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The addition of neostigmine - a drug used in the treatment of the rare disease myasthenia gravis - may improve the quality of epidural pain relief, according to the new research, led by Dr. James Eisenach of Wake Forest University School of Medicine, Winston-Salem, N.C.
After a pilot study to establish the safety of epidural neostigmine, the researchers performed a randomized trial in 40 women giving birth by planned caesarean section. All patients received patient-controlled epidural analgesia using the local anaesthetic bupivacaine. Half of the women received a combination of neostigmine plus bupivacaine; the rest received bupivacaine alone.
The pilot study showed no ill effects of neostigmine in either the mother or foetus. In the randomized trial, women receiving neostigmine used significantly less local anaesthetic - 19% less, on average, than women receiving epidural bupivacaine without neostigmine. For women who required epidural analgesia for four hours or longer, the difference was 25%. Both groups had excellent pain control, despite the lower dose of local anaesthetic.
Neostigmine may have caused some mild sedation in the mothers, but there were no problems with nausea. All other outcomes - including the foetal heart rate, a key indicator of the baby's well-being during labour - were similar with or without bupivacaine.
Anaesthesiologists in developed countries primarily provide analgesia for women in labour by giving them an epidural anaesthetic, which blocks the pain of labour contractions from reaching the spinal cord and brain. Epidural anaesthesia almost always consists of a cocktail comprised of a local anaesthetic, such as bupivacaine, and a morphine-like drug, such as fentanyl. However, these opioid drugs can cause significant side effects, including abnormalities of the foetal heart rate.
The new study suggests that adding neostigmine instead of opioids can improve the quality of epidural pain relief for women in labour, while decreasing the amount of local anaesthetic required. "This represents an important advance in providing safe and effective pain relief for women in labour, because it may allow anaesthesiologists to replace the morphine-like drugs with less toxic drugs such as neostigmine," according to an accompanying editorial by Dr. Cynthia Wong of Northwestern University, Chicago. However, Dr. Eisenach notes that large safety studies are still needed provide assurance that neostigmine itself has an adequate safety profile to permit widespread clinical use.
