Sarah Bruyn Jones

Pain medications are a common prescription for post-cesarean care, but little scientific evidence exists proving which drug is most effective.

Researchers from the Cochrane Pregnancy and Childbirth Group concluded that the data for oral painkillers is insufficient and called for larger, better-designed studies that could shed light on the safest and most effective way to manage post-cesarean pain.

- Little scientific evidence is available when it comes to understanding the safest and most effective way to treat post-cesarean pain, according to a 

For the meta-analysis, the authors identified just eight studies involving a combined 962 women. However, only half the studies were deemed “high quality,” and those were all small, each involving between 40 and 136 women.

“Due to limited data available, no conclusions can be made regarding the safest and the most effective form of oral analgesia for post-caesarean pain,” the authors concluded. “Further studies are necessary. More research is needed to compare different types of painkillers and in relation to different outcomes such as safety, efficacy and cost.”

The authors found no data on important secondary outcomes, such as number of postoperative hospital days, re-hospitalization due to incisional pain, fully breastfeeding on discharge, mixed feeding at discharge, pain at the incision site 6 weeks post-cesarean, maternal postpartum depression, effect (negative) on mother and baby interaction, and cost of treatment.

The analysis attempted to compare non-opioid, opioid, and a combination of oral tablets with placebo or no treatment. However, there was insufficient evidence to determine the effect of additional painkillers (pills or injections) among women who took opioid or non-opioid or combination painkillers in comparison to placebo.

In addition, the analysis couldn’t even answer the question of what type of analgesia-opioid, non-opioid, or a combination of painkillers-offers the best pain relief.

When looking at non-opioid drugs, the researchers found some evidence that use of gabapentin resulted in less need for additional pain relief compared with placebo, but the analysis of data for other tablets (celexocib, ibuprofen, ketoprofen, naproxen, and acetaminophen [paracetamol]) gave more uncertain results.

Prescribing acetaminophen plus codeine resulted in less need for additional pain relief in comparison to placebo. Also, both high and low doses of gabapentin, and a high dose of ketoprofen, were more effective than placebo in relation to the need for additional pain relief.

Still, a low dose of ketoprofen, as well as high and low doses of tramadol, did not differ with placebo in terms of pain control.

Articles

A meta-analysis sought to determine which oral painkillers were most effective after a c-section, but the findings were disappointing.

Which Oral Drug Is Best for Post-Cesarean Pain?

A cell-free fetal DNA screening test for Down syndrome proved to be more sensitive and have a lower false-positive rate than the standard screening measures for younger, low-risk women, researchers found.

 is the largest to show cell-free DNA tests for trisomy 21 are accurate in even low-risk women. Previously, most tests have focused on older women who are at increased risk of having a baby with Down syndrome. For this study, the mean maternal age was 30.7 years, and the mean gestational age at testing was 12.5 weeks.

While the researchers suggested that the test could reduce the need for more invasive testing, such as amniocentesis, they noted that it does not replace diagnostic testing. Instead, because of fewer false-positive results and a higher positive predictive value than the current standard test, they said the test's accuracy should reduce the number of unnecessary follow-up diagnostic tests.

- Using a cell-free fetal DNA blood test was more accurate in identifying trisomy 21 in younger, low-risk pregnant women than the current standard test.

The investigators compare the performance of standard screening for trisomy 21, which involves the measurement of nuchal translucency and biochemical analytes, with results obtained from cell-free DNA testing in nearly 16,000 pregnancies with well-documented outcomes. All testing occurred between 10 and 14 weeks' gestation. The cell-free DNA test identified all 38 cases of Down syndrome, compared with 30 detected by standard screening.

There were 9 false-positive results from the cell-free DNA screening, but that was significantly better than the standard testing. They found that the cell-free DNA test had a false-positive rate of 0.06%, compared with a false-positive rate of 5.4% for standard screening.

The cell-free DNA test was not accurate in detecting all chromosomal defects, however. For nearly 500 women who underwent cell-free DNA testing, the screening was not able to provide any results because there was not enough fetal DNA in the pregnant women’s blood. Additional testing also showed that 2.7% of fetuses had chromosomal defects, including those that could not have been detected by the new cell-free fetal DNA technique.

