Neuraxial opioids and the newborn. Petter Kainu 7.10.11 SOAT, Tartto. Epidural analgesia in the latent phase of labor and the risk of cesarean delivery: a five-year randomized controlled trial. Wang F. Shen X. Guo X. Peng Y. Gu X. Labor Analgesia Examining Group.
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Neuraxial opioids and the newborn Petter Kainu 7.10.11 SOAT, Tartto
Epidural analgesia in the latent phase of labor and the risk of cesarean delivery: a five-year randomized controlled trial. • Wang F. Shen X. Guo X. Peng Y. Gu X. Labor Analgesia Examining Group. • Anesthesiology 2009. 111(4):871-80
Labour analgesia and the baby: good news is no newsFelicity Reynolds, IJOA 2011
Backround • newborn is very sensitive to opioids • newborn metabolizes opioids slowly • no balancing pain
Assessing newborn • Apgar-scores • are developed originally to assess drug-influence • unsensitive • Neonatal acid-base status • reflects the function of placenta • reflects poorly drug influences
Assessing newborn • NACS (Neurologic and Adaptive Capacity Scoring System) + and other scoring systems • muscular tone, reactivity ,reaction to different stimuli • beginning of spontaneous breathing • pCO2 • pulseoximetry • drug concentrations from blood samples
Kinetics of epidural opioid • epidurally administered opioids enter rapidly circulation • lipophilic opioids rapidly cross the placenta • ion trapping (acidotic fetus)
Kinetics of epidural opioid • if ≥ 150-200 µg of fentanyl is used, the baby has measurable amouts of fentanyl in circulation • Epidural fentanyl in labour. Carrie LE. O'Sullivan GM. Seegobin R. Anaesthesia 1981. 36(10):965-9 • if epidural-infusions are used, fentanyl does not seem to accumulate • Maternal and neonatal fentanyl and bupivacaine concentrations after epidural infusion during labor. Bader AM. Fragneto R. Terui K. Arthur GR. Loferski B. Datta S. Anesthesia & Analgesia 1995. 81(4):829-32
Epidural opioid & respiratory depression • case reports • Epidural Opioid Analgesia and Neonatal Respiratory Depression.Kumar M, Paes B. Journal of Perinatology 2003. 23(5):425-7
Epidural opioid & NACS • with epid-/iv-opioid. vs no analgesic in some studies babies have had lower NACS • Maternal analgesia during labor disturbs newborn behavior: effects on breastfeeding, temperature, and crying. Ransjo-Arvidson AB. Matthiesen AS. Lilja G. Nissen E. Widstrom AM. Uvnas-Moberg K. Birth 2001. 28(1):5-12 • observational study (n=28) • unmedicated infants were more active (video recorded and analyzed by experts)
Epidural opioid & NACS • Effect of labor epidural analgesia with and without fentanyl on infant breast-feeding: a prospective, randomized, double-blind study. Beilin Y. Bodian CA. Weiser J. Hossain S. Arnold I. Feierman DE. Martin G. Holzman I. Anesthesiology 2005: 103(6):1211-7 • when ≥ 150 μg fentanyl was used, NACS were slightly lower (p=0,03)
Breast feeding & epidural analgesia • the initiation of breast feeding is crucial for breast feeding to be succesfull • if infant is less active or ”tired” the interaction may become disturbed • opioid may supress activity of the infant
Breast feeding & epidural analgesia • Breast-feeding problems after epidural analgesia for labour: a retrospective cohort study of pain, obstetrical procedures and breast-feeding practices. Volmanen P. Valanne J. Alahuhta S. International Journal of Obstetric Anesthesia 2004. 13(1):25-9
Volmanen et al. • only part of the epidurals had fentanyl • bupivacaine?
The impact of intrapartum analgesia on infant feeding. Jordan S. Emery S. Bradshaw C.Watkins A. Friswell W. International Journal of Obstetrics & Gynaecology 2005. 112(7):927-34 • retrospective review, 18165 pts
Intrapartum epidural analgesia and breastfeeding: a prospective cohort studyTorvaldsen S. Roberts CL. Simpson JM. Thompson JF. Ellwood DA.International Breastfeeding Journal 2006, 1:24 • n=1280
Epidural analgesia and breastfeeding: a randomised controlled trial of epidural techniques with and without fentanyl and a non-epidural comparison group. Wilson M. J. A. MacArthur C. Cooper G. M. Bick D. Moore P. A. S. Shennan A. Anaesthesia 2010. 65(2):145-153
n=1064 • Study groups: • Low dose infusion-group (LDI group): bolus (30 µg fent +15 mg bupiv in 15 ml), followed by infusion (10 ml/h) • CSE-group: Spinal (Bup 5mg + Fent 25 µg) follwed by epidural infusion as in LDI-group • Control group: Epidural bolus (15 mg bup without fentanyl), infusion without fentanyl • Two comparison groups without epidural analgesia (pethidin/no pethidin- not randomized) • Rescue medication: • Control group: Epidural fentanyl 50µg • Results: • Epidural fentanyl did not affect breast feeding • Pethidine had negative influence on breast feeding
Conclusions • epidural labour analgesia/opioid can influence infant • serious influences are unlikely • breast feeding seems to be adversely affected • most studies are non-randomized cohort studies • except • Beilin et al 2005 • Wang et al 2009 • Wilson et al 2010
Conclusions • Editorial in Anesthesiology in regard to Beilin study: • ”We should continue to use medications that are known to be effective and are satisfactory to patients, and provide the best obstetric outcome possible.” • Obstetric Anesthesia Diggest: • ”As lower consentrations of local anesthetic are assosiated with many benefical effects for mother and baby, fentanyl should not be discarded based on weak links.”
Reynolds F:Labour analgesia and the baby: good news is no news.International Journal of Obstetric Anesthesia 2011. 20(1):38-50 ”The effect on breast feeding has yet to be established, though it is certainly no worse than that of systemic opioid analgesia.”
However, • should we restrict larger doses of epidural opioids? • not > 150 µg of fentanyl?