Announcement

Collapse
No announcement yet.

Miscarriage misoprostol pain relief

Collapse
X
  • Filter
  • Time
  • Show
Clear All
new posts

  • Miscarriage misoprostol pain relief

    I recently underwent medical management for miscarriage and was given Misoprostol vaginally (4 tabs initially, then 2 tabs). Within 4 hours I was experiencing EXCRUIATING pain. Doctor said it would be "bad period"- it was more close to labour pain.

    Nurses tried initially paracetamol 1g + codeine 30mg- done nothing
    Then given Codeine 60mg- done nothing
    Then given tramadol 50mg- Worked excellent and was able to rest. However pain relief lasted for approx 2 hours

    Hospital pharmacist came told her tramadol worked but not codeine. She said stick to tramadol if case. Nurse said pharmacist shouldn't have said that as we need to work in a stepwise ladder.

    Agonising pain started again;
    Nurse gave paracetamol + codeine again- declined as made no difference
    Nurse gave oramorph 5mg liquid- no difference to pain; just caused vomiting (even though doctor said to nurse give morphine injection)
    Nurse gave IV paracetamol; no difference
    Within an hour nurse then gave tramadol 50mg again; finally pain ceased and went to sleep

    My frustration is why nurses are so damn insistent on paracetamol when it clearly isn't working?! Also for future reference if you are used to taking stronger painkillers like opioids, amitriptylline, NSAIDs could that be the reason mild painkillers no longer work?

    I went through 12 hours of hell with this pain, however it definitely gives me a more realistic expectation of labour pain and perhaps I definitely need to think of a good pain relief plan.

    Any thoughts on this pain management?



  • #2
    What a dreadful experience, right through. Every sympathy. The nurse was clearly following the rules without thinking about how they were working. There’s an old adgae 'Rules are for the obswrvance of fools and the guidance of wise men.’
    In other words if in doubt, follow the rules, but that doesn’t mean they have to be slavishly followed. Medicine, in it’s widest sense, is an art, not a science, if by science we mean something where mathmatecal principles can be applied.

    Comment


    • #3
      I watched "Sully" yesterday. If he had followed the rules, 155 people would have died.
      johnep

      Comment


      • #4
        I am so sorry you have been through such a dreadful experience. I was lead pharmacist in a tertiary referral women's hospital. All I can say is I trained my nurses to use their common sense... if I had been the pharmacist I would have discussed it with the nurse and made a note on the drug chart. Frankly very few nurses would go against what I suggested!! (There s a reason I call myself DRAGONlady!!!!) To be fair Paracetamol IS the main painkiller with or without Codeine in obstetrics and gynaecology but if there was a prescription for Tramadol I cannot see why they made such a fuss about it. Some nurses are jobsworths I am afraid......I do hope you are getting the support you need after your miscarriage.

        Comment


        • #5
          When I was in Export had a letter from a hospital in West Africa begging us to send them some pethidine for their maternity wards. Said they only had aspirin. I had to reply that they would have to go through the correct channels and that our local agent would advise. However, heard no more.
          johnep

          Comment


          • #6
            You have my sympathies.

            Codeine is known to lack efficacy in a large proportion of the population. It's not unusual for it not to have any benefit so your past use of stronger painkillers is unlikely to be of significance. Paracetamol itself would not be expected to a have a large effect on severe pain, speaking from personal experience, when it comes to acute pain I take paracetamol + NSAID and then if that is not enough, morphine.

            It makes no sense to take a medication if it has no effect on the pain as one risks being harmed by it for no clinical benefit and I am somewhat astonished that given the circumstances the nurse suggested you take more of it when you reported it had not helped!

            As time goes on we are starting to see the use of weak opioids such as codeine phased out as their risk to benefit ratio is unfavourable compared even with other, stronger opioids.

