F. Bayoumeu

Colostrum morphine concentrations during postcesarean intravenous patient-controlled analgesia.

UNLABELLED Patient-controlled analgesia (PCA) with morphine is a convenient method for providing postoperative analgesia. Despite the fact that it is used after cesarean delivery, data on transfer of morphine and of its active metabolite morphine-6 glucuronide (M6G) into maternal milk are scarce. It is not known whether breast-feeding during PCA with morphine has neonatal implications. We sought to measure morphine and M6G concentrations in colostrum during postpartum IV PCA and evaluate the potential for drug intake by neonates being breast-fed by these mothers. Seven informed and consenting mothers, given IV PCA with morphine, were investigated. Plasma and milk samples were obtained at titration, and at 12, 24, 36, and 48 h. Morphine and M6G were measured by high-performance liquid chromatography. In plasma, morphine concentrations ranged from <1 to 274 ng/mL, M6G ranged from <5 to 974 ng/mL. In milk, opioids were found in only 3 patients in whom morphine concentrations ranged from <1 to 48 ng/mL and M6G from <5 to 1084 ng/mL. The milk-to-plasma ratio was always <1 for morphine. In conclusion, we observed very small morphine and M6G concentrations in colostrum during PCA with morphine. Under these conditions, the amounts of drug likely to be transferred to the breast-fed neonate are negligible. IMPLICATIONS Colostrum concentrations of morphine and its active metabolite morphine-6 glucuronide were measured in mothers receiving patient-controlled analgesia with morphine after cesarean delivery. The concentrations were found to be very small, thus supporting the safety of breast-feeding in mothers receiving IV patient-controlled analgesia with morphine.

Do prophylactic prostaglandins reduce the transfusion rate at cesarean section in high-order multiple pregnancies?

OBJECTIVE Cesarean section is the more usual mode of delivery in high-order multiple pregnancy (> or =3). Excessive uterine distension increases the risk of bleeding and the need for transfusion. The aim of this study was to investigate if prophylactic use of prostaglandins at cesarean section for high-order multiple pregnancies reduces blood loss and transfusion requirement based on historic data. STUDY DESIGN We studied a prospective series of 28 parturients with high-order multiple pregnancy (group 2) who were treated, after clamping the last umbilical cord, with oxytocin (5IU intravenous then 35IU in a 24h infusion) combined with intravenous prostaglandin. A comparable retrospective series of 14 patients (group 1) had been given oxytocin alone at the same dose. Postoperative serum hemoglobin and transfusion rate as well as adverse effects were compared between the two groups. Students t-test was used to compare continuous variables. Chi square test and Fisher exact test were used to compare categorical variables. RESULTS The two groups were comparable for anthropometric data and duration of pregnancy. None of the patients in group 2 required red cell transfusion while 21.4% of those in group 1 required transfusion. A significant lower decrease of postoperative haemoglobin is noted in group 2 (P=0.0006). Multivariate analysis using variables significant at univariate analysis and pre-eclampsia confirmed this difference. There were no adverse reactions to treatment. CONCLUSION In our experience, prophylactic prostaglandin infusion at cesarean section in high-order multiple pregnancy is associated with a lower need for per operative red cell transfusion and a higher postoperative hemoglobin level. This observation merits confirmation in larger studies.