neuraxial opioids and the newborn · –maternal analgesia during labor disturbs newborn behavior:...

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 news

Felicity 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 study Torvaldsen 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?

More studies are warranted!