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Epinephrine Pregnancy and Breastfeeding Warnings

Epinephrine is also known as: Adrenaclick, Adrenalin, Adrenalin Chloride, Ana-Guard, Asthmahaler, Auvi-Q, Bronchial Mist with Pump, Bronitin, Bronkaid Mist, Epi EZ Pen, EpiPen, EpiPen 2-Pak, EpiPen Auto-Injector, EpiPen JR 2-Pak, EpiPen JR Auto-Injector, EpiPen Jr, Medihaler-Epi, Primatene Mist, Sus-Phrine Injection, Twinject, Twinject Auto-Injector, Twinject Auto-Injector Two Pack

Epinephrine Pregnancy Warnings

Epinephrine has been assigned to pregnancy category C by the FDA. Animal studies have revealed evidence of teratogenicity when epinephrine was given in doses approximately 25 times the usual recommended human dose (on a per kg basis). There are no reports of teratogenicity in humans. There are no controlled data in human pregnancy. Epinephrine is only recommended for use during pregnancy when benefit outweighs risk.

Because epinephrine is an endogenous catecholamine its relationship to adverse pregnancy outcomes is difficult to determine. Moreover, it is usually only used in dire situations that may otherwise portend fetal risk, such as shock, allergic reactions, and severe bronchial asthma. Epinephrine crosses the human placenta and may, in high concentrations, cause both maternal and fetal glycogenolysis and elevated blood glucose concentrations. Animal data indicate that epinephrine may cause decreased placental blood flow, increasing the risk of fetal hypoxemia. There has been an interesting debate in the medical literature as to whether endogenous epinephrine and other vasoactive substances play an etiologic role in placental insufficiency, preeclampsia or toxemia of pregnancy. Data from the Collaborative Perinatal Project (CPP), in which 50,282 mother-child pairs were retrospectively examined, reveal a survival- and race-standardized relative risk for any malformation associated with epinephrine and any sympathomimetic agent of 1.99 and 1.30, respectively. These data are based on an incidence of 22 malformed children from 189 cases (of the 50,282 pairs) where there was first trimester exposures to epinephrine. These data reveal evidence of an association between the use of epinephrine and congenital malformations, although underlying diseases were not accounted for in the analysis. Data from the Michigan Medicaid Birth Defects Study (MMBDS) reveal no evidence of an association between the use of epinephrine and congenital malformations (written communication, Franz Rosa, MD, Food and Drug Administration, 1994). The MMBDS is a retrospective study of 229,101 deliveries between 1985 and 1992. Of the 229,101 deliveries, 35 were exposed to epinephrine during the first trimester. No defects were observed. Epinephrine has been extensively and safely used to prolong the analgesic effect of epidurally administered local anesthetics during human pregnancy. In vitro data have shown that epinephrine increases placental lactate production and increases placental glycogenolysis. While some in vitro data have shown that epinephrine stimulates the spontaneous contractile activity of the nonpregnant uterus, in vivo data have shown that the drug may inhibit uterine contractions and prolong the first stage of labor.

See references

Epinephrine Breastfeeding Warnings

There are no data on the excretion of epinephrine into human milk. The manufacturer states that epinephrine is excreted into human milk. The manufacturer recommends that due to the potential for serious adverse effects in nursing infants, a decision should be made to discontinue nursing or discontinue the drug, taking into account the importance of the drug to the mother.

