Douleur périnéale du post-partum : intérêt de l’infiltration locale de ropivacaïne

Ropivacaine perineal infiltration for postpartum pain management in episiotomy repair: a double-blind, randomised, placebo-controlled trial

OBJECTIVE

To investigate whether perineal infiltration of ropivacaine after episiotomy would decrease the incidence of postpartum pain compared with placebo.

DESIGN

Two-centre, double-blind, randomised, controlled trial.

SETTING

Two French maternity units, October 2017 to April 2020.

POPULATION

272 women undergoing epidural analgesia with vaginal singleton delivery and mediolateral episiotomy at term (≥37 weeks) were randomly allocated perineal infiltration of ropivacaine (n = 135) or placebo (n = 137) in a 1:1 ratio before episiotomy repair.

METHODS

Patients were followed at short term (12, 24, 48 h), mid-term (day 7) and long-term (3 and 6 months).

MAIN OUTCOME MEASURES

The primary outcome was the rate of perineal pain, defined by a Numerical Pain Rating Scale (NPRS) exceeding 3/10, in the mid-term (day 7) postpartum period. Secondary outcomes were perineal pain (NPRS) and analgesic intake, quality of life (SF-36), postpartum depression (EPDS), pain neuropathic component (DN4) and sexual health (FSFI).

RESULTS

Perineal pain occurred to an equal extent in the ropivacaine and placebo groups at day 7 (34.2% versus 30.4%, odds ratio 1.1, 95% confidence interval 0.7-1.8, p = 0.63). Similar results were recorded in the short and long term. High rates of dyspareunia and postpartum depression were documented in both groups. No differences were highlighted between the groups in terms of analgesic intake, adverse events, pain neuropathic component and postpartum quality of life.

CONCLUSIONS

This study did not demonstrate any benefit of ropivacaine infiltration over placebo.

Ropivacaine versus lidocaine infiltration for postpartum perineal pain: A systematic review and meta-analysis

AIM

To systematically and meta-analytically examine the efficacy of ropivacaine versus lidocaine infiltration for controlling postpartum perineal pain secondary to spontaneous tear or selective episiotomy.

METHODS

We searched four databases from inception to 20-September-2020. We included all relevant randomized and nonrandomized studies and assessed their risk of bias. We pooled data as standardized mean difference (SMD), weighted mean difference (WMD), or odds ratio (OR) with 95 % confidence intervals (95 % CIs).

RESULTS

Four studies met the inclusion criteria (one and three studies were nonrandomized and randomized, respectively). There were 405 patients; 205 and 200 patients received lidocaine and ropivacaine, respectively. There was no significant difference between ropivacaine and lidocaine groups with regard to visual analogue scale (VAS) pain scores at suturing (WMD = -0.04, 95 % CI [-0.41, 0.32], P = 0.82), 2 h (SMD = -1.50, 95 % CI [-3.50, 0.50], P = 0.14), and 24 h (SMD = -0.40, 95 % CI [-1.15, 0.34], P = 0.29) post repair of perineal trauma. Proportion of patients with mild VAS pain score ≤3 at 24 h was significantly higher in the ropivacaine group (OR = 4.34, 95 % CI [2.03, 9.29], P < 0.001). Proportion of patients who did not require additional analgesia during the first 24 h post perineal repair did not significantly differ between both groups (OR = 2.44, 95 % CI [0.09, 68.21], P = 0.60). Ropivacaine group achieved higher maternal satisfaction (OR = 7.13, 95 % CI [3.63, 13.99], P < 0.001).

CONCLUSIONS

During repair of postpartum perineal trauma, pain efficacy is relatively longer with ropivacaine but safety is not well investigated. High-quality and large-sized studies are needed to consolidate these findings.

Ropivacaine 75 mg versus placebo in perineal infiltration for analgesic efficacy at mid- and long-term for episiotomy repair in postpartum women - the ROPISIO study: a two-center, randomized, double-blind, placebo-controlled trials

Background

Perineal pain due to episiotomy is commonly reported and can be severe enough to disturb the mother–infant dyad during the postpartum period. Its incidence at day 7 postpartum varies from 63% to 74%. Recent studies have investigated the analgesic efficacy of perineal infiltration of ropivacaine after episiotomy but have only focused on the immediate postpartum period (at 24 and 48 h after birth). Large, adequately powered, multicenter, randomized controlled trials are required to evaluate the impact of ropivacaine infiltration on perineal pain and mid- and long-term quality of life before the widespread use of ropivacaine to prevent perineal pain after episiotomy can be recommended.

