Pregnancy +ESI

[painfree23]

consulted for an epidural steroid injection during 1st trimester because of significant pain low back pain. I want to say no, but want to make sure. Would have to be blind, right?

Thoughts?

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[NOSfan]

What does the MRI show?

OB wanted an ESI on similar patient, recommended MRI which revealed psosas abscess 😉

 

[pastafan]

If MRI demonstrates disc herniation then blind LOR ILESI.

 

[willabeast]

consulted for an epidural steroid injection during 1st trimester because of significant pain low back pain. I want to say no, but want to make sure. Would have to be blind, right?

Thoughts?

Get OB/GYN permission (they will say OK) and document. Do injection with no radiation. BTW back pain is not ordinarily an indication for ESI.

 

[bedrock]

Never touch a preggo. They decided to grow a parasite and there is 18 years of time during which they can decide some random thing in the kids life was your fault and sue.

No procedures on preggos particularly epidurals with or without x Ray.

 

[myrandom2003]

ultrasound guided caudal?

Just spitballing

 

[Extralong]

Never touch a preggo. They decided to grow a parasite and there is 18 years of time during which they can decide some random thing in the kids life was your fault and sue.

No procedures on preggos particularly epidurals with or without x Ray.

Yep. Totally agree.

 

[lobelsteve]

No thanks.

 

[SSdoc33]

Nope

 

[onewithpain]

I had one that I gave a TENS unit to in the first trimester. She did well through gestation and labored to 8 cm. Then she wanted an epidural but OB said too late.

 

[SommeRiver]

Nah...

 

[Ducttape]

I had one that I gave a TENS unit to in the first trimester. She did well through gestation and labored to 8 cm. Then she wanted an epidural but OB said too late.

technically, TENS is "contraindicated" in pregnancy...

 

[Orin]

What is the indication and exam? LBP in pregnancy is rarely caused by something I would expect to be responsive to a LESI.

I just don't see a real good reason to pursue an elective procedure in a high risk patient in what most would consider a substandard manner.

I suspect it isn't indicated and that it could cause some harm to the fetus from the steroid exposure, but I'm happy to do a blind LESI. The fluoro's just for finding midline and billing more right?

 

[Ducttape]

steroids are "appropriate when indicated" in pregnancy. they use it in preterm labor frequently.

the fluoro is for patient safety...

 

[SSdoc33]

I've found that herniations tend to hurt less as the pregnancy progresses for some reason. Relaxin? They will come back for the shot around 6-9 months once the baby high/low wears off

 

[Ronin1]

I’ve done a few over the last 20 years for acute disc herniation. It’s not that big a deal. Document the plan with the OB and proceed. But then again I did thousands of epidurals without image guidance over the years.

 

[geauxg8rs]

I’ve done a few over the last 20 years for acute disc herniation. It’s not that big a deal. Document the plan with the OB and proceed. But then again I did thousands of epidurals without image guidance over the years.

I would not do it. I get 1 new patient per month who claims their back
Pain has been there since a “botched labor epidural.” I realize this is not a labor epidural, but still there is a lot of potential risk here

 

[onewithpain]

technically, TENS is "contraindicated" in pregnancy...

Transcutaneous electrical nerve stimulation improves low back pain during pregnancy. - PubMed - NCBI

Women wanting a "natural childbirth" use them. Some apply TENS to the acupuncture points on the wrist to help control nausea in the first trimester.

 

[Orin]

I def agree with steroids only when indicated and worth the risks to mom/fetus.
Repeated doses/exposure carries risks for both. The data about neurocognitive outcomes and LBW are concerning for harm for the fetus.
PTL usage for lung maturation is great but repeated exposure is not ideal for mom or fetus.

I like TENS and there are guidelines for safety.

https://pdfs.semanticscholar.org/70ce/3a430f2e721bfc10e0f44d77264a1eb336aa.pdf

 

[NOSfan]

I like TENS and there are guidelines for safety.
https://pdfs.semanticscholar.org/70ce/3a430f2e721bfc10e0f44d77264a1eb336aa.pdf

Appreciate the article.
Cheers

 

[Ducttape]

from a TENS company:

Pregnancy And Transcutaneous Electrical Nerve Stimulation

Pregnancy And Transcutaneous Electrical Nerve Stimulation
It can be scary to use anything new or unknown to you during pregnancy, and while the TENS unit should NEVER be used by a pregnant woman before labor, during labor it can help to relieve some of the pain caused by contractions. There have been various studies done on this subject to certify whether or not transcutaneous electrical nerve stimulation is safe for a growing fetus. The findings have made it clear that while the baby is growing in utero it shouldn’t be used to ease back pain or discomfort, but once a woman goes into labor and pain becomes increasingly severe, TENS can be used safely with no harm to the child.

Safety studies suggest that TENS may not lead to fetal deformity, but like opioids, data limited. Massage, ROM exercise, and focusing on baby shower seem more apropos.

Do agree- safer than opioids.

 

[oreosandsake]

have a consult for this today

normal 30 y/o F new onset acute radic 31 weeks pregnant. what are my options? I wouldn't want to perform the eSI anyways on pregnant patient.

 

[lobelsteve]

I would make sure you’re completely booked out for nine more weeks. After that you can do an epidural whenever you would like.

 

[Ducttape]

i second lobelsteve.

tell the patient that the best epidural for this patient would be a "labor" epidural...

 

[callmeanesthesia]

have a consult for this today

normal 30 y/o F new onset acute radic 31 weeks pregnant. what are my options? I wouldn't want to perform the eSI anyways on pregnant patient.

I’ve seen landmark based ESI done for severe, disabling radiculopathy in pregnancy in fellowship. Obviously need to get clearance from OB and document the hell out of risk/benefit discussion, and be very comfortable doing landmark based interlaminar ESI (i.e. anesthesia-trained).