See references

References for pregnancy information

  1. Holdcroft A "Use of adrenaline in obstetric analgesia." Anaesthesia 47 (1992): 987-90
  2. Davies J, Robson JM, Sullivan FM "Effects of drugs on placental function and their relation to congenital abnormalities." Proc R Soc Med 62 (1969): 317-8
  3. Levinson G, Shnider SM "Vasopressors in obstetrics." Clin Anesth 10 (1973): 77-109
  4. Cartwright PD, McCarroll SM, Antzaka C "Maternal heart rate changes with a plain epidural test dose." Anesthesiology 65 (1986): 226-8
  5. Greenburger PA "Management of asthmaduring pregnancy." N Engl J Med 313 (1985): 518
  6. Oyston J, Prince G "Epinephrine and the obstetric epidural test dose." Anesthesiology 66 (1987): 571-3
  7. Altenburger KM "Management of asthma during pregnancy." N Engl J Med 313 (1985): 517
  8. Heller PJ, Goodman C "Use of local anesthetics with epinephrine for epidural anesthesia in preeclampsia." Anesthesiology 65 (1986): 224-6
  9. Gomel V, Hardwick DF "Search for a pressor substance in toxemia of pregnancy." Am J Obstet Gynecol 94 (1966): 308-9
  10. Greenberger PA, Patterson R "Current concepts. Management of asthma during pregnancy." N Engl J Med 312 (1985): 897-902
  11. Craft JB Jr, Epstein BS, Coakley CS "Effect of lidocaine with epinephrine versus lidocaine (plain) on induced labor." Anesth Analg 51 (1972): 243-6
  12. Martin JE, Pauerstein CJ "The initiation of labor." Clin Anesth 10 (1973): 51-69
  13. Abouleish EI "Epinephrine improves the quality of spinal hyperbaric bupivacaine for cesarean section." Anesth Analg 66 (1987): 395-400
  14. Newman LM, Patel RV, Krolick T, Ivankovich AD "Muscular spasm in the lower limbs of laboring patients after intrathecal administration of epinephrine and sufentanil." Anesthesiology 80 (1994): 468-71
  15. Pinto RM, Lerner U, Pontelli H, Rabow W "Action of epinephrine and norepinephrine on contractile activity of the three separate layers of the human uterus." Am J Obstet Gynecol 102 (1968): 333-9
  16. Martin R, Lamarche Y, Tetreault L "Comparison of the clinical effectiveness of lidocaine hydrocarbonate and lidocaine hydrochloride with and without epinephrine in epidural anaesthesia." Can Anaesth Soc J 28 (1981): 217-23
  17. Albright GA, Jouppila R, Hollmen AI, Jouppila P, Vierola H, Koivula A "Epinephrine does not alter human intervillous blood flow during epidural anesthesia." Anesthesiology 54 (1981): 131-5
  18. Bonnici F "Management of asthma during pregnancy." N Engl J Med 313 (1985): 517
  19. Chadwick HS, Benedetti C, Ready LB, Williams V "Epinephrine-containing test doses--don't throw the baby out with the bath water." Anesthesiology 66 (1987): 571
  20. Zuspan FP, Whaley WH, Nelson GH, Ahlquist RP "Placental transfer of epinephrine. I. Maternal-fetal metabolic alterations of glucose and nonesterified fatty acids." Am J Obstet Gynecol 95 (1966): 284-9
  21. Zakowski MI, Ramanathan S, Sharnick S, Turndorf H "Uptake and distribution of bupivacaine and morphine after intrathecal administration in parturients: effects of epinephrine." Anesth Analg 74 (1992): 664-9
  22. Van Nimwegen D, Dyer DC "The action of vasopressors on isolated uterine arteries." Am J Obstet Gynecol 118 (1974): 1099-103
  23. Briggs GG, Freeman RK, Yaffe SJ.. "Drugs in Pregnancy and Lactation. 5th ed." Baltimore, MD: Williams & Wilkins (1998):
  24. Scoggin CH "Management of asthmas during pregnancy." N Engl J Med 313 (1985): 517-8
  25. Peleg D, Munsick RA, Diker D, Goldman JA, Ben-Jonathan N "Distribution of catecholamines between fetal and maternal compartments during human pregnancy with emphasis on L-dopa and dopamine." J Clin Endocrinol Metab 62 (1986): 911-4
  26. Abboud TK, David S, Nagappala S, Costandi J, Yanagi T, Haroutunian S, Yeh SU "Maternal, fetal, and neonatal effects of lidocaine with and without epinephrine for epidural anesthesia in obstetrics." Anesth Analg 63 (1984): 973-9
  27. Abboud TK, Sheik-ol-Eslam A, Yanagi T, Murakawa K, Costandi J, Zakarian M, Hoffman D, Haroutunian S "Safety and efficacy of epinephrine added to bupivacaine for lumbar epidural analgesia in obstetrics." Anesth Analg 64 (1985): 585-91
  28. Okamura K, Watanabe T, Tanigawara S, Endo H, Iwamoto M, Murotsuki J, Yajima A "Catecholamine levels and their correlation to blood gases in umbilical venous blood obtained by cordocentesis." Fetal Diagn Ther 5 (1990): 147-52
  29. Altura BM, Malaviya D, Reich CF, Orkin LR "Effects of vasoactive agents on isolated human umbilical arteries and veins." Am J Physiol 222 (1972): 345-55
  30. Robinson DA "Epinephrine should not be used with local anesthetics for epidural anesthesia in pre-eclampsia [published erratum appears in Anesthesiology 1987 Jul;67(1):156]." Anesthesiology 66 (1987): 577-9
  31. Reynolds F, Laishley R, Morgan B, Lee A "Effect of time and adrenaline on the feto-maternal distribution of bupivacaine." Br J Anaesth 62 (1989): 509-14
  32. Bromage PR "The physiology and pharmacology of epidural blockade." Clin Anesth 2 (1969): 45-61
  33. Costin M, Milliken RA "Epinephrine is unsafe in the preeclamptic patient." Anesthesiology 66 (1987): 99-100
  34. Levinson G, Shnider SM "Placental transfer of local anesthetics: clinical implications." Clin Anesth 10 (1973): 173-85
  35. Ginsburg J "The effect of adrenaline on placental metabolism." Proc R Soc Med 59 (1966): 748-50
  36. Alahuhta S, Rasanen J, Jouppila R, Jouppila P, Hollmen AI "Effects of extradural bupivacaine with adrenaline for caesarean section on uteroplacental and fetal circulation." Br J Anaesth 67 (1991): 678-82
  37. Yurth DA "Placental transfer of local anesthetics." Clin Perinatol 9 (1982): 13-28
  38. Barden TP, Stander RW "Effects of adrenergic blocking agents and catecholamines in human pregnancy." Am J Obstet Gynecol 102 (1968): 226-35
  39. Blouquit MF, Sturbois G, Breart G, Grill C, Sureau C, Roffi J "Catecholamine levels in newborn human plasma in normal and abnormal conditions and in maternal plasma at delivery." Experientia 35 (1979): 618-9
  40. Albright GA "Epinephrine should be used with the therapeutic dose of bupivacaine in obstetrics." Anesthesiology 61 (1984): 217-9
  41. Goodall M, Diddle AW "Epinephrine and norepinephrine in pregnancy. A comparative study of the adrenal gland and catechol output in different species of animals and man." Am J Obstet Gynecol 111 (1971): 896-904
  42. Zuspan FP "Catecholamines. Their role in pregnancy and the development of pregnancy-induced hypertension." J Reprod Med 23 (1979): 143-50
  43. Chestnut DH, Weiner CP "Monitoring maternal heart rate during epidural injection of a test dose containing epinephrine." Anesthesiology 64 (1986): 839-40

References for breastfeeding information

  1. "Product Information. Epinephrine Hydrochloride Injection (epinephrine)." Abbott Pharmaceutical, Abbott Park, IL.

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