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Postcesarean Oxytocin Boluses of Low Benefit

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Postcesarean Oxytocin Boluses of Low Benefit June 15, 2007 • www.obgynnews.com Obstetrics 15 D RUGS, PREGNANCY, Postcesarean Oxytocin A ND L ACTATION Boluses of Low Benefit Hypnotic Sleep Aids BY KATE JOHNSON tocin in 500 mL of normal saline he physical discomforts of pregnancy imal data on the other nonbenzodiazepines Montreal Bureau over 30 minutes, followed by 20 U that are induced by the surge of prog- suggest low risk in pregnancy. Nevertheless, of oxytocin in 1 L of saline over Testerone and the expanding uterus will as with most drugs, the best course is to B ANFF, ALTA. — The routine the next 8 hours. result in nearly universal sleep deprivation in avoid them in the first trimester. Occasional practice of giving oxytocin bolus- “Our hypothesis was that the pregnancy. An increased need to urinate, nau- use during the second and third trimesters es to reduce the risk of postpartum bolus, given in addition to the in- sea and vomiting, heartburn, difficulty in find- probably is low risk, but long-term use (more hemorrhage appears to be of lim- fusion, would reduce the need for ing a comfortable sleeping position, and, as the than 4 weeks) should be avoided. Although ited benefit even in high-risk pa- additional drugs to contract the pregnancy progresses, the kicking and move- small amounts of these drugs are excreted tients after cesarean section, as uterus,” said Dr. King. Because ment of the fetus, all conspire against a good into milk, occasional, short-term use proba- long as an appropriate oxytocin previous studies have suggested night’s sleep. bly is compatible with breast-feeding. infusion is given, according to the that oxytocin may have little or no Prescribing sleeping medications in preg- Ǡ OTC antihistamines. There are two in this first randomized, placebo-con- effect in a low-risk population, nancy may not be the best solution because category, diphenhydramine (for example, Be- trolled trial of the practice, said Dr. study subjects were specifically se- long-term use can lead to habituation in the nadryl) and doxylamine (Unisom Nighttime Kylie King from Maitland (Aus- lected as being high risk for post- woman, as well as in her fetus. Sleep Aid). Diphenhydramine tralia) Hospital. partum hemorrhage. “Multiple However, patients will frequent- (risk factor B) is safe throughout The practice of administering gestations and macrosomia were ly seek drug therapy to help them gestation, as is doxylamine (risk oxytocin boluses has recently come the most common risk factors.” sleep, so it is essential to have ad- factor A). A major advantage of under scrutiny. “Although the ad- Overall, 53% of the cesarean equate knowledge of what is rel- these antihistamines is that both verse hemodynamic effects [of oxy- sections were elective, with 47% atively safe and what is not. have antiemetic properties that tocin boluses] are well document- classified as emergency proce- Hypnotics can be categorized can reduce pregnancy-induced ed, one recently reported death dures. The need for additional into five subclasses: barbiturates, nausea and vomiting. If pyridox- associated with a 10-U bolus in the uterotonics was high—between benzodiazepines, nonbenzodi- ine (vitamin B6) is taken with U.K. has prompted a change in 30% and 40% overall—confirming azepines, over-the-counter anti- doxylamine, the combination is dose from 10 to 5 units given slow- that the population was indeed histamines, and herbal and nat- the antiemetic most frequently ly,” she said at the annual meeting high risk, but need for more utero- ural products. studied in pregnancy. There is lit- of the Society for Obstetric Anes- tonics was similar in both groups Ǡ Oral barbiturates. In this BY GERALD G. tle or no experience with these BRIGGS, B.PHARM, thesia and Perinatology. “This begs as assessed by a surgeon who was group are aprobarbital (preg- FCCP agents during lactation. Although the question: Is a bolus necessary? blinded to the patients’ random- nancy risk factor C) (Alurate); some manufacturers consider Is 5 U the right dose? How slowly ization. In addition, there was no pentobarbital (D) (Nembutal); and secobar- them contraindicated during breast-feeding, should it be given? And might an difference between groups in the bital (D) (Seconal). Developmental toxicity the lack of toxicity reports suggests that these infusion be sufficient?” secondary outcomes of estimated has not been proven, but more studies are antihistamines probably are low risk for full- Her study, which was conducted blood loss, need for blood transfu- needed regarding the potential for behavioral term nursing infants. at British Columbia Women’s sion or hypotension. toxicity after long-term in utero exposure. Ǡ Natural products. Although about 50 nat- Hospital in Vancouver, compared “Even in a high-risk group, a 5- Their long elimination half-lives (24, 22-50, ural products are or have been advocated for 143 subjects: 70 received an intra- U bolus is of