To Whom It May Concern,

My name is Dr. Srikanth Kolli D.C. and I currently work for Ampla Health Lindhurst Medical Center, in Olivehurst, CA.  Ampla Health is a 501 (c)3 non-profit network of community-based Federally Qualified Health Centers (FQHC), offering comprehensive medical, dental, behavioral health, pediatrics, chiropractic, and specialty healthcare services in Butte, Colusa, Glenn, Sutter, Tehama, and Yuba counties. We serve an underprivileged rural environment in need of care. I am reaching out to you regarding Chiropractic Care for the patients of our communities. The Chiropractic program has been able to serve our pregnant population for the past six years with lots of success for our patients. Chiropractic care is 100% covered for our MediCal patient population. Ampla also has a sliding fee program, for low income patients without insurance, as well as a low copay for patients that have private insurance requesting for Chiropractic care.

I would like to work with you to offer Chiropractic services to OB patients that do not know we are an available resource.  I would also like to have an opportunity to speak with the members of the OB/GYN department to answer any questions regarding care and encourage them to take advantage of our services. Chiropractic has been shown to alleviate the severity of back pain during pregnancy. This allows patients an alternative to pain medications during the course of their pregnancy as well as postpartum, especially with c-sections.

Severe and persistent pain which is not effectively treated during pregnancy can result in depression, anxiety, and high blood pressure in the mother.¹ Medicines including nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, and acetaminophen can help treat severe and persistent pain.  However, it is important to carefully weigh the benefits and risks of using prescription and OTC pain medications during pregnancy. Current drug labels state that NSAIDs should not be used by pregnant women in their third trimester of pregnancy because of the risk of premature closure of the ductus arteriosus in the fetus. The U.S. Food and Drug Administration (FDA), as of 10/15/2020, is now warning that use of NSAIDs around 20 weeks or later in pregnancy may cause rare but serious kidney problems in an unborn baby. This can lead to low levels of amniotic fluid surrounding the baby and possible complications. A significant concern of prescription NSAIDs include the risk of miscarriage in the first half of pregnancy.^2-6  Opioids, which are available only by prescription, have a risk of birth defects of the brain, spine, or spinal cord in babies born to women who took these products during the first trimester of pregnancy.^{7, 8}

Low back pain is often described as an inevitable complication of pregnancy.⁹ Fascial constraint and spinal pelvic subluxation may be the cause of low back pain in pregnancy.⁹As the growing uterus expands, it pulls the sacral base anterior, causing an anterior tilt of the pelvis and flexion of the hips. This orientation of the pelvis causes an increase in the lumbar lordosis, which increases the activity of the iliopsoas muscles. The piriformis muscle remains in a contracted state to maintain the external rotation of the legs, which compensates for a lack of balance as the center of gravity shifts as the pregnancy progresses.¹⁰ However, gentle myofascial relaxation of the piriformis and iliopsoas can greatly aide in the reduction of pain and tension. Also, improving the strength of the transvers abdominus muscle is thought to prevent some of the typical postural alterations that are seen in the third trimester that come with anterior pelvic tilt.¹⁰ Anterior translation of the cervical spine and extension of the occiput on the atlas can occur and be related to muscle spasms and suboccipital headaches to compensate for the laxity experienced as gestation progresses.¹¹ Release of these spasms can be quite beneficial in alleviating continuous cephalgia. Also, exaggerated thoracic kyphosis, anterior translation of the head, and the increased weight of the breast tissue may cause cervicothoracic pain, thoracic outlet syndrome symptoms, or myofascial pain syndromes.¹²

A variety of medicines are prescribed to treat severe and persistent pain for pregnant patients. These include NSAIDs, acetaminophen, and opioids. Findings from two U.S. studies indicate that approximately 18-25 percent of pregnancies are exposed to OTC ibuprofen and 4 percent of pregnancies are exposed to OTC naproxen.^13,14 Findings from two U.S. studies indicate that 65-70 percent of pregnant U.S. women reported using acetaminophen anytime during pregnancy.¹³ During each trimester of pregnancy, approximately six percent of pregnant women in the U.S. are exposed to opioids.¹⁴ Examples of opioids include oxycodone, hydrocodone, hydromorphone, morphine, and codeine.

