Management of post-cesarean delivery analgesia: Pharmacologic strategies
Keywords:
Cesarean section, Pain postoperative, Analgesia, Drug therapy, Pharmacology
Abstract
Introduction:
Several analgesic modalities - pharmacological and non-pharmacological-may be used during the cesarean section postoperative period. This document focuses on the different pharmacological strategies available.
Objectives:
To establish the advantages and disadvantages of the various pharmacological options used to control pain following a C-section, improving safety and patient satisfaction.
Methods:
A search was done in Medline, Embase, Lilacs, and The Cochrane Library using the terms "Cesarean section", "Cesarean pain", "Maternal risk", and "Analgesia for cesarean", reviewing articles published in both English and Spanish during the last twenty years. Duplicated articles, redundant or irrelevant content, and articles with methodological flaws were excluded.
Results:
Neuraxial opioids are widely used in postoperative cesarean section analgesia. However, they have to administered at low doses to ensure the best risk-benefit profile. The use of systemic opioids is also appropriate in these patients, reducing the occurrence of some adverse events associated with intrathecal administration. Multimodal analgesia has proven its effectiveness in postoperative pain control after cesarean delivery, significantly reducing the use of opioids and their associated adverse effects.
Conclusions:
Notwithstanding the adverse effects described in the literature, the cornerstone of analgesia therapy after cesarean section are opioids, both neuraxial or parenteral administration. Multimodal management using NSAIDs or paracetamol, improves the safety profile and the quality of analgesia, reducing the opioid requirements.
References
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35. Momeni M, Crucitti M, De Kock M. Patient-controlled analgesia in the management of postoperative pain. Drugs. 2006;66:2321-37.
36. Alon E, Jaquenod M, Schaeppi B. Post-operative epidural versus intravenous patient-controlled analgesia. Minerva Anestesiol. 2003;69:443-6.
37. Gadsden J, Hart S, Santos AC. Post-cesarean delivery analgesia. Anesth Analg. 2005;101 Suppl.:S62-9.
38. Andziak M, Beta J, Barwijuk M, Issat T, Jakimiuk AJ. Efficacy and tolerability of intravenous morphine patient-controlled analgesia (PCA) in women undergoing cesarean delivery. Ginekol Pol. 2015;86:453-6.
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2. Pfuntner A, Wier LM, Stocks C. Most frequent procedures performed in U.S. Hospitals, 2010: statistical brief #149. Healthcare Cost and Utilization Project (HCUP) statistical briefs. Rockville, MD: Agency for Healthcare Research and Quality (US); 2006-2013.
3. Hamilton BE, Martin JA, Ventura SJ. Births: preliminary data for 2007. Hyattsville, MD: National Center for Health Statistics. NVSS. 2009;57:1-23. [
4. MacDorman M, Declercq E, Menacker F. Recent trends and patterns in cesarean and vaginal birth after cesarean (VBAC) deliveries in the United States. Clin Perinatol. 2011;38: 179-92.
5. Rubio-Romero JA, Fonseca-Pérez JE, Molina S, Buitrago Leal M, Zuleta JJ, Ángel-Müller E, et al. Racionalización del uso de la cesárea en Colombia. Consenso de la Federación Colombiana de Obstetricia y Ginecología (Fecolsog) y la Federación Colombiana de Perinatología (Fecopen). Rev Colomb Obstet Ginecol. 2014;65:139-51.
6. Betrán AP, Jianfeng Y, Moller AB, Zhang J, Gülmezoglu AM, Torloni MR. The increasing trend in caesarean section rates: global, regional and national estimates: 1990-2014. PLOS ONE. 2016;11:e0148343.
7. Ramires de Jesus G, Ramires de Jesus N, Peixoto-Filho FM, Lobato G. Caesarean rates in Brazil: what is involved? BJOG. 2015;122:606-9.
8. Eisenach JC, Pan PH, Smiley R, Lavand'homme P, Landau R, Houle TT. Severity of acute pain after childbirth, but not type of delivery, predicts persistent pain and postpartum depression. Pain. 2008;140:87-94.