 

[Orin]

Don't punish her for being pregnant.

You or an anesthesia trained colleague can safely do this without fluoroscopy or with ultrasound.

The harder part is whether it is truly indicated and what the risk actually is for patient/fetus.

Interlaminar w/ nonparticulate +/- low dose lidocaine, no contrast and epi test dose

 

[painfree23]

Don't punish her for being pregnant.

You or an anesthesia trained colleague can safely do this without fluoroscopy or with ultrasound.

The harder part is whether it is truly indicated and what the risk actually is for patient/fetus.

Interlaminar w/ nonparticulate +/- low dose lidocaine, no contrast and epi test dose

Ur not punishing her. This is an ELECTIVE case.

 

[oreosandsake]

So why do I offer her? What meds are reasonable for radic in pregnancy? Epidural wasn’t in my plan anyways

 

[lobelsteve]

No meds. No shots. Tough it out. Apparently there have been 10s of thousands of years of women being pregnant and this ist the first case of radic. Bite a rope. I would not offer anything because the risks have not been adequately studied. Some other doc can take those risks on your unborn child.

 

[oreosandsake]

No meds. No shots. Tough it out. Apparently there have been 10s of thousands of years of women being pregnant and this ist the first case of radic. Bite a rope. I would not offer anything because the risks have not been adequately studied. Some other doc can take those risks on your unborn child.

Thanks Steve... that was my thought as well

 

[Taus]

Tylenol. PT w Mckenzie. Reassurance. Theatrical placebo if they want (acupuncture, Chiro). No esi.

 

[SommeRiver]

Just make sure the chiropractor does intrauterine adjustments on the unborn fetus - God help that child if both hips aren't EXACTLY the same height.

 

[jesspt]

Tylenol. PT w Mckenzie. Reassurance. Theatrical placebo if they want (acupuncture, Chiro). No esi.

A PT who specializes in Women's Health might be of help - you can locate on here, or direct the patient to the web site to find their own PT.

 

[Orin]

Ur not punishing her. This is an ELECTIVE case.

It's all elective, so why do you do any of it? Because you believe it's worth the benefit I assume?

I agree with PT if you don't feel comfortable offering her medications or interventions.

 

[Ducttape]

It’s the risk benefit analysis that I think you are missing.

ESI - potentially high risk and not just to mom. Short term benefit.

Orbs are sometimes worried about even giving Tylenol to pregnant women. Why risk injection with steroid?

Do this - ask the Ob if they gave patient a course of oral steroids. If they say no, ask why not...

 

[SommeRiver]

Don't steroids have implications into the fetal lung? No way would I do this bc you're talking about something that will POSSIBLY help mom. Different than a pregnant woman with an infected appendix that must come out or she could become septic and die.

If she is SEVERELY painful you can technically give her oxycodone, but I personally wouldn't.

 

[Agast]

I had a patient with severe sciatica persisting after delivering the baby, so I ordered her MRI. Very minimal disc bulge effacing thecal sac, no frank herniation. PT, NSAIDs and no procedure needed just reassurance. I don't think the ob/gyn are ordering imaging while the patient is pregnant and big pain =/= big herniation. I think the combination of heavy pelvic load and shifting joints/ligaments makes the sciatica worse than it really is.

 

[SSdoc33]

no shot.

one of my colleagues does it-- under flouro. i think he is out of his mind

 

[painfree23]

no shot.

one of my colleagues does it-- under flouro. i think he is out of his mind

Waaaaat

 

[Orin]

It’s the risk benefit analysis that I think you are missing.

ESI - potentially high risk and not just to mom. Short term benefit.

Orbs are sometimes worried about even giving Tylenol to pregnant women. Why risk injection with steroid?

Do this - ask the Ob if they gave patient a course of oral steroids. If they say no, ask why not...

I agree. Steroids can carry risk to the mother and fetus, both for lung, body weight, and cognitive development.

Now, if the OB would give an oral course of steroids, would you do an ESI? Are oral steroids superior to ESIs for an acute radic? Is there significantly added risk to an interlaminar epidural for an acute radic vs an epidural catheter for labor?

Again, I'm not disagreeing about the factors for analysis here, we just arrive at a different conclusion, because I don't see pregnancy and a fetus as a contraindication to appropriate treatment options. I would prefer the ESI to AEDs or opioids, assuming they need an ESI.

I do agree that pain/symptoms in pregnancy does not mean a pathologic disc requiring surgery, as those nerves are often more sensitized, but if the patient weren't pregnant, I assume we would be all doing an ESI?

 

[emd123]

A: Steroids in pregnancy can help a fetus.
B: Steroids in pregnancy can harm a fetus.
C: 100,000 things can go wrong with babies that can falsely be blamed on B by persuasive lawyers
D: No good dead goes unpunished

A is the poison apple bait. A, is you doing a bunch of treatments on pregnant women that aren't potentially life or limb saving. There's an entire cottage industry of lawyers, circling above you right now, waiting for you to take the bait so they can swoop down and prove B+C= D. This equation also can be written as, "Put a lawyer's kid through college."

 

[olafa]

from a TENS company:

Pregnancy And Transcutaneous Electrical Nerve Stimulation



Safety studies suggest that TENS may not lead to fetal deformity, but like opioids, data limited. Massage, ROM exercise, and focusing on baby shower seem more apropos.

Do agree- safer than opioids.

I think the issue is PRE-TERM labour secondary to stimulation of the muscle contraction

 

[Aether2000]

Of course you could tunnel the epidural catheter, inject it with steroid and leave it in for the labor pain to come ;-) Paraphrasing Hamilton, you don't want to throw away your shot.