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Sobot Novakovic S, Uletilovic S, Mandic-Kovacevic N, Cvjetkovic T, Stojiljkovic MP, Skrbic R, Loncar-Stojiljkovic D. Comparative Effects of Target-Controlled Infusion of Propofol Versus Spinal and Thiopental-Sevoflurane Anesthesia on Lipid Peroxidation in Elective Cesarean Section: A Prospective, Open-Label Study. Cureus 2024; 16:e61995. [PMID: 38984000 PMCID: PMC11231961 DOI: 10.7759/cureus.61995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2024] [Indexed: 07/11/2024] Open
Abstract
BACKGROUND During pregnancy, physiological changes can increase oxidative stress (OS) in both mothers and fetuses. The use of anesthesia for cesarean sections (CSs) could exacerbate this stress due to its impact on the ischemia-reperfusion effect. Our study aimed to explore the effects of target-controlled infusion of propofol on OS during CSs, and to compare these effects with those of spinal and thiopental-sevoflurane anesthesia. METHODS The study included ninety parturients undergoing elective CS, allocated into three groups: Group S (spinal) (n = 30), Group P (propofol) (n = 30), and Group TS (thiopental-sevoflurane) (n = 30). Venous blood samples were taken from mothers at three time points, before, during, and after surgery, and one sample was taken from the umbilical vein after delivery. Blood samples were analyzed with the thiobarbituric acid reactive substances (TBARS) assay and blood gas analysis. A statistical comparison between groups was obtained by one-way analysis of variance (ANOVA) and the Wilcoxon test where appropriate. RESULTS Levels of TBARS after the induction of anesthesia were lower in all groups compared to values preoperatively. In Group P, TBARS levels started to decrease in the first five minutes after the induction (1.90 ± 0.47; P < 0.001) and had significantly lower values compared to Group S (2.22 ± 0.21) and Group TS (2.40 ± 0.20). Two hours after surgery, TBARS values were the lowest in Group P (1.76 ± 0.15, P<0.001), compared to Group S (2.18 ± 0.24) and Group TS (2.41 ± 0.21). TBARS value in umbilical venous blood was significantly lower in Group P (1.56 ± 0.16, P < 0.001) compared to Group S (2.18 ± 0.17) and Group TS (2.09 ± 0.09). Umbilical cord venous blood gas values (pH, PCO2, HCO3, lactates, and base excess (BE)) were not different between the groups, except for PO2, which was significantly lower in Group S (20.5 ± 5.0; P < 0.001) compared to Group P (36.5 ± 19.2) and Group TS (33.5 ± 10.1). CONCLUSION Target-controlled infusion of propofol anesthesia could be advantageous for parturients with compromised oxidative status, especially those undergoing emergency CSs when general anesthesia is required.
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Affiliation(s)
- Suzana Sobot Novakovic
- Anesthesiology and Critical Care, University Clinical Centre of the Republic of Srpska, Banja Luka, BIH
- Anesthesiology and Critical Care, Centre for Biomedical Research, Faculty of Medicine, University of Banja Luka, Banja Luka, BIH
| | - Snezana Uletilovic
- Medical Biochemistry and Chemistry, Centre for Biomedical Research, Faculty of Medicine, University of Banja Luka, Banja Luka, BIH
| | - Nebojsa Mandic-Kovacevic
- Pharmacy, Centre for Biomedical Research, Faculty of Medicine, University of Banja Luka, Banja Luka, BIH
| | - Tanja Cvjetkovic
- Medical Biochemistry and Chemistry, Centre for Biomedical Research, Faculty of Medicine, University of Banja Luka, Banja Luka, BIH
| | - Milos P Stojiljkovic
- Pharmacology, Toxicology and Clinical Pharmacology, Centre for Biomedical Research, Faculty of Medicine, University of Banja Luka, Banja Luka, BIH
| | - Ranko Skrbic
- Pharmacology, Toxicology and Clinical Pharmacology, Centre for Biomedical Research, Faculty of Medicine, University of Banja Luka, Banja Luka, BIH
| | - Dragana Loncar-Stojiljkovic
- Anesthesiology and Critical Care, Institute for Cardiovascular Diseases "Dedinje", Belgrade, SRB
- Anesthesiology and Critical Care, Centre for Biomedical Research, Faculty of Medicine, University of Banja Luka, The Republic of Srpska, Banja Luka, BIH
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Comparison of thiol disulfide values in the cord blood of patients undergoing cesarean section under spinal or general anesthesia. JOURNAL OF SURGERY AND MEDICINE 2022. [DOI: 10.28982/josam.1000340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background/Aim: Oxidative stress is known to increase in patients receiving anesthesia before undergoing surgery. Since newborns are more sensitive to oxygen-free radicals, the effects and characteristics of anesthesia methods that are used for pregnant women require analysis. This study aimed to evaluate the effects of spinal and general anesthesia on oxidative stress by investigating thiol disulfide and ischemia modified albumin (IMA) concentrations in the cord blood of patients undergoing cesarean section (C-section) via spinal or general anesthesia.