limited additional and 28 hours, respectively) can cause pro- sleep, few have enough data to recommend venous 5-U bolus of oxytocin, and benefit provided that an adequate longed sedation, or hangover. They are con- their use in pregnancy or lactation. Moreover, 73 received normal saline, given infusion is given,” concluded Dr. trolled substances with potential for abuse, the content and purity of natural products are over 30 seconds following cesare- King. “Getting a stronger initial which makes them more difficult to prescribe. generally unregulated. an section and cord clamping. contraction at 1 minute doesn’t re- Although they are excreted into milk in low Low risk: With these qualifications, the Both groups also received an duce the need for additional utero- amounts, they can be classified as compatible agents that appear to be low risk are gin- identical infusion of 40 U of oxy- tonics over the next 24 hours.” ■ with breast-feeding. seng (not Siberian), honey, nutmeg, oats, Ǡ Benzodiazepines. Estazolam (ProSom), and St. John’s wort. It should be noted, flurazepam (Dalmane), quazepam (Doral), though, that ginseng potentially can cause and temazepam (Restoril) are in this catego- hypertension and hypoglycemia. Ultralight Epidural Works as Both ry. Data on the use of these agents in preg- Avoid: Natural products that should be nancy are very limited. Although there has avoided in pregnancy and lactation are Infusion, Patient-Controlled Bolus been no proven association between any of American hellebore, butterbur or other these agents and birth defects, they probably petasites, kava, marijuana, melatonin B ANFF, ALTA. — Ultralight tology, is the first to compare out- have effects on the embryo or fetus similar to (available only as an orphan drug in the doses of epidural analgesia given ei- comes using an ultralight epidural diazepam (Valium), including neonatal motor United States), mugwort, passion flower, ther as a continuous infusion or as solution of 0.0625% bupivacaine depression (floppy infant syndrome) and/or quassia, rauwolfia, Siberian ginseng, patient-controlled boluses appear plus 2 mcg/mL fentanyl. Fifteen withdrawal when used in the third trimester. taumelloolch, tulip tree, and valerian. to result in comparable pain and nulliparous parturients requesting Moreover, all four agents are categorized as A nonpharmacologic approach is the best Apgar scores as well as medication epidural were randomized to the contraindicated (risk factor X) by their man- and safest course for pregnant patients with in- usage, according to the preliminary continuous-infusion epidural anal- ufacturers, so they should not be prescribed. somnia. If medications are required, occa- results of an ongoing study. gesia (CIEA) arm and received the Small amounts of quazepam and temazepam sional, short-term use is recommended; one of “Our numbers are very small solution at a dose of 14 L/hr. An- are excreted into milk, and the other two the OTC antihistamines is probably the best right now, but as soon as we get other 15 women were randomized agents are most likely in milk as well. Occa- choice. A nonbenzodiazepine agent, such as more I am sure we will see a sta- to PCEA and received an 8-mL/hr sional dosing during breast-feeding is proba- zolpidem would be my second choice. For tistical difference between the two background infusion of the same bly safe, but the long-term effects on a nurs- more information, clinicians can visit in terms of patient satisfaction,” solution with the option for 5-mL ing infant are unknown. www.babycenter.com, a Web site frequently predicted Dr. Maya Suresh, chief boluses on demand at a 5-minute Ǡ Nonbenzodiazepines. The five drugs in visited by women to obtain information about of obstetric anesthesiology at Bay- lockout interval, and an hourly lim- this category are chloral hydrate (for example, their pregnancies, including tips on sleeping lor College of Medicine, Houston. it of 26 mL, reported Dr. LaToya Somnote), ramelteon (Rozerem), zaleplon well. “I think patient-controlled epidur- Mason from the same institution, (Sonata), and low-dose (25-75 mg) trazodone al analgesia [PCEA] is advanta- who presented the study. (Desyrel), all risk factor C, and zolpidem MR. BRIGGS is pharmacist clinical specialist, geous to the patient because she is There was no statistically signif- (Ambien), which is risk factor B. The use for Women’s Pavilion, Miller Children’s Hospital, in control of her own pain. And, if icant difference between the sleep of the antidepressant trazodone is off la- Long Beach, Calif.; clinical professor of you are not called frequently to in- groups in umbilical artery pH bel, but the drug is sometimes combined pharmacy, University of California, San tervene or to trouble-shoot that scores, Apgar scores, or pain with other antidepressants for this purpose. Francisco; and adjunct professor of pharmacy, also adds to the provider’s satis- scores, said Dr. Mason. All patients As with the benzodiazepines, the human preg- University of Southern California, Los Angeles.
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