Yvonne Jelting

Incidence and severity of chronic pain after caesarean section: A systematic review with meta-analysis.

BACKGROUND The frequency of caesarean section has increased dramatically in recent decades. Despite this, robust data regarding the consequences of caesarean section in terms of developing chronic postsurgical pain (CPSP) are still lacking. OBJECTIVE This systematic review analysed the incidence and severity of CPSP in women 3 to less than 6, 6 to less than 12, and at least 12 months after caesarean section. DESIGN Systematic review of prospective and retrospective observational studies and randomised controlled trials with meta-analysis. DATA SOURCE We searched MEDLINE to May 2015. ELIGIBILITY CRITERIA We included all studies investigating the incidence and/or severity of CPSP at least 3 months after caesarean section. The primary outcome was chronic postsurgical wound pain (CPSP ‘wound’). Secondary outcomes were persistent pain in the back area, pelvic region or reported as residual pain, and severity of ‘birth-related’ chronic pain. RESULTS Meta-analysis using the random-effects model based on 15 studies (n = 4475) reporting CPSP ‘wound’ at 3 to less than 6 months after caesarean section revealed an incidence of 15.4% [95% confidence interval (CI): 9.9 to 20.9%]. For 6 to less than 12 and at least 12 months after caesarean section, the incidence of CPSP ‘wound’ was estimated at 11.5% (95% CI: 8.1 to 15.0%, n = 3345) and 11.2% (95% CI: 7.4 to 15.0%, n = 3451), respectively. Meta-regression analysis using the publication year as predictor revealed stable CPSP ‘wound’ incidences at each postoperative time slot from 2002 to the present. Of those patients who reported chronic pain, 9.6% (95% CI: 0.0 to 21.0%) had severe pain, 23.5% (95% CI: 10.0 to 37.0%) had moderate pain and 49.2% (95% CI: 18.9 to 79.4%) had mild pain at 6 months. LIMITATIONS Major limitations are high statistical heterogeneity of the meta-analyses and inconsistencies in reporting severity of chronic ‘birth-related’ pain. CONCLUSION This meta-analysis finds a clinically relevant incidence of CPSP ‘wound’ after caesarean section ranging from 15% at 3 months to 11% at 12 months or longer that has been largely stable in recent years.

Patient-controlled analgesia with remifentanil vs. alternative parenteral methods for pain management in labour: a Cochrane systematic review

We aimed to assess the effectiveness of remifentanil used as intravenous patient‐controlled analgesia for the pain of labour. We performed a systematic literature search in December 2015 (updated in December 2016). We included randomised, controlled and cluster‐randomised trials of women in labour with planned vaginal delivery receiving patient‐controlled remifentanil compared principally with other parenteral and patient‐controlled opioids, epidural analgesia and continuous remifentanil infusion or placebo. The primary outcomes were patient satisfaction with pain relief and the occurrence of adverse events for mothers and newborns. We assessed risk of bias for each included study and applied the GRADE approach for the quality of evidence. We included total zero event trials, using a constant continuity correction of 0.01 and a random‐effect meta‐analysis. Twenty studies were included in the qualitative analysis; within these, 3713 participants were randomised and 3569 analysed. Most of our pre‐specified outcomes were not studied in the included trials. However, we found evidence that women using patient‐controlled remifentanil were more satisfied with pain relief than women receiving parenteral opioids (four trials, 216 patients, very low quality evidence) with a standardised mean difference ([SMD] 95%CI) of 2.11 (0.72–3.49), but were less satisfied than women receiving epidural analgesia (seven trials, 2135 patients, very low quality evidence), −0.22 (−0.40 to −0.04). Data on adverse events were sparse. However, the relative risk (95%CI) for maternal respiratory depression for patient‐controlled remifentanil compared with epidural analgesia (three trials, 687 patients, low‐quality evidence) was 0.91 (0.51–1.62). Compared with continuous intravenous infusion of remifentanil (two trials, 135 patients, low‐quality evidence) no conclusion could be reached as all study arms showed zero events. The relative risk (95%CI) of Apgar scores less than 7 at 5 min after birth compared with epidural analgesia (five trials, 1322 participants, low‐quality evidence) was 1.26 (0.62–2.57).

Predictive risk scores for post-discharge nausea and vomiting: Simple lessons learned for improving clinical practice.

Postoperative nausea and vomiting (PONV) is still a frequently observed clinical problem in patients undergoing surgery with general anaesthesia, and thus is an issue of ongoing research and debate. Approximately, one in three patients with no prior prophylaxis has to face this complication during the first day after an operation. In the majority of cases, PONV occurs during the first 24 h postoperatively with a peak occurring in the immediate postoperative hours.

Preventing nausea and vomiting in women undergoing regional anesthesia for cesarean section: challenges and solutions

Background Intraoperative nausea and vomiting (IONV) or postoperative nausea and vomiting (PONV) affecting women undergoing regional anesthesia for cesarean section is an important clinical problem since these techniques are used widely. There are burdens of literature about IONV/PONV and several in parturient and cesarean. However, it needs more attention. The underlying mechanisms of IONV and PONV in the obstetrical setting mainly include hypotension due to sympathicolysis during neuraxial anesthesia, bradycardia owing to an increased vagal tone, the visceral stimulation via the surgical procedure and intravenously administered opioids. Methods Given the high and even increasing rate of cesarean sections and the sparse information on the etiology, incidence and severity of nausea and vomiting and the impact of prophylactic measures on the incidence of PONV/IONV, this article aims to review the available information and provide pragmatic suggestions on how to prevent nausea and vomiting in this patient cohort. Current literature and guidelines were identified by electronic database searching (MEDLINE via PubMed and Cochrane database of systematic reviews) up to present, searching through reference lists of included literature and personal contact with experts. Discussion and conclusion Taking into account the current guidelines and literature as well as everyday clinical experience, the first step for decreasing the incidence of IONV and PONV is a comprehensive management of circulatory parameters. This management includes liberal perioperative fluid administration and the application of vasopressors as the circumstances require. By using low-dose local anesthetics, an additional application of intrathecal or spinal opioids or hyperbaric solutions for a sufficient controllability of neuraxial distribution, maternal hypotension might be reduced. Performing a combined spinal–epidural anesthesia or epidural anesthesia may be considered as an alternative to spinal anesthesia. Antiemetic drugs may be administered restrainedly due to off-label use in pregnant women for IONV or PONV prophylaxis and may be reserved for treatment.

Drugs for preventing postoperative nausea and vomiting in adults after general anaesthesia: a network meta-analysis

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To compare the efficacy and safety of different prophylactic pharmacological interventions (antiemetic drugs) either against no treatment, placebo or against each other (as mono- or combination prophylaxis) for the prevention of postoperative nausea and vomiting in adults undergoing any type of surgery under general anaesthesia. To explore the best dose or dose range of the antiemetic drugs in terms of efficacy and safety. To generate a clinically useful ranking of antiemetic drugs (mono- and combination prophylaxis) according to efficacy and safety.