Chiropractic has been shown to be a safe and effective alternative to the use of pain medications. Chiropractic care has typically included the care of pregnant patients to assure the patient a comfortable pregnancy and to help facilitate an uncomplicated labor and delivery. Majority of our pregnant patients who received chiropractic care stated that they found relief from pain and did not feel a need to use OTC medications during their pregnancy. Literature within the osteopathic profession also includes evidence of improved outcomes in labor and delivery for women who receive prenatal osteopathic manipulative treatment.¹⁵

Dr. Srikanth Kolli D.C.

Doctor of Chiropractic

References:

1. Babb M, Koren G, Einarson A. Treating pain during pregnancy. Can Fam Physician 2010;56:25, 27.
2. Nakhai-Pour HR, Broy P, Sheehy O, Bérard A. Use of nonaspirin nonsteroidal anti-inflammatory drugs during pregnancy and the risk of spontaneous abortion. CMAJ 2011;183:1713-20.
3. Nielsen GL, Sørensen HT, Larsen H, Pedersen L. Risk of adverse birth outcome and miscarriage in pregnant users of non-steroidal anti-inflammatory drugs: population based observational study and case-control study. BMJ 2001;322:266-70.
4. Nielsen GL, Skriver MV, Pedersen L, Sørensen HT. Danish group reanalyses miscarriage in NSAID users. BMJ 2004;328:109.
5. Li DK, Liu L, Odouli R. Exposure to non-steroidal anti-inflammatory drugs during pregnancy and risk of miscarriage: population based cohort study. BMJ 2003;327:368.
6. Edwards DR, Aldridge T, Baird DD, Funk MJ, Savitz DA, Hartmann KE. Periconceptional over-the-counter nonsteroidal anti-inflammatory drug exposure and risk for spontaneous abortion. Obstet Gynecol 2012;120:113-22.
7. Yazdy MM1, Mitchell AA, Tinker SC, Parker SE, Werler MM. Periconceptional use of opioids and the risk of neural tube defects. Obstet Gynecol 2013;122:838-44.
8. Broussard CS, Rasmussen SA, Reefhuis J, Friedman JM, Jann MW, Riehle-Colarusso T, et al. Maternal treatment with opioid analgesics and risk for birth defects. Am J Obstet Gynecol. 2011;204:314.e1-11.
9. Vallone S. The role of chiropractic in pregnancy. ICA Int Rev Chiropr. 2002:47–51
10. Bartol K.M. Back to basics: considerations in adjusting women. Top Clin Chiropr. 1997;4(3):1–10.
11. Chalker H.M. Spinal compensation of pregnancy. Am Chiropr. 1993;15(3):23–26.
12. Liew Z, Ritz B, Rebordosa C, Lee PC, Olsen J. Acetaminophen use during pregnancy, behavioral problems, and hyperkinetic disorders. JAMA Pediatr 2014;168:313-20.
13. Werler MM, Mitchell AA, Hernandez-Diaz S, Honein MA. Use of over-the-counter medications during pregnancy. Am J Obstet Gynecol 2005;193(3 Pt 1):771-7.
14. Bateman BT, Hernandez-Diaz S, Rathmell JP, Seeger JD, Doherty MS, Fischer MA, et al.  Patterns of opioid utilization in pregnancy in a large cohort of commercial insurance beneficiaries in the United States.  Anesthesiology 2014;120:1216-24.
15. King H.H., Tettambel M.A., Lockwood M.D., Johnson K.H., Arsenault D.A., Quist R. Osteopathic manipulative treatment in prenatal care: a retrospective case control design study. J Am Osteopath Assoc. 2003;103(12):577–582.