Methods: This cross-sectional prospective study included 60 patients who were indicated for elective cesarean section. Patients with chronic disease, pregnancy complications and/or required emergency cesareans were not included. Group 1 (n = 30) underwent general anesthesia, and Group 2 (n = 30) underwent spinal anesthesia during their C-sections. Thiol–disulfide levels were evaluated concurrently in all blood samples taken from the umbilical artery remaining on the placental side.
Results: The mean age (SD) of the mothers was 30.6 (4.4) years and the mean gestational age (SD) was 39.0 (0.9) weeks. Gestational age, birth weight, and first and fifth min Apgar scores of the two groups were similar. The mean (SD) native thiol (362.4 [63.8]; 323.2 [45.8]), total thiol (409.6 [70.2]; 363.5 [46.1]), and disulfide values (23.6 (5.4); 20.2 (4.3)) were significantly higher in group 1 than group 2, while the median (interquartile range [IQR]) values of IMA (0.89 (0.85-max 0.92); 0.85 (min 0.82-max 0.879) were significantly higher in group 2 than group 1 (P < 0.05).
Conclusions: As general anesthesia may cause a higher degree of oxidative stress, selecting the appropriate anesthetic technique may be especially important for risky pregnancies in which increased oxidative stress in the mother and baby may be critical for the outcome.
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Oksuz M, Abitagaoglu S, Kaciroglu A, Koksal C, Ozturk BY, Erel O, Senat A, Erdogan Ari D. Effects of general anaesthesia and ultrasonography-guided interscalene block on pain and oxidative stress in shoulder arthroscopy: A randomised trial. Int J Clin Pract 2021; 75:e14948. [PMID: 34614288 DOI: 10.1111/ijcp.14948] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Accepted: 10/04/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND/AIM The aim of this study was to evaluate the effects of general anaesthesia and ultrasonography-guided interscalene block on pain and oxidative stress evaluated by thiol-disulphide balance and C-reactive protein levels in patients undergoing shoulder arthroscopy. MATERIALS AND METHODS A total of 42 patients aged 18-75 years who were scheduled to undergo shoulder arthroscopy were randomised into interscalene block group (Group-IB, n = 20) and general anaesthesia group (Group-GA, n = 22). All patients received patient-controlled analgesia during the postoperative period. Additional analgesics were administered to patients with a visual analogue scale score of >4. Native-thiol, total-thiol, disulphide and C-reactive protein levels were measured. Patients' visual analogue scale scores, morphine and additional analgesic consumption were recorded. A shift in thiol-disulphide balance towards decreased thiol and increased disulphide levels was regarded as an indicator of oxidative stress. RESULTS Pain level, morphine and additional analgesic consumption were higher in Group-GA. Native-thiol and total-thiol levels were higher in Group-IB postoperatively and also disulphide levels were lower at postoperative 18 hours. C-reactive protein levels were similar in both the groups. CONCLUSION Interscalene block induced less oxidative stress during the postoperative period, as evaluated by thiol-disulphide balance. In shoulder arthroscopy, interscalene block provides more stable haemodynamics perioperatively and facilitates better postoperative pain control.