Methods/design

The ROPISIO study is a two-center, randomized, double-blind, placebo-controlled trial being conducted in La Roche sur Yon and Nantes, France. It will involve 272 women with vaginal singleton delivery and mediolateral episiotomy at term (≥ 37 weeks). Perineal infiltration (ropivacaine 75 mg or placebo) will be administrated just after vaginal birth and before episiotomy repair. The primary outcome will be the analgesic efficacy at day 7 postpartum (midterm), defined by the Numeric Pain Rating Scale (NPRS) strictly superior to 3/10 on the perineal repair area. Secondary outcomes will be the analgesic efficacy (NPRS) and the impact of pain on daily behavior, on the quality of life (36-item Short Form Health Survey), on the occurrence of symptoms of postpartum depression (Edinburgh Postnatal Depression Scale), and on sexual health (Female Sexual Function Index) at 3 and 6 months (long-term) using validated online questionnaires. This study will have 90% power to show approximately 30% relative risk reduction in the incidence of perineal pain at day 7, from 70.0% to 50.0%.

Discussion

Ropivacaine is a promising candidate drug, inexpensive, and easy to administer, and it would be suitable to include in the routine management of deliveries in labor ward. This study will investigate if perineal ropivacaine infiltration just after birth can reduce mid- and long-term postpartum pain and increase quality of life in women with mediolateral episiotomy.

Trial registration

ClinicalTrials.gov, NCT03084549. Registered on 14 April 2017.

Lignocaine Versus Ropivacaine Infiltration for Postpartum Perineal Pain

Background:

Millions of women worldwide undergo postpartum perineal repair under local infiltration. Inadequate postpartum pain management can negatively impact a mother's physical and psychological recovery.

Aims:

To study and compare the analgesic effect and maternal satisfaction with lignocaine versus ropivacaine infiltration for postpartum perineal pain relief.

Materials and Methods:

After clearance from the Institutional Ethics Committee, a double-blind prospective randomized study carried out on 100 parturients of aged 18–40 years who had spontaneous vaginal delivery, comparing 1% lignocaine and 0.75% ropivacaine infiltration for the repair of selective episiotomy or perineal injury. Time of the first analgesic (TFA) demand, maternal satisfaction at 24 h, and visual analog scale (VAS) pain score were studied.

Statistical Analysis:

Chi-square test and Student's t-test were used and P < 0.05 was considered as significant.

Results:

VAS pain score was significantly lower at 2 and 4 h in ropivacaine group versus lignocaine group (P < 0.0001). Significantly, longer TFA (10.2 ± 1.54 vs. 2.20 ± 0.44 h, P < 0.0001) and higher percentage of maternal satisfaction (86% vs. 44%) were observed in ropivacaine as compared to lignocaine group (P < 0.0001).

Conclusions:

Prolonged analgesia and higher rate of maternal satisfaction were found when ropivacaine infiltration was used for perineal repair as compared to lignocaine.

Lidocaine versus ropivacaine for perineal infiltration post-episiotomy

OBJECTIVE

To evaluate maternal analgesia after an episiotomy during delivery.

METHODS

The present case-control study compared 2 protocols of post-episiotomy infiltration: period A, 20 mL of lidocaine 10mg/mL; period B, 20 mL of ropivacaine 7.5mg/mL. The primary study endpoint was the visual analog scale (VAS) score at 24 hours after episiotomy; secondary endpoints were the VAS scores during suturing and at 2 and 48 hours, and patient satisfaction at 48 hours.

RESULTS

In total, 102 women were included in the study. The median VAS score at 24 hours was significantly lower during the ropivacaine period (3 [1.5-4]) than during the lidocaine period (4 [2-6]; P=0.004). A VAS score below 4 at 24 hours was significantly more frequent with ropivacaine (71% versus 43%; P=0.009). The VAS scores at 2 and 48 hours were also lower in the ropivacaine group (2 hours, 0 [0-1] versus 1 [0-3], P=0.01; and 48 hours, 2 [0-3] versus 3 [2-5], P<0.001). Maternal satisfaction was significantly higher in the ropivacaine group.

CONCLUSION

Analgesia and maternal satisfaction were improved during the period when ropivacaine was used as opposed to lidocaine. The effect lasted for up to 48 hours.