9. Hawkins JL, Chang J, Palmer SK, Gibbs CP, Callaghan WM. Anesthesia-related maternal mortality in the United States: 1979-2002. Obstet Gynecol. 2011;117:69-74.
10. Sultan P, Gutierrez MC, Carvalho B. Neuraxial morphine and respiratory depression: finding the right balance. Drugs. 2011;71:1807-19.
11. Practice Guidelines for Obstetric An updated report by the American Society of Anesthesiologists Task Force on obstetric anesthesia and the society for obstetric anesthesia and perinatology. Anesthesiology. 2016;124:270-300.
12. Armstrong S, Fernando R. Side effects and efficacy of neuraxial opioids in pregnant patients at delivery: a comprehensive review. Drug Saf. 2016;39:381-99.
13. Carvalho B. Respiratory depression after neuraxial opioids in the obstetric setting. Anesth Analg. 2008;107:956-61.
14. Carvalho B, Butwick AJ. Postcesarean delivery analgesia. Best Pract Res Clin Anaesthesiol. 2017;31:69-79.
15. Davis KM, Esposito MA, Meyer BA. Oral analgesia compared with intra-venous patient-controlled analgesia for pain after cesarean delivery: a randomized controlled trial. Am J Obstet Gynecol. 2006;194:967-71.
16. Girgin NK, Gurbet A, Turker G, Aksu H, Gulhan N. Intrathecal morphine in anesthesia for cesarean delivery: dose-response relationship for combinations of low-dose intrathecal morphine and spinal bupivacaine. J Clin Anesth. 2008;20:180-5.
17. Wong JY, Carvalho B, Riley ET. Intrathecal morphine100 and 200µg for post-cesarean delivery analgesia: a trade-off between analgesic efficacy and side effects. Int J Obstet Anesth. 2013;22:36-41.
18. Sultan P, Halpern SH, Pushpanathan E, Patel S, Carvalho B. The effect of intrathecal morphine dose on outcomes after elective cesarean delivery: a meta-analysis. Anesth Analg. 2016;123:154-64.
19. De Carvalho FA, Tenório SB. Estudio comparativo entre dosis de morfina intratecal para analgesia después de la cesárea. Rev Bras Anestesiol. 2013;63:492-9.
20. Brill S, Gurman GM, Fisher A. A history of neuraxial administration of local analgesics and opioids. Eur J Anaesthesiol. 2003;20:682-9.
21. Herrera-Gómez PJ, Garzón JF. Opiáceos intratecales y depresión respiratoria: ¿un mito en obstetricia? Rev Colomb Anestesiol. 2015;43:101-3.
22. Practice guidelines for the prevention, detection, and management of respiratory depression associated with neuraxial opioid administration: an updated report by the American Society of Anesthesiologists Task Force on neuraxial opioids and the American Society of Regional Anesthesia and Pain Medicine. Anesthesiology. 2016;124:535-52.
23. Bonnet MP, Mignon A, Mazoit JX, Ozier Y, Marret E. Analgesic efficacy and adverse effects of epidural morphine compared to parenteral opioids after elective caesarean section: a systematic review. Eur J Pain. 2010;14, 894.e1-9.
24. Tan M. Post-cesarean analgesia. Trends Anest Crit Care. 2012;2:128-32.
25. Paech MJ, Pavy TJ, Orlikowski CE, Yeo ST, Banks SL, Evans SF, et al. Postcesarean analgesia with spinal morphine, clonidine, or their combination. Anesth Analg. 2004;98:1460e6.
26. Cossu AP, De Giudici LM, Piras D, Mura P, Scanu M, Cossu M, et al. A systematic review of the effects of adding neostigmine to local anesthetics for neuraxial administration in obstetric anesthesia and analgesia. Int J Obstet Anesth. 2015;24: 237-46.
