It is important to discuss medication choices with your GP if you feel your pain is not well controlled. Pain relief is available to buy over the counter at your local pharmacy, but it is helpful to talk with your midwife or GP to make them aware that you have severe pain. It is often a case of trial and error to find the medication that suits you best, so do not be too downhearted if the first product you try does not help. Although PGP is a common condition, your GP may be relatively unfamiliar with its treatment and you may have to stress your need for pain relief if you have severe pain. Many women find that during pregnancy, GPs not used to managing PGP may be unwilling to prescribe anything stronger than paracetamol, in which case you can ask for a referral to a consultant (e.g. an obstetrician) who has more experience of pain management.
Be aware that taking painkillers regularly usually gives the best effect with chronic pain. However, if you take them regularly when you are not experiencing pain, your body may become accustomed to them, and they will become ineffective when you do experience pain.
More information about any of these drugs can be found in the British National Formulary (BNF). The side effects of all drugs can be found in the leaflets provided by the manufacturers, so do read them before starting to take any medication. It is usually best to take painkillers with food to reduce any potential irritant effects on the stomach.
Diclofenac is a non-steroidal anti-inflammatory drug (NSAID). In single doses it is used for mild to moderate pain but it is also used regularly as an anti-inflammatory medication which is often particularly effective in PGP. Diclofenac usually starts to work after about an hour, with the duration of action depending on the preparation used. It is available as tablets, slow-release tablets and suppositories (which may sound unpleasant but are acceptable and very effective). It is not usually used in the last trimester of pregnancy owing to effects on the baby. Small amounts are passed into breast milk but it is commonly used on maternity wards after birth. Naproxen and ketoprofen are possible alternatives as they are both in the same class of drugs.
Codeine is a mild opioid analgesic and is effective for mild to moderate pain. It may cause constipation and/or drowsiness. Codeine should not be taken in the first trimester of pregnancy as there is a possible association with respiratory and cardiac conditions in the baby. It can also lead to drug dependence in the baby which may include withdrawal symptoms after birth. Codeine passes into breast milk and so is regarded as unsafe to take during breastfeeding.
Tramadol is indicated for moderate to severe pain, but its use in pregnancy and breastfeeding is not advised although it is often prescribed by consultants during pregnancy.
Opiate patches are starting to be more commonly used, particularly through pain clinics, for example, buprenorphine (Transtec®).
Nefopam is a non-opioid analgesic. It can be used to treat moderate pain. It is not recommended in pregnancy or when breastfeeding.
An injection may be used to temporarily block the nerve carrying the pain message, and it can also be used to help diagnose the causes of chronic pain. However, this is generally not very useful in PGP as it does not treat the cause of the problem, only the symptoms, and as it is an injection, it is invasive. If it is being offered, it is worth thinking again about whether you are really receiving the most effective manual therapy possible and whether a second opinion might give you a better result. Your manual therapist may recommend a nerve block if your symptoms are very irritable.
Neuropathic pain is caused by damage to nerves and is often described as burning, sharp or shooting. Sensitivity to things which are not usually painful (e.g. light touch) and heightened pain sensation to things which are painful are both common.
The two main groups of drugs used to treat neuropathic pain are the medicines commonly used to treat depression and epilepsy;
Amitriptyline and Nortriptyline
Antidepressants are effective in treating neuropathic pain at much lower doses than those used to treat depression. They work in a different way to their effect on depression.
Traditionally, Amitriptyline and Nortriptyline are most often used (doses between 10 mg and 100 mg) but some of the newer antidepressants such as Venlafaxine have also proved to be effective.
Amitriptyline is not recommended in pregnancy but the amount passed into breast milk is thought to be too small to be harmful.
Gabapentin is one of the antiepileptic drugs and has well-documented effectiveness in the treatment of neuropathic pain. Other antiepileptics are also used and all have different modes of action so that failure to respond to one does not mean that others will not work.
It is recommended that the dose should be monitored carefully during pregnancy and after birth. Gabapentin is present in breast milk, discuss the risks with your GP.
Often a combination of drugs works best, e.g. antidepressant and antiepileptic. These medications are often prescribed for chronic pain following pregnancy.
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