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Pregnant (10wks) TIbial shaft fracture (Drug classification (Class A -…
Pregnant (10wks) TIbial shaft fracture
Potential problems
Drugs crossing placenta
Especially dangerous during
Organogenesis (weeks 4-10)
Just prior to delivery
Liaise with obstetrician if ? timing
Drug classification
Class A - Taken by many, no increase in malformation or other harm (Paracetamol)
Class B1 - Taken by limited number, no increase in malformation or harm, studies in animals show no problem (ropivacaine)
Class B2 - Taken by limited number, noincrease in malformation or harm, animal studies inadequate or data lacking (Venlafaxine)
Class B3 - Taken by limited number, no increase in malformation or harm, some animal studies show harm (Celecoxib)
Class C - Have caused harmful effects but no malformation, harm may be reversible (NSAIDS, Tramadol, opioids)
Class D - Evidence of malformation or irreversible damage, may have adverse pharmacological effect (Sodium Valproate, phenytoin)
Class X - High risk of causing permanent damage
Options
Non pharmacological
Elevate leg
Immobilise and comfortable positioning
Heat/cold
Distraction, meditation, hypnosis, visual imagery
Pharmacological
Paracetamol
NSAID
Tramadol
Opioid - enteral or parenteral
Local anaesthetic
Femoral nerve block
Spinal
Epidural
Systemic LA infusion
Antineuropathic agents
Ketamine
Surgical
Fixation, splinting, traction and immobilisation
My choice
Use in line with institutional practice
Foetal monitoring as indicated (unlikely helpful at 10 weeks)
Non pharma - as discussed immobilise limb and coping techniques, low risk and may aid analgesia
Pharmacological
Paracetamol - well established efficacy and safety in pregnancy
NSAID - opioid sparing, may increase risk miscarriage in early pregnancy. Risk / benefit consider Celecoxib first (B3)
Opioids - Regular slow release Oxycodone for background analgesia (10mg BD), PCA if oral route difficult, PRN Tramadol - low risk of irreversible harm
Regional: Intraop - single shot spinal (avoid GA risk, decreased DVT vs GA), Postop consider single shot femoral nerve block/catheter/epidura (D/w ortho re: compartment syndrome riskl