group. Discussion and Conclusions: Future research of variables related to postpartum treatment retention is needed to provide guidelines regarding MOUD during the perinatal period and to optimize maternal and fetal well-being. Scientific Significance: This study supports previous recommendations that aggressive treatment of withdrawal symptoms in pregnant women with OUD is needed to maximize treatment retention. This is the first study to find that breastfeeding was associated with postpartum treatment retention; while, increased use of benzodiazepines during pregnancy was associated with postpartum treatment dropout.