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Levobupivacaine use while Breastfeeding

Drugs containing Levobupivacaine: Chirocaine

Levobupivacaine Levels and Effects while Breastfeeding

Summary of Use during Lactation

Levobupivacaine has not ben studied during breastfeeding, but bupivacaine, which is the racemic mixture of levobupivacaine and dextrobupivacaine, has been studied. Bupivacaine levels in breastmilk are low, and it is not orally absorbed, amounts received by the infant are small and it has not caused any adverse effects in breastfed infants. Levobupivacaine is likely to be similar to bupivacaine during breastfeeding.

Bupivacaine during labor and delivery with other anesthetics and analgesics has been reported by some to interfere with breastfeeding. However, this assessment is controversial and complex because of the many different combinations of drugs, dosages and patient populations studied as well as the variety of techniques used. In contrast, epidural bupivacaine begun after clamping of the umbilical cord appears to enhance breastfeeding success because of improved pain control.

Drug Levels

Levobupivacaine is the levo isomer of bupivacaine, which is a racemic mixture of levo- and dextrobupivacaine.

Maternal Levels. Bupivacaine milk levels were measured in 5 women who were given epidural bupivacaine analgesia (dosage not stated) for vaginal delivery. Bupivacaine was undetectable (<20 mcg/L) in all samples taken at 2, 8, 24 and 48 hours postpartum.[1]

One woman received bupivacaine 50 mg intrapleurally, followed in 1 hour by a continuous infusion of 25 mg/hour for 5 days for operative and postoperative analgesia. Four milk samples were taken during the infusion. The milk bupivacaine level was 400 mcg/L at 6 hours after the bolus dose and approximately 200 mcg/L at 24, 48 and 72 hours after the bolus dose.[2]

Twenty-two women received epidural lidocaine 2% and bupivacaine 0.5% for pain control during cesarean delivery. Lidocaine dosage averaged 82 mg (range 25 to 168 mg). Average milk bupivacaine concentrations were 90 mcg/L at 2 hours after delivery, 60 mcg/L at 4 hours after delivery and 40 mcg/L at 12 hours after delivery.[3]

Infant Levels. One woman received bupivacaine 50 mg intrapleurally, followed in 1 hour by a continuous infusion of 25 mg/hour for 5 days for operative and postoperative analgesia. Breastfeeding resumed postoperatively 22 hours after the start of the infusion. A serum sample taken from the infant 5 hours after the morning feeding on day 3 postoperatively (52.5 hours after the bolus dose) contained undetectable (lower limit not stated) amounts of bupivacaine by gas chromatography.[2]

Effects in Breastfed Infants

Bupivacaine administered to the mother by intrapleural or epidural routes had no effect on 13 breastfed infants.[3]

Possible Effects on Lactation

Thirty women who delivered by cesarean section received either spinal anesthesia (not defined) alone (n = 15) or spinal anesthesia plus bupivacaine (n = 15) by extradural infusion after clamping the umbilical cord. A bupivacaine bolus of 12.5 mg was followed by a continuous infusion of 17.5 mg/hour for 3 days postpartum. Patients who received bupivacaine had better pain relief as indicated by lower pain scores and a lower consumption of supplemental diclofenac for pain. Bupivacaine-treated patients also produced more milk per day than the untreated women, a difference that was statistically significant from day 3 to the end of the study on day 11 postpartum. The authors concluded that improved pain relief improved breastfeeding performance.[4]

Twenty women who delivered by cesarean section received either bupivacaine alone or bupivacaine plus buprenorphine by extradural infusion after clamping the umbilical cord. A bupivacaine bolus of 12.5 mg was followed by a continuous infusion of 17.5 mg/hour for 3 days. The buprenorphine was given as a bolus of 200 mcg followed by 8.4 mcg/hour for 3 days. Patients started breastfeeding as soon as they were able to sit up. Both the amount of milk fed and infant weight increased in both groups over the first 10 days postpartum; however, the increases were greater in those who received bupivacaine alone.[3][5]

A prospective cohort study compared women who received no analgesia (n = 63) to women who received continuous epidural analgesia with fentanyl and either bupivacaine 0.05 to 0.1% (n = 39) or ropivacaine (n = 13) during labor and delivery. The total dosage of bupivacaine was 31 to 62 mg and the average total infusion time from start to delivery was 219 minutes. The study found no differences between the groups in breastfeeding effectiveness or infant neurobehavioral status at 8 to 12 hours postpartum or the number exclusively or partially breastfeeding at 4 weeks postpartum.[6]