The study was funded by Ariosa Diagnostics, which makes the cell-free DNA test. The test is expected to be heavily promoted by Roche, which markets the test under the name Harmony Prenatal Test.

Cell-free fetal DNA screening tests for trisomy 21 are more accurate than standard screening with nuchal translucency even in low-risk women.

Cell-Free DNA Screening for Trisomy 21

Both men and women are at increased risk for major depression during fertility treatment, California researchers found. A previous diagnosis of major depression is a key risk factor in predicting who may be most at risk.

- Men and women are at increased risk for major depression during fertility treatments.

- The biggest predictor of a major depressive disorder during fertility treatment is a history of depression.

Investigators at San Francisco State University looked at 174 women and 144 of their male partners who did not have a successful child-related outcome during the 18 months of the study. They found 39.1% of the women and 15.3% of the men met the criteria for major depressive disorder (MDD). That is significantly higher than the US annual prevalence rate for MDD, which is 8.4% for women and 5.2% for men.

The researchers suggest that their findings could help inform clinicians on how to best screen couples for depression during fertility treatments.

"The things that are typically assessed, such as whether you are feeling down or anxious when treatment begins, can be really useful information, but our research shows that a past history of MDD is actually a stronger indicator of whether a fertility patient will develop MDD during treatment," said Sarah Holley, PhD, the lead author of the study, in a news release. "This suggests it would be useful to include an assessment of a history of MDD as part of a pre-treatment screener."

A pre-screening could help ensure that proper counseling and support are in place for both men and women during the fertility treatment process, she said.

Past depression came up as a major predictor even when researchers controlled for other well-known risk factors, such as baseline levels of depression, anxiety, and partner support.

Unsuccessful fertility treatment takes a toll on both partners, and knowing their mental health history can help predict depression risk.

Depression Risk and Fertility Treatment

An adjustable single-incision sling for treating urinary incontinence was less painful postoperatively than the standard synthetic midurethral sling placed via the transobturator route (TVT-O), according to recently published results of a randomized trial.

The study, conducted in The Netherlands, was an early assessment of a new transobturator device called Ajust, which does not require penetration of the external obturator and adductor muscles of the upper leg for proper placement. The new sling is being compared with the standard TVT-O, in the hopes of reducing postoperative pain while maintaining results.

- A new adjustable single-incision sling device for treating urinary incontinence proved to have lower postoperative pain scores when compared with the standard TVT-O, a recent study found.

The single-blinded, controlled study allocated 156 women with stress urinary incontinence to receive either an adjustable single incision using Ajust or TVT-O. Those who received the Ajust sling reported lower early postoperative pain scores using a visual analog scale, according the published results in 

In the first week postoperatively, the mean pain score was significantly lower at all time points for women in the adjustable single-incision sling group compared with the TVT-O group. However, there was no statistical difference in the use of pain medication, the authors reported.

The study also compared cure rates for both procedures, finding them to be comparable (90.8% for the adjustable single-incision sling vs 88.6% for the transobturator sling). There were no differences in complication rates for either device.

Because placing a synthetic midurethral sling using the transobturator approach is associated with more groin pain than the retropubic TVT approach, the new device aims to reduce pain associated with the procedure, according to information filed with the Netherlands Trial Register. The primary benefit of the transobturator approach, compared with the retropubic approach, is that the risk of bladder perforation is minimal.

“The groin pain is most likely due to perforation of the external obturator and adductor muscles of the upper leg,” the trial information explains. “The new transobturator device Ajust does not penetrate these muscles and is therefore in theory less painful as compared to the TVT-O, with the benefit of reducing the risk of bladder perforation as compared to the retropubic TVT.”

 looked at data on postoperative pain for up to six weeks after the procedure and involved weekly telephone interviews with patients.

A new adjustable single-incision bladder sling placed via the transobturator route for women with stress urinary incontinence shows promise.

New Sling Causes Less Pain after UI Surgery

Ultrasound should be the primary imaging tool when examining women who present with pelvic symptoms, a group of 7 physicians urge in the 

American Journal of Obstetrics & Gynecology.

Not only is ultrasound safe, it is significantly more cost-effective than other imaging modalities, the authors argued in support of a broader campaign of the American Institute of Ultrasound Medicine (AIUM), which urges to “put ultrasound first.”

