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Consultation for total pain in high-risk obstetrics
  1. Warren Mackie-Jenkins1,
  2. Regina M Tosca2 and
  3. Hunter Groninger2,3
  1. 1 Department of Medicine, MedStar Washington Hospital Center Washington, Washington, District of Columbia, USA
  2. 2 Section of Palliative Care, MedStar Washington Hospital Center, Washington, District of Columbia, USA
  3. 3 Department of Medicine, Georgetown University School of Medicine, Washington, District of Columbia, USA
  1. Correspondence to Dr Hunter Groninger, Section of Palliative Care, MedStar Washington Hospital Center, Washington DC 20010, USA; hunter.groninger{at}


Palliative care (PC) consultation rarely takes place in the clinical setting of high-risk obstetrics, where ‘total pain’ may be undermanaged. Here, we present a case of a young woman carrying twins and hospitalised for acute abdominal pain. Workup for her pain revealed non-viable fetal tissue positioned in the uterine horn; the remaining fetus was viable. Initial attempts to control the patient’s pain with strong parenteral opioids by the obstetrics team and the acute pain service failed. The PC service was consulted to assist. Applying a customary interdisciplinary approach in a novel PC clinical setting, the PC service was able to identify and attend to the patient’s physical, psychosocial and spiritual pain, resulting in an overall decrease in reported pain scores, decreased opioid requirement and a plan for preservation of the viable fetus.

  • pain
  • clinical assessment
  • total pain
  • psychological care
  • obstetrics

Statistics from


Palliative care (PC) consultation has been well described in perinatal settings, where the neonate’s expected poor prognosis is attended to with best family-centred multidisciplinary palliative approaches, often at end-of-life.1 2 However, such models of supportive care have not been explored upstream in high-risk obstetrics, particularly regarding symptom management. Here, we present the case of a young woman with complex symptomatology best addressed through concepts of ‘total pain’.3 Since the patient was lost to follow-up despite multiple attempts to contact her and family, we sought institutional review board (IRB) approval to present this case; the IRB determined approval was not necessary given that personal health information has been removed.

Case report

A female in her 20s with twin gestation at 17 weeks and 4 days by last menstrual period was admitted to the inpatient obstetrics service in May 2016 reporting 2 days of severe, acute right lower quadrant abdominal pain.i Two months prior, she had been evaluated for 2 weeks of progressive abdominal cramping and an ultrasound showed demise of the right fundal twin at around 11 weeks, with the left fundal twin still alive. Repeat ultrasound at hospital admission demonstrated the live twin was still developing and that the non-viable twin had migrated into the uterine horn. (figure 1).

Figure 1

MRI coronal view of the gravid pelvis demonstrating deceased fetal tissue (A) in the right uterine horn and the viable fetus (B) in the cephalic presentation.

At admission, the patient ranked her abdominal pain as 9/10 describing it as constant aching and radiating to her back. She also described spasms ‘like contractions’ approximately every 10 min that she rated as 10/10. On physical exam, the gravid abdomen was very tender even to superficial palpation. Pain interfered with physical activity, and she limited her movement to the hospital room and bathroom. She endorsed poor sleep and very anxious mood, but denied other symptoms, including nausea, constipation or dyspnoea.

On hospital day 1, the admitting obstetrics team consulted the hospital Acute Pain Service (APS) which recommended 1–2 mg of intravenous hydromorphone every 3 hours and 10 mg of oral oxycodone every 4 hours. Over the next 24 hours, she received approximately 70 mg of oral morphine equivalents in opioid. When this regimen failed to significantly improve her pain, the APS recommended surgical removal of the non-viable fetal tissue as the only truly effective way to remove her abdominal pain. However, such a surgical intervention would most likely result in the termination of the viable pregnancy, an unacceptable outcome for her. APS signed off on the consult.

On hospital day 4, the attending obstetrician chose to consult the palliative care (PC) team specifically for acute pain management recommendations. Our hospital PC consult team is designed to be highly interdisciplinary and includes physicians, social workers, palliative-trained clinical pharmacists, a chaplain and a nurse practitioner. Palliative team members practise transdisciplinary care; during routine consults, it is equally common for medical providers to carefully assess psychosocial–-spiritual distress and for social workers or chaplains to verbally assess physical symptomatology. On the day of initial consultation, the patient was seen by both the PC physician and pharmacist, who recommended transitioning from parenteral opioids to oral oxycodone. Alert to the concept of multimodal total pain, the team’s social worker and chaplain joined the consult the following morning.

During palliative visits, much of the patient dialogue centred on her intention to maintain her viable pregnancy, despite the severe pain and substantial risk it posed to both her and the fetus. During these visits, she tearfully recalled the fear she experienced when her elementary-school age son, who was strong and healthy, had been born 3 months premature. Initially, the patient reported no specific religious or spiritual practice. However, as the therapeutic relationship progressed, she increasingly described feeling existential angst about her circumstances (‘why is God doing this to me?’). She described praying for her viable twin: ‘I want this baby so bad I can’t even describe what it feels like’.

Additionally, she was also still grieving the untimely death of her son’s father, who had died of cancer 2 years earlier. While he was involved and supportive, he remained concerned about the potential consequences of a continued pregnancy on his wife’s health. His preference to terminate the viable pregnancy for safety concerns created an emotional wedge and contributed further to the patient’s feelings of isolation and loss. As a component of her psychosocial treatment plan, the PC social worker conducted short-term counselling with both patient and husband, facilitating empathic discussions around their individual concerns.

During the span of the palliative consultation and interventions, her reports of physical pain improved substantially. Sleep lengthened, activity increased and her mood lightened. Her daily opioid use diminished from approximately 70 mg daily oral morphine equivalents to occasional doses of oxycodone 5 mg. The social worker and the chaplain conducted psychoeducation with the patient around the concept of total pain, emphasising the interplay of physical and emotional and/or spiritual distress. A repeat ultrasound 4 days into the admission showed further compression of the fetal sac that had traversed into the uterine horn. She was discharged after 1 week on oral acetaminophen and oxycodone as needed and was also provided referrals to continue grief counselling as an outpatient. In subsequent months, she moved near family in another state.


This case highlights the clinical benefit to an interdisciplinary palliative approach to total pain in a relatively novel setting. While suffering abounds in the context of fetal demise, thus far palliative encounters have generally been limited to participating in perinatal care.1 2 4 5 Nevertheless, although not considered a traditional ‘palliative diagnoses’, cases within the field of maternal–fetal medicine certainly present in the clinical context of a serious illness. Here, marked physical complaints were unsuccessfully alleviated, despite significant opioid administration, until a holistic approach was employed. Future opportunities to educate obstetrics providers around upstream PC benefits should be welcomed.


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  • i To preserve anonymity, patient’s initials, specific age and date of last menstrual period have been slightly modified.

  • Competing interests None declared.

  • Patient consent Detail has been removed from this case description/these case descriptions to ensure anonymity. The editors and reviewers have seen the detailed information available and are satisfied that the information backs up the case the authors are making.

  • Provenance and peer review Not commissioned; internally peer reviewed.

  • Data sharing statement None declared.

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