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Affiliation(s)
- Murat Oksuz
- Anesthesiology and Reanimation Department, University of Health Sciences Sancaktepe Şehit Prof. Dr. İlhan Varank Health Application and Research Center, Istanbul, Turkey
| | - Suheyla Abitagaoglu
- Anesthesiology and Reanimation Department, University of Health Sciences Fatih Sultan Mehmet Health Application and Research Center, Istanbul, Turkey
| | - Ahmet Kaciroglu
- Anesthesiology and Reanimation Department, University of Health Sciences Fatih Sultan Mehmet Health Application and Research Center, Istanbul, Turkey
- Ministery of Health Bursa City Hospital, Bursa, Turkey
| | - Ceren Koksal
- Anesthesiology and Reanimation Department, University of Health Sciences Fatih Sultan Mehmet Health Application and Research Center, Istanbul, Turkey
| | - Burak Yagmur Ozturk
- Orthopedic Surgery Department, University of Health Sciences Fatih Sultan Mehmet Health Application and Research Center, Istanbul, Turkey
| | - Ozcan Erel
- Biochemistry Department, Yıldırım Beyazıt University, Ankara, Turkey
| | - Almila Senat
- Biochemistry Department, Yıldırım Beyazıt University, Ankara, Turkey
| | - Dilek Erdogan Ari
- Anesthesiology and Reanimation Department, University of Health Sciences Fatih Sultan Mehmet Health Application and Research Center, Istanbul, Turkey
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Kahraman E, Cevik B, Tolga Saracoglu K. The effects of pre-emptive intravenous ibuprofen on the thiol/disulfide homeostasis and C-reactive protein level as the markers of oxidative stress and inflammation during gynecologic laparoscopy: A randomised clinical trial. Int J Clin Pract 2021; 75:e14872. [PMID: 34525247 DOI: 10.1111/ijcp.14872] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 08/16/2021] [Accepted: 09/10/2021] [Indexed: 11/27/2022] Open
Abstract
AIMS In this study, we aimed to investigate the anti-inflammatory and antioxidant effects of intravenous ibuprofen by using the C-reactive protein level and thiol/disulfide homeostasis as the oxidative stress marker. MATERIALS AND METHODS This study was conducted on 70 patients aged between 30 and 65 who were scheduled for elective laparoscopic hysterectomy. The patients were divided into two groups to receive either pre-emptive 800mg of intravenous ibuprofen plus 1000 mg of intravenous paracetamol (Group IP) or only 1000 mg of intravenous paracetamol as a control group (Group P). The blood samples for thiol/disulfide homeostasis were collected as follows: before induction of anesthesia (T0), before pneumoperitoneum (T1), following postdeflation and discontinuation of anesthesia (T2), and postoperative 24th hour (T3). Simultaneous blood samples for C-reactive protein (CRP) were also collected. The pre- and postoperative urea, creatinine, alanine aminotransferase (ALT), and aspartate aminotransferase (AST) levels were measured. RESULTS A total of 69 patients were included in the study. The patient's characteristics and intraoperative variables were comparable between groups (P > .05). The number of patients requiring rescue analgesia, the total amount of analgesic used, Visual Analog Scale (VAS) scores, and postoperative side effects were significantly lower in Group IP (P < .001). The decrease in native and total thiol levels at T1, T2, and T3 measurement points was significant in Group IP (P < .001). In both groups, the comparison to baseline values demonstrated no significant changes in terms of disulfide level (P > .05). The simultaneous CRP levels indicated a significant increase at the postoperative 24 hour in both groups (P < .001). The difference between groups was insignificant (P > .05). There was a significant increase in urea and creatinine levels in patients of Group IP (P < .05). CONCLUSION The pre-emptive administration of ibuprofen provided effective pain control after gynecologic laparoscopy. However, ibuprofen changed the thiol/disulfide homeostasis in favor of oxidation and had no beneficial effect in surgically induced oxidative stress.