            Comment


            • Dragonlady
              Dragonlady commented
              Editing a comment
              While clearly the normal risks associated with an NSAID would be mitigated by giving it in these circumstances trust me an NSAID is not effective during labour....which this effectively was. Also I can see lots of reasons why the normal instruction to take an NSAID with or after might not be possible in these circumstances. What you say with regard to codeine may well be true in chronic pain...but acute pain is different When for whatever reason an NSAID cannot be given, what are people supposed to take? Tramadol is effective in about 50% of people. The other 50% find it just makes them sick. My old pain team leader described it as an emetic with analgesia as a side effect. In my womens hospital we used paracetamol diclofenac and oramorph it as part of standard post c/section analgesia but they went home with codeine if they needed more than paracetamol and an NSAID on discharge. Codeine and Tramadol are the mainstay of post op discharge medication. But the pain will be short lived. .Chronic pain is a whole different kettle of fish and to be honest drugs are of limited help. .Chronic pain is certainly an area where my other skills are useful

          • #7
            Originally posted by Dragonlady
            While clearly the normal risks associated with an NSAID would be mitigated by giving it in these circumstances trust me an NSAID is not effective during labour....which this effectively was. Also I can see lots of reasons why the normal instruction to take an NSAID with or after might not be possible in these circumstances. What you say with regard to codeine may well be true in chronic pain...but acute pain is different When for whatever reason an NSAID cannot be given, what are people supposed to take? Tramadol is effective in about 50% of people. The other 50% find it just makes them sick. My old pain team leader described it as an emetic with analgesia as a side effect. In my womens hospital we used paracetamol diclofenac and oramorph it as part of standard post c/section analgesia but they went home with codeine if they needed more than paracetamol and an NSAID on discharge. Codeine and Tramadol are the mainstay of post op discharge medication. But the pain will be short lived. .Chronic pain is a whole different kettle of fish and to be honest drugs are of limited help. .Chronic pain is certainly an area where my other skills are useful
            I wouldn't imagine an NSAID would be effective for labor pain either.

            If a classic mu-opioid agonist is indicated then nearly any standard strong opioid is what I would prefer over codeine, based on the efficacy limiting pharacokinetic issues we see in poor metabolisers of the drug and the corresponding increased side effect burden compared to an equipotent dose of say morphine. This is not even to consider the potential dangers posed to extensive metabolisers of the drug. This is the reason why as I say, we are seeing some clinics phase the use of codeine out in favour of using low doses of strong opioids like morphine and hydromorphone in a variety of settings. The overall growing body of evidence does increasingly seem to be supporting the superiority of low dose strong opioids over the use of codeine.

            I am not a fan of the use of codeine in clinical practice at all really given it's limitations and the overriding impression I am left with is that the only reason it enjoys much use at all in the UK is because of political pressure not to use a drug with a higher abuse potential rather than any real major clinical desirability.

            In chronic pain we have many more options available to us such as anticonvulsants, tricyclic antidepressants, nefopam, flupirtine and I even know of personal friends being prescribed oral ketamine, so opioids are becoming less of a necessity than in the past.
            Last edited by Energize; 25th, March 2017, 04:01 AM.

            Comment


            • Dragonlady
              Dragonlady commented
              Editing a comment
              You may well be right about why Hydromorphone is not used much....that plus the cost factor....its cheap!! Also codeine can be sold OTC relieving doctors of the need to prescribe it.....but don't get me going on the issues of addiction to OTC drugs!! Codeine has abuse potential and we all know it. But for short term post op pain none of the drugs you mention would be suitable....and the OTC products are for short term use in theory (no I am not going to talk about OTC addiction!!!) And in chronic pain a variety of drug and non drug options are possible. There is good evidence of the value of mindfulness and qigong in chronic pain..and the possibly more scientifically acceptable option of TENS as well. Drugs are only ever part of the answer in chronic pain

          • #8
            So sorry to read about your miscarriage. I hope that things go better for you in the future.

            With respect to your query, in all the hospitals that I have worked there is a step wise progression of pain relief. The aim is to leave the patient either pain free or in tolerable pain if it's impossible to reduce their pain any further without severe adverse effects.

            in your specific case once it had been found that your pain could be managed by Tramadol, then you should have been asked by the nurse before she administered your next pain relief, what level of pain you were in. If you still had high levels then the pain relief that had been found to be effective, in this case Tramadol, would be administered.

            What the nurse told you about having to try everything every time step by step is not only stupid, it's actually cruelty to leave a patient in severe pain that could knowingly be prevented with a specific drug. Only if you reported that the pain had reduced should they have started to step down from the effective pain relief.

            I'm surprised the pharmacist didn't fight his corner after expressing the opinion that you should remain on Tramadol. It might have been advisable to speak to either the Ward Manager or the supervising doctor about what was happening.

            I hate Tramadol. I was given it after my ileostomy last year and thought that I was dying. I couldn't tolerate it at all.

            Comment

            Working...
            X