27. Khezri MB, Ghasemi J, Mohammadi N. Evaluation of the analgesic effect of ketamine as an additive to intrathecal bupivacaine in patients undergoing cesarean section. Acta Anaesthesiol Taiwan. 2013;51:155-60.
28. Nasr IA, Elokda SA. Safety and efficacy of intrathecal adjuvants for cesarean section: bupivacaine, sufentanil, or dexmedetomidine. Ains Shams J Anaesth. 2015;8:388-95.
29. Nayagam HA, Singh NR, Singh HS. A prospective randomised double blind study of intrathecal fentanyl and dexmedetomidine added to low dose bupivacaine for spinal anesthesia for lower abdominal surgeries. Indian J Anaesth. 2014;58:430-5.
30. Safari F, Aminnejad R, Mohajerani SA, Farivar F, Mottaghi K, Safdari H. Intrathecal dexmedetomidine and fentanyl as adjuvant to bupivacaine on duration of spinal block in addicted patients. Anesth Pain Med. 2016;6:e26714.
31. Magdy H, Mohsen M, Saleh M. The effect of intrathecal compared with intravenous dexmedetomidin as an adjuvant to spinal bupivacaine anesthesia for cesarean section. Ain Shams J Anaesth. 2015;8:93-9.
32. Sun Y, Xu Y, Wang GN. Comparative evaluation of intrathecal bupivacaine alone, bupivacaine-fentanyl, and bupivacaine-dexmedetomidine in caesarean section. Drug Res. 2015;65:468-72.
33. Naaz S, Bandey J, Ozair E, Asghar A. Optimal dose of intrathecal dexmedetomidine in lower abdominal surgeries in average Indian adult. J Clin Diagn Res. 2016;10:UC09-13.
34. Gupta R, Verma R, Bogra J, Kohli M, Raman R, Kushwaha JK. A comparative study of intrathecal dexmedetomidine and fentanyl as adjuvants to bupivacaine. J Anaesthesiol Clin Pharmacol. 2011;27:339-43.
35. Momeni M, Crucitti M, De Kock M. Patient-controlled analgesia in the management of postoperative pain. Drugs. 2006;66:2321-37.
36. Alon E, Jaquenod M, Schaeppi B. Post-operative epidural versus intravenous patient-controlled analgesia. Minerva Anestesiol. 2003;69:443-6.
37. Gadsden J, Hart S, Santos AC. Post-cesarean delivery analgesia. Anesth Analg. 2005;101 Suppl.:S62-9.
38. Andziak M, Beta J, Barwijuk M, Issat T, Jakimiuk AJ. Efficacy and tolerability of intravenous morphine patient-controlled analgesia (PCA) in women undergoing cesarean delivery. Ginekol Pol. 2015;86:453-6.
39. Patel N, Bryant A, Duncan K, Kukreja P, Powell MF. Cost comparison of intrathecal morphine to intravenous patient-controlled analgesia for the first 24 h post cesarean delivery: a retrospective cohort study. J Anesth. 2017;31: 44-50.
40. López-Millán JM, Alcañiz JB, De las Mulas M. Analgesia del Trabajo de Parto con Remifentanilo por vía intravenosa mediante un Sistema de Analgesia Controlada por la Paciente (PCIA). Rev Soc Esp Dolor. 2007;14:416-21.
41. Morales Muñoz C, Albadejo Serrano A. Estudio descriptivo de la analgesia obtenida durante el trabajo de parto con PCA de remifentanilo: modelo británico. Rev Soc Esp Dolor. 2014;21:307-14.
42. Lam J, Kelly L, Ciszkowski C, Landsmeer ML, Nauta M, Carleton BC, et al. Central nervous system depression of neonates breastfed by mothers receiving oxycodone for postpartum analgesia. J Pediatr. 2012;160, 33-7.e2.
43. Seaton S, Reeves M, McLean S. Oxycodone as a component of multimodal analgesia for lactating mothers after Caesarean section: relationships between maternal plasma, breast milk and neonatal plasma levels. Aust N Z J Obstet Gynaecol. 2007;47:181-5.
