Effect on Neonatal Outcome of Pharmacological Interventions for Attenuation of the Maternal Haemodynamic Response to Tracheal Intubation: A Systematic Review

Abstract

The primary aim of this systematic review was to assess the effect on neonatal outcome of pharmacological interventions used for attenuation of the haemodynamic response to tracheal intubation in patients undergoing caesarean Section under general anaesthesia. A systematic search of randomised controlled trials from 1990 to 2015 was conducted. The primary outcome measure was the Apgar score at five minutes and secondary outcomes were umbilical arterial blood gas parameters and neurological adaptive capacity scores. Twenty-seven randomised controlled trials (1,689 patients) were included in the qualitative synthesis. Only five studies using opioids (383 patients) and five studies using non-opioid analgesics (358 patients) were subjected to meta-analysis. The Apgar score at five minutes was significantly lower in neonates of opioid-treated mothers (mean difference: −0.29, 95% confidence interval −0.56 to −0.02, P-value=0.03) compared to mothers in the control group; the umbilical arterial pH was lower and there was a higher requirement for tactile stimulation in neonates. No difference was seen in Apgar scores of neonates of mothers administered non-opioid analgesics compared to placebo. No difference was observed in other parameters between opioid- or non-opioid-treated mothers. This review suggests that opioid interventions for attenuation of the haemodynamic response to tracheal intubation in pregnant patients under general anaesthesia affect neonatal Apgar scores at five minutes in neonates but the difference did not appear to be clinically meaningful. We were unable to demonstrate any difference in safety.

Paracetamol preceding very preterm birth: Is it safe?

“…A large meta‐analysis confirmed increased risks for severe intracerebral hemorrhage, necrotizing enterocolitis, and periventricular leukomalacia after antenatal indomethacin exposure 8 . Another meta‐analysis of maternal opioid treatment found that the umbilical artery pH and 5‐min Apgar scores were lower and that the requirement for tactile stimulation of infants was higher upon opioid exposure 9 . Paracetamol has been used as a well‐tolerated option before delivery despite the lack of studies on intrauterine exposure and its acute effects on the perinatal transition.…”

“… 8 Another meta‐analysis of maternal opioid treatment found that the umbilical artery pH and 5‐min Apgar scores were lower and that the requirement for tactile stimulation of infants was higher upon opioid exposure. 9 Paracetamol has been used as a well‐tolerated option before delivery despite the lack of studies on intrauterine exposure and its acute effects on the perinatal transition. In the present study, prenatally administered paracetamol decreased the combined need for delivery room treatments (Table 2 ).…”

“…[6][7][8] A systematic review reported that maternal opioid use was associated with lower umbilical artery pH and a higher need for postnatal tactile stimulation in neonates. 9 Severe fetal consequences are well known for some maternal medications, whereas others (eg corticosteroids, magnesium infusions, antibiotics, and antiarrhythmic medications) have been used during pregnancy for the treatment or prevention of fetal or neonatal diseases. 10,11 Although the precise molecular mechanisms of action remain unknown, paracetamol inhibits the peroxidase subcomponent of the prostaglandin synthase enzyme and decreases prostaglandin synthesis.…”

“…Conversely, maternal indomethacin medication is associated with serious adverse reactions in neonates, including fetal ductus arteriosus contraction, severe intraventricular hemorrhage, periventricular leukomalacia, bronchopulmonary dysplasia, and necrotizing enterocolitis 6–8 . A systematic review reported that maternal opioid use was associated with lower umbilical artery pH and a higher need for postnatal tactile stimulation in neonates 9 . Severe fetal consequences are well known for some maternal medications, whereas others (eg corticosteroids, magnesium infusions, antibiotics, and antiarrhythmic medications) have been used during pregnancy for the treatment or prevention of fetal or neonatal diseases 10,11 …”

General Anesthesia with the Use of SUPREME Laryngeal Mask Airway for Emergency Cesarean delivery: A Retrospective Analysis of 1039 Parturients

“…As previous report 20 , a low dose fentanyl (50ug) exerts temporary depressant effects on fetal biophysical parameters at delivery. Albeit fentanyl was routinely used for induction and the time from skin incision to delivery was approximately 5 minutes, which may have the potential impact to neonates 21 , in a meta-analysis 22 , opioid interventions in parturient under GA affect neonatal at 5-min Apgar scores in neonates but appear no clinically meaning in safety, they could attenuate haemodynamic response for airway establishment and obstetric operation. It is a controversial practice but haemodynamic stability is required for parturient undergoing emergency cesarean delivery.…”