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Oral Concurrent Session 2 - Clinical Obstetrics and Quality

Oral Concurrent Sessions

Oral Concurrent Session 2 - Clinical Obstetrics and Quality

(20) Decreased Neuraxial Morphine Dose to Reduce Opioid Side Effects and use After Cesarean Delivery RCT

Thursday, January 30, 2025
1:45 PM – 2:00 PM  
Location: Aurora Ballroom B, Lobby Level

    Submitting Author and Presenting Author(s)

  • Ayodeji Sanusi, MD, MPH (he/him/his)

    Assistant Professor, Maternal Fetal Medicine
    Center for Women’s Reproductive Health, University of Alabama at Birmingham
    Birmingham, Alabama, United States

    • Coauthor(s)

  • YX

    Yumo Xue, PhD

    University of Alabama at Birmingham
    Birmingham, Alabama, United States

  • Kevin S. Shrestha, MD, MPH

    Fellow
    University of Alabama at Birmingham
    Birmingham, Alabama, United States

  • Ayamo Oben, MD, MPH

    Attending Physician, Maternal Fetal Medicine
    Maternal Fetal Consultants of Houston
    Houston, Texas, United States

  • HH

    Hanna Hussey, MD

    Assistant Professor
    University of Alabama at Birmingham
    Birmingham, Alabama, United States

  • AN

    Annalese Neuenschwander, MD

    Assistant Professor
    University of Alabama at Birmingham
    Birmingham, Alabama, United States

  • MT

    Michelle Tubinis, MD

    Assistant Professor
    University of Alabama at Birmingham
    Birmingham, Alabama, United States

  • MP

    Mark Powell, MD

    Assistant Professor
    University of Alabama at Birmingham
    Birmingham, Alabama, United States

  • Alan T. Tita, MD, PhD (he/him/his)

    Professor/Senior Associate Dean Obstetrics & Gynecology-Maternal Fetal Medicine
    University of Alabama at Birmingham
    Birmingham, Alabama, United States

  • CB

    Casey Brian, MD

    Professor of Obstetrics & Gynecology
    West Virginia University
    Morgantown, West Virginia, United States

Objective: 1 in 300 opioid naive women become persistent opioid users after cesarean delivery (CD). Regional anesthesia with neuraxial morphine (NM) reduces opioid consumption after surgery. However, >70% of patients have pruritus or urinary retention with the standard 150mcg NM dose. We assessed if reduced NM dose decreases opioid side effects while preserving pain control at CD.

Study Design: RCT of 85 patients undergoing scheduled CD at a US tertiary center. Exclusion criteria were quadratus lumborum (QL) block refusal, preeclampsia, insulin-treated diabetes, placental abnormalities or opioid use disorder. Primary exposure was NM dose. The intervention was 50 mcg NM, bilateral ultrasound-guided QL block, spinal 12 mg bupivacaine and 15mcg fentanyl. The control group received 150 mcg NM and adjunctive therapies above. Scheduled acetaminophen/NSAIDS and additional opioid therapy for breakthrough pain were available for both groups. Primary outcomes were opioid use 24hours prior to discharge and opioid side effects (recorded medications or urinary retention). Regression models estimated risk ratios/differences for outcomes between groups. Analyses were intent to treat.

Results: :

Of 85 eligible patients, 43(50.6%) were randomized to 50mcg NM and 42(49.4%) to 150mcg NM. The mean age and BMI were 30.3 ± 5.6yrs and 36.0 ± 8.1kg/m
2

, and >95% had a low transverse hysterotomy. There were no significant differences in baseline characteristics between groups. Lower NM dose did not significantly reduce opioid side effects (itching RR 0.55, 95% CI 0.27-1.10; nausea/vomiting RR 0.90, 95% CI 0.45-1.80), or use 24 hours prior to discharge (RD -1.63, 95% CI -8.47-5.21). Among secondary outcomes, total OMEs were similar between groups. However, intervention group had higher OMEs for parenteral opioids and in the first 24hours, as well as higher recovery room and day of surgery pain scores. No significant differences in other secondary outcomes were noted.

Conclusion: Lower NM dose was not associated with significant reductions in opioid side effects or use 24hours prior to discharge.