Ms. C is an exceptional 27-year-old woman (not the woman in the image) diagnosed at age 15 with a rare chronic condition, Davies-Colley Syndrome, resulting in resection of multiple lower ribs, who presented in her 20th week of pregnancy. She had severe anterior chest wall pain and was unable to complete her work-day because of intractable pain. She was short of breath at rest and could barely complete a sentence because inhalation was so severely restricted by pain. She was having difficulty swallowing and eating despite the fact that she was always hungry. Her pain had become so severe she was not gaining weight even with Ensure. When she got home after work, all she could do was go to bed. She was suffering from a combination of neuropathic and somatic pain related to rib resections dramatically exacerbated by her pregnancy.
A multidisciplinary approach was indicated. She was seen by an Occupational Medicine colleague. Was this a partial disability issue or a workers compensation issue? She wanted to continue working. Could her employer make accommodations. She knew she would be worse off if she had to stay home all day. I treated her with lidoderm patches and a TENS unit. She saw a psychologist to learn behavioral strategies and began having weekly acupuncture in our center, which had worked for her in the past. She did not want to take any oral drugs and had tried most of them anyway over the years, including opioids, without getting substantial relief. I spent time with her and discussed with her the not unusual protective nature of pregnancy and other relevant considerations. She was intelligent, pleasant, motivated, had excellent coping skills, and was committed to her baby. Our goal was to see her deliver a healthy baby.
When seen a week later, she had less pain, less SOB, and was eating better. At 31 weeks she had increased pain, was unable to lie down at all because of pain, and was barely able to sleep. She had missed one week of acupuncture and this seemed to make a big difference. She had not used opioids up to that point and was encouraged to do so. She experienced nausea and vomiting with low doses and stopped using them. She was provided with 10% ketamine patches but they did not help. We spoke of implanting an epidural catheter and managing it as an outpatient. She improved quickly with acupuncture and continued behavioral and occupational support. She worked into her 35th week. She was induced at 36 weeks; had an epidural for delivery; and delivered a healthy 90th percentile baby. Two weeks later she came to our clinic with her baby so we could all meet him.
The accompanying portrait is of Eleanor Davies-Colley, a womens rights pioneer; an early 20th century surgeon from England. Please note that in the Davies-Colley Syndrome link, Dr Davies-Colley is referred to as a “he”. “He” in fact was a “she”.