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Affiliation(s)
- Ersin Kahraman
- The Department of Anesthesiology and Reanimation, University of Health Sciences, Kartal Dr. Lütfi Kırdar City Hospital, Istanbul, Turkey
| | - Banu Cevik
- The Department of Anesthesiology and Reanimation, University of Health Sciences, Kartal Dr. Lütfi Kırdar City Hospital, Istanbul, Turkey
| | - Kemal Tolga Saracoglu
- The Department of Anesthesiology and Reanimation, University of Health Sciences, Kartal Dr. Lütfi Kırdar City Hospital, Istanbul, Turkey
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Kazancioglu L, Batcik S, Arpa M, Erdivanli B, Ozergin Coskun Z, Celebi Erdivanli O, Bahceci I, Kazdal H, Erel O, Neselioglu S. Dynamic thiol/disulphide balance in patients undergoing hypotensive anesthesia in elective septoplasties. Int J Clin Pract 2021; 75:e14838. [PMID: 34519144 DOI: 10.1111/ijcp.14838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 09/08/2021] [Accepted: 09/10/2021] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE We aimed to investigate the effects of hypotensive anaesthesia on oxidative stress with serum thiol/disulphide balance in patients undergoing elective septoplasty procedures under general anaesthesia. METHODS Seventy-two patients between the ages of 18-60, with a physical condition I -II, according to the American Society of Anesthesiologists, were included in this prospective observational study. Septoplasty was chosen for standard surgical stress. According to the maintenance of anaesthesia, patients were divided into the groups as Hypotensive Anaesthesia (n = 40) and Normotensive Anaesthesia (n = 32). Serum thiol/disulphide levels were measured by the method developed by Erel & Neşelioğlu. RESULTS The native thiol and total thiol values of both groups measured at the 60th min intraoperatively were significantly lower than the preoperative values (both P < .01). Intraoperatively, at the 60th min, there was no significant difference in terms of post-native thiol and post-total thiol levels between hypotensive and normotensive anaesthesia groups (P = .68 and .81, respectively). Age >40 years and female gender were found to have a significant effect on dynamic oxidative stress (P = .002 and .001, respectively). CONCLUSION This pilot study has found that hypotensive anaesthesia had no adverse effect on dynamic thiol/disulphide balance in elective surgeries.
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Affiliation(s)
- Leyla Kazancioglu
- Department of Anesthesiology and Reanimation, Recep Tayyip Erdogan University, Rize, Turkey
| | - Sule Batcik
- Department of Anesthesiology and Reanimation, Recep Tayyip Erdogan University, Rize, Turkey
| | - Medeni Arpa
- Department of Medical Biochemistry, Recep Tayyip Erdogan University, Rize, Turkey
| | - Basar Erdivanli
- Department of Anesthesiology and Reanimation, Recep Tayyip Erdogan University, Rize, Turkey
| | | | | | - Ilkay Bahceci
- Department of Medical Microbiology and Clinical Microbiology, Recep Tayyip Erdogan University, Rize, Turkey
| | - Hizir Kazdal
- Department of Anesthesiology and Reanimation, Recep Tayyip Erdogan University, Rize, Turkey
| | - Ozcan Erel
- Department of Medical Biochemistry, Ankara Yildirim Beyazit University Medical Faculty, Ankara, Turkey
| | - Salim Neselioglu
- Department of Medical Biochemistry, Ankara Yildirim Beyazit University Medical Faculty, Ankara, Turkey