A randomized, prospective study measured infant breastfeeding behavior following epidural or intravenous fentanyl during delivery in 100 multiparous mothers undergoing cesarean section and delivering fullterm, healthy infants. The epidural group received epidural bupivacaine 100 mg initially, followed by a continuous infusion of 25 mg/hour. The intravenous fentanyl group received a spinal injection of 15 to 20 mg of bupivacaine. A slight difference was seen in breastfeeding behavior between the groups, with the infants in the intravenous fentanyl group performing slightly worse than those in the epidural group. However, all mothers were able to breastfeed their infants at 24 hours. None had severe breastfeeding problems; 10 women in the epidural group reported mild or moderate problems and 7 women in the intravenous group reported breastfeeding problems. Twenty mothers in the epidural group and 14 in the intravenous group used supplemental bottle feeding, with the difference not statistically significant.[7]

A randomized, but nonblinded, study in women undergoing cesarean section compared epidural anesthesia with bupivacaine to general anesthesia with intravenous thiopental 4 mg/kg and succinylcholine 1.5 mg/kg for induction followed by nitrous oxide and isoflurane. The time to the first breastfeed was significantly shorter (107 vs 228 minutes) with the epidural anesthesia than with general anesthesia. This difference was probably caused by the anesthesia's effects on the infant, because the Apgar and neurologic and adaptive scores were significantly lower in the general anesthesia group of infants.[8]

A national survey of women and their infants from late pregnancy through 12 months postpartum compared the time of lactogenesis II in mothers who did and did not receive pain medication during labor. Categories of medication were spinal or epidural only, spinal or epidural plus another medication, and other pain medication only. Women who received medications from any of the categories had about twice the risk of having delayed lactogenesis II (>72 hours) compared to women who received no labor pain medication.[9]

A nonrandomized convenience sample of women who did (n = 209) or did not (n = 157) receive epidural analgesia during labor was analyzed to determine whether epidurals affected the onset of lactation. Although not standardized, the typical procedure used sufentanil 10 to 15 mg together with either ropivacaine 0.1% or levobupivacaine 0.0625% epidurally, supplemented by epidural boluses of ropivacaine 0.1% or levobupivacaine 0.0625% about every 2 hours. No difference was found in the time of lactation onset between the two groups. Although women in both groups stated they wished to breastfeed prior to delivery, exclusive breastfeeding at 20 days postpartum was less frequent in the women who received an epidural (43%) than in women who did not (57%).[10]

Alternate Drugs to Consider

Lidocaine, Ropivacaine

References

1. Naulty JS, Ostheimer G et al. Bupivacaine in breast milk following epidural anesthesia for vaginal delivery. Reg Anesth. 1983;8:44-5. Abstract.

2. Baker PA, Schroeder D. Interpleural bupivacaine for postoperative pain during lactation. Anesth Analg. 1989;69:400-2. PMID: 2774239

3. Ortega D, Viviand X et al. Excretion of lidocaine and bupivacaine in breast milk following epidural anesthesia for cesarean delivery. Acta Anaesthesiol Scand. 1999;43:394-7. PMID: 10225071

4. Hirose M, Hara Y et al. The effect of postoperative analgesia with continuous epidural bupivacaine after cesarean section on the amount of breast feeding and infant weight gain. Anesth Analg. 1996;82:1166-9. PMID: 8638785

5. Hirose M, Hosokawa T, Tanaka Y. Extradural buprenorphine suppresses breast feeding after cesarean section. Br J Anaesth. 1997;79:120-1. PMID: 9301399

6. Chang ZM, Heaman MI. Epidural analgesia during labor and delivery: effects on the initiation and continuation of effective breastfeeding. J Hum Lact. 2005;21:305-14. PMID: 16113019

7. Goma HM, Said RN, El-Ela AM. Study of the newborn feeding behaviors and fentanyl concentration in colostrum after an analgesic dose of epidural and intravenous fentanyl in cesarean section. Saudi Med J. 2008;29:678-82. PMID: 18454213

8. Sener EB, Guldogus N, Karakaya D et al. Comparison of neonatal effects of epidural and general anesthesia for cesarean section. Gynecol Obstet Investig. 2003;55:41-55. PMID: 12624551

9. Lind JN, Perrine CG, Li R. Relationship between use of labor pain medications and delayed onset of lactation. J Hum Lact. 2014;30:167-73. PMID: 24451212

10. Mauri PA, Contini NN, Giliberti S, Barretta F, Consonni D, Negri M et al. Intrapartum epidural analgesia and onset of lactation: A prospective study in an Italian birth centre. Matern Child Health J. 2014. PMID: 24894732

Levobupivacaine Identification

Substance Name

Levobupivacaine

CAS Registry Number

27262-47-1

Drug Class

  • Anesthetics, Local

Administrative Information

LactMed Record Number

709

Information from the National Library of Medicine's LactMed Database.

Last Revision Date

2014-07-03

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