44. Madadi P, Moretti M, Djokanovic N, Bozzo P, Nulma I, Ito S, et al. Guidelines for maternal codeine use during breastfeeding. Can Fam Physician. 2009;55, 1077-8. 45.
45. Edwards JE, Rudy AC, Wermeling DP, Desai N, McNamara PJ. Hydromorphone transfer into breast milk after intranasal administration. Pharmacotherapy. 2003;23:153-8.
46. Baka NE, Bayoumeu F, Boutroy MJ, Laxenaire MC. Colostrum morphine concentrations during postcesarean intravenous patient-controlled analgesia. Anesth Analg. 2002;94:184-7.
47. Hendrickson RG, McKeown NJ. Is maternal opioid use hazardous to breast-fed infants? Clin Toxicol. 2012;50: 1-14.
48. Anderson PO, Manoguerra AS, Valdés V. A review of adverse reactions in infants from medications in breastmilk. Clin Pediatr. 2016;55:236-44.
49. UNICEF. World Health Organization. Breastfeeding and maternal medication: recommendations for drugs in the eleventh WHO model list of essential drugs. Geneva, Switzerland: Department of Child and Adolescent Health and Development, World Health Organization; 2002. p. 1-35.
50. Maund E, McDaid C, Rice S, Wright K, Jenkins B, Woolacott N. Paracetamol and selective and non-selective non-steroidal anti-inflammatory drugs for the reduction in morphine-related side-effects after major surgery: a systematic review. Br J Anaesth. 2011;106:292-7.
51. Zeng AM, Nami NF, Wu CL, Murphy JD. The analgesic efficacy of nonsteroidal anti-inflammatory agents (NSAIDs) in patients undergoing cesarean deliveries. A meta-analysis. Reg Anesth Pain Med. 2016;41:763-72.
52. Berger JS, Gonzalez A, Hopkins A, Alshaeri T, Jeon D, Wang S, et al. Dose-response ofintrathecal morphine when administered with intravenous ketorolac for post-cesarean analgesia: a two-center, prospective, randomized, blinded trial. Int J Obstet Anesth. 2016;28:3-11.
53. Bozkurt N, Kurdoglu M, Kurdoglu Z, Kutlusoy F, Biberoglu K. Postoperative pain control after cesarean section: can diclofenac sodium be used instead of meperidine? J Matern Fetal Neonatal Med. 2009;22:1144-50.
54. Hyllested M, Jones S, Pedersen JL, Kehlet H. Comparative effect of paracetamol, NSAIDs or their combination in postoperative pain management: a qualitative review. Br J Anaesth. 2002;88:199-214.
55. Munishankar B, Fettes P, Moore C, McLeod GA. A double-blind randomised controlled trial of paracetamol, diclofenac or the combination for pain relief after caesarean section. Int J Obstet Anesth. 2008;17:9-14.
56. Valentine AR, Carvalho B, Lazo TA, Riley ET. Scheduled acetaminophen with as-needed opioids compared to as-needed acetaminophen plus opioids for post-cesarean pain management. Int J Obstet Anesth. 2015;24:210-6.
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How to Cite
1.
Ramos-Rangel GE, Ferrer-Zaccaro LE, Mojica-Manrique VL, González-La Rotta M. Management of post-cesarean delivery analgesia: Pharmacologic strategies. Colomb. J. Anesthesiol. [Internet]. 2017 Oct. 1 [cited 2024 Apr. 19];45(4):327–334. Available from: https://www.revcolanest.com.co/index.php/rca/article/view/561
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2017-10-01
How to Cite
1.
Ramos-Rangel GE, Ferrer-Zaccaro LE, Mojica-Manrique VL, González-La Rotta M. Management of post-cesarean delivery analgesia: Pharmacologic strategies. Colomb. J. Anesthesiol. [Internet]. 2017 Oct. 1 [cited 2024 Apr. 19];45(4):327–334. Available from: https://www.revcolanest.com.co/index.php/rca/article/view/561
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Narrative review
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