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Kutluhan H, Yuce Y, Geyık FD, Saracoglu KT, Cevik B. Stress response in vertebra surgery by total intravenous and inhalation anaesthesia. Int J Clin Pract 2021; 75:e14602. [PMID: 34228856 DOI: 10.1111/ijcp.14602] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 07/02/2021] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE We compared inhalational and total intravenous anaesthesia about haemodynamic stability and oxidative stress response in vertebral surgery. BACKGROUNDS AND METHODS Fifty-nine elective vertebral surgery patients were randomly divided into propofol (Group P) and desflurane (Group D) groups. Intraoperative haemodynamic parameters, preoperative and post-operative native thiol, total thiol, disulfide, C-reactive protein (CRP), albumin, cortisol and catalase levels were studied. RESULTS Post-operative native thiol and total thiol values in Group P were higher (P = .044 and P = .031). Post-operative albumin value in Group P was lower than the preoperative value (P < .001). The post-operative CRP and albumin values in Group D were lower than the preoperative value. The cortisol value was high (P = .03, P < .001 and P < .001). The post-operative albumin value in Group P was higher (P = .03). There is a positive correlation between CRP and disulfide values (P = .017), between albumin and native thiol values (P < .001), between total thiol value (P < .001), between the cortisol value and the disulfide/native thiol value (P = .002) and between native/total thiol value (P = .003) and a negative correlation between disulfide/native thiol value (P = .005), between disulfide/total thiol value (P = .003) and between the native/total thiol value (P = .001). CONCLUSION Dynamic thiol/disulfide haemostasis reflects oxidative stress. Propofol positively contributes to oxidative stress in elective vertebral surgery.
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Affiliation(s)
- Hilal Kutluhan
- Anaesthesiology and Reanimation Department, University of Health Sciences Kartal Dr. Lutfi Kirdar Education and Research Hospital, Istanbul, Turkey
| | - Yucel Yuce
- Anaesthesiology and Reanimation Department, University of Health Sciences Kartal Dr. Lutfi Kirdar Education and Research Hospital, Istanbul, Turkey
| | - Fatih Dogu Geyık
- Anaesthesiology and Reanimation Department, University of Health Sciences Kartal Dr. Lutfi Kirdar Education and Research Hospital, Istanbul, Turkey
| | - Kemal Tolga Saracoglu
- Anaesthesiology and Reanimation Department, University of Health Sciences Kartal Dr. Lutfi Kirdar Education and Research Hospital, Istanbul, Turkey
| | - Banu Cevik
- Anaesthesiology and Reanimation Department, University of Health Sciences Kartal Dr. Lutfi Kirdar Education and Research Hospital, Istanbul, Turkey
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Cavaliere F, Allegri M, Apan A, Calderini E, Carassiti M, Cohen E, Coluzzi F, Di Marco P, Langeron O, Rossi M, Spieth P, Turnbull D. A year in review in Minerva Anestesiologica 2019. Anesthesia, analgesia, and perioperative medicine. Minerva Anestesiol 2021; 86:225-239. [PMID: 32118384 DOI: 10.23736/s0375-9393.20.14424-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Franco Cavaliere
- Department of Cardiovascular and Thoracic Sciences, A. Gemelli University Polyclinic, IRCCS and Foundation, Sacred Heart Catholic University, Rome, Italy -
| | - Massimo Allegri
- Unità Operativa Terapia del Dolore della Colonna e dello Sportivo, Policlinic of Monza, Monza, Italy.,Italian Pain Group, Milan, Italy
| | - Alparslan Apan
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, University of Giresun, Giresun, Turkey
| | - Edoardo Calderini
- Unit of Women-Child Anesthesia and Intensive Care, Maggiore Polyclinic Hospital, Ca' Granda IRCCS and Foundation, Milan, Italy
| | - Massimiliano Carassiti
- Unit of Anesthesia, Intensive Care and Pain Management, Campus Bio-Medico University Hospital, Rome, Italy
| | - Edmond Cohen
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Department of Thoracic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Flaminia Coluzzi
- Unit of Anesthesia, Department of Medical and Surgical Sciences and Biotechnologies, Intensive Care and Pain Medicine, Sapienza University, Rome, Italy
| | - Pierangelo Di Marco