- Clinicians should utilize ultrasounds before any other imaging technologies when investigating the source of pelvic pain in women.

The recommendation, which is spelled out in an opinion piece that published online March 31, suggests that for women presenting with things such as pelvic pain, masses, flank pain, should first have an ultrasound. Too often clinicians send women for CT scans, which are more costly and involve unnecessary radiation.

"This recommendation applies particularly to obstetric and gynecologic patients,” explained lead author and AIUM president Beryl R. Benacerraf, MD, Clinical Professor in Obstetrics, Gynecology, and Reproductive Biology and Radiology at Harvard Medical School, and Brigham and Women's Hospital, in a news release. “A skillfully performed and well-interpreted ultrasound usually eliminates the need to perform additional more costly and complex cross-sectional imaging techniques.”

CT and MRI of the pelvis can provide indeterminate and confusing findings that only then lead to a need for an ultrasound to better clarify the results, she explained.

In supporting their argument, the authors also point to the major advances in ultrasound technology, including 3D volume imaging, real-time evaluation of pelvic organs along with a physical examination with the transvaginal ultrasound transducer, and Doppler blood flow mapping.

"Doing a CT scan first for female patients with lower abdominal pain is dangerous, wasteful, and expensive," noted Benacerraf. "We must educate the medical community to consider adopting 3D ultrasound as the first assessment tool for specific gynecologic indications, such as evaluating the uterus for MÃ¼llerian anomalies or localization of IUDs or other intracavitary lesions."

OB/GYNs should begin with ultrasound to examine women presenting with pelvic symptoms, urges a physician group.

Ultrasound Best for Investigating Pelvic Symptoms

Using liposomal bupivacaine to control pain in patients after gynecological surgery reduced the amount of narcotics needed and may lead to faster recovery times, a recent study found.

In the study, which included about 400 surgical patients, researchers compared the efficacy of liposomal bupivacaine and bupivacaine hydrochloride (HCl) for controlling postoperative pain after laparotomy for gynecological malignancies. Sean C. Dowdy, MD, clinical director for the National Surgical Quality Improvement Program for the Department of Surgery at Mayo Clinic, presented the results at the annual meeting of the Society of Gynecologic Surgeons.

- The use of liposomal bupivacaine, compared with use of bupivacaine HCl, following gynecologic surgery decreased the need for narcotics and reduced the use of patient-controlled analgesia.

Bupivacaine HCl treats pain for about 6 to 8 hours, whereas liposomal bupivacaine works for multiple days. Unsurprisingly, the researchers found that patients who received liposomal bupivacaine following complex cytoreductive surgery required significantly fewer doses of intravenous opioids during the first and second postoperative days than those whose pain was managed with bupivacaine HCl. They also continued to use less opioids for the remainder of their hospitalization. The median stay was 5 days.

During the first day following surgery, 21.5% of the patients treated with liposomal bupivacaine required opioids, while 46.9% of patients who received bupivacaine HCI were given opioids to control pain. By day two, just 7.4% of patients treated with liposomal bupivacaine were given opioids compared with 27.2% in the other group.

Still, the researchers also found that the pain scores were the same between the two groups.

Similarly, when the researchers looked at opioid use among women who underwent staging laparotomy, they found that pain scores were similar between those who received liposomal bupivacaine and those who were given bupivacaine HCl. However, they also found that the cumulative opioid use didn’t differ between the two cohorts.

Still, the data pointed to a reduction in use of patient-controlled analgesia among those who were treated with liposomal bupivacaine (1.4% vs 8.3%, P=.05). This was also found among women who underwent cytoreductive surgeries, with 4.1% of the women treated with liposomal bupivacaine using patient-controlled analgesia compared with 33.3% of women in the control group.

The research is part of an ongoing post-operative approach at the Mayo Clinic to get patients eating, drinking, and walking faster. By limiting narcotic use, the researchers believe common adverse effects, such as constipation and nausea, are reduced, allowing for a speedier recovery.

Data from the Mayo Clinic study was presented during the 

Use of a certain form of bupivacaine for pain control after gynecological surgery reduced the amount of opioids needed and may reduce recovery time.