- Department of Cardiovascular, Respiratory, Nephrological, Anesthesiologic, and Geriatric Sciences, Sapienza University, Rome, Italy
| | - Olivier Langeron
- Department of Anesthesia and Intensive Care, Henri Mondor University Hospital, Sorbonne University, Assistance Publique-Hôpitaux de Paris, Créteil, France
| | - Marco Rossi
- Institute of Anesthesia and Intensive Care, Sacred Heart Catholic University, Rome, Italy
| | - Peter Spieth
- Department of Anesthesiology and Critical Care Medicine, University Hospital of Dresden, Dresden, Germany
| | - David Turnbull
- Department of Anaesthetics and Neuro Critical Care, Royal Hallamshire Hospital, Sheffield, UK
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Aparici-Gonzalo S, Carrasco-García Á, Gombert M, Carrasco-Luna J, Pin-Arboledas G, Codoñer-Franch P. Melatonin Content of Human Milk: The Effect of Mode of Delivery. Breastfeed Med 2020; 15:589-594. [PMID: 32721174 DOI: 10.1089/bfm.2020.0157] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Objective: Cesarean section rates are increasing in developed countries and could be performed as an emergency or elective procedure. Our research aim was to determine whether elective cesarean section influences the melatonin content, the main circadian hormone, in human milk. Methods: Twenty-one women after vaginal delivery and 18 women after elective cesarean section were included. Only healthy mothers with normal newborns exclusively breastfed were recruited. Two samples of human milk were collected for each woman at three stages of lactation: colostrum, transitional milk, and mature milk; at each stage, one daytime sample and another nighttime sample were obtained. In total, 228 milk samples were studied. The melatonin content was analyzed by enzyme-linked immunosorbent assay. Results: Melatonin rhythmicity with higher melatonin content at night was maintained at each of the three stages of lactation, regardless of the type of delivery. A higher melatonin content was found in daytime colostrum after cesarean section with respect to colostrum obtained from mothers after vaginal delivery (30.3 pg/mL versus 14.7 pg/mL, p = 0.020). Melatonin content decreased progressively throughout the course of lactation in both groups. This decrease was significant when comparing transitional milk to colostrum in the cesarean group, both in the daytime (p = 0.016) and nighttime samples (p = 0.048). Conclusions: Cesarean section is associated with an increase in daytime colostrum melatonin. No difference was observed in mature milk with respect to vaginal delivery. Melatonin values in human milk decrease during the first month of lactation and circadian rhythmicity was observed irrespective of the mode of delivery.
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Affiliation(s)
- Sonia Aparici-Gonzalo
- Department of Pediatrics, Pediatric Sleep Unit, Hospital Quironsalud, Valencia, Spain
| | - Álvaro Carrasco-García
- Department of Pediatrics, Obstetrics and Gynecology, University of Valencia, Valencia, Spain
| | - Marie Gombert
- Department of Pediatrics, Obstetrics and Gynecology, University of Valencia, Valencia, Spain.,Department of Biotechnology, University of La Rochelle, La Rochelle, France
| | - Joaquín Carrasco-Luna
- Department of Pediatrics, Obstetrics and Gynecology, University of Valencia, Valencia, Spain.,Department Experimental Sciences, Catholic University of Valencia, Valencia, Spain
| | - Gonzalo Pin-Arboledas
- Department of Pediatrics, Pediatric Sleep Unit, Hospital Quironsalud, Valencia, Spain
| | - Pilar Codoñer-Franch
- Department of Pediatrics, Obstetrics and Gynecology, University of Valencia, Valencia, Spain.,Department of Pediatrics, Dr. Peset University Hospital, Valencia, Spain.,Foundation for the Promotion of Health and Biomedical Research in the Valencian Region (FISABIO), Valencia, Spain
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