Surgical transversus abdominis plane block with liposomal bupivacaine at cesarean: a pilot randomized trial.

BACKGROUND: Postcesarean pain control is challenging. In addition to intrathecal morphine, recent studies have shown that liposomal bupivacaine administered via conventional transversus abdominis plane block reduces postcesarean opioid use. However, whether the administration of liposomal bupivacaine via a surgical approach also reduces opioid use is unknown. OBJECTIVE: This study aimed to investigate whether the administration of liposomal bupivacaine via surgical transversus abdominis plane block (TAP block) reduces the cumulative dose of opioids administered in the first 48 hours after cesarean delivery among participants who also receive intrathecal morphine. STUDY DESIGN: This was a pilot single-blind randomized controlled trial of 60 parturients undergoing cesarean delivery at a community tertiary referral hospital staffed by academic physicians. Immediately before fascial closure during cesarean delivery, a total of 80 mL of dilute bupivacaine plus liposomal bupivacaine or dilute bupivacaine alone was administered via surgical transversus abdominis plane block (40 mL on each side). The primary outcome was a median cumulative opioid dose received within the first 48 hours after cesarean delivery measured in morphine milligram equivalents. In addition, opioid use at other time points, pain scores, and participant satisfaction were assessed. A sample size of 60 was determined to be adequate to inform a potential future adequately powered randomized trial. The primary outcome of morphine milligram equivalents and pain scores were compared using a Wilcoxon rank-sum test. RESULTS: Between October 11, 2021, and August 29, 2022, 60 participants were randomized and analyzed: 31 were allocated to liposomal bupivacaine plus regular bupivacaine (intervention group), and 29 were allocated to regular bupivacaine alone (control group). Participants allocated to the intervention group used a median cumulative dose of 2 morphine milligram equivalents of opioids (interquartile range, 0-24) in the first 48 hours compared with 8 morphine milligram equivalents (interquartile range, 0-40) among participants allocated to the control group (P=.236). The percentage of participants who used ≤15 morphine milligram equivalents of opioids was 61% in the intervention arm and 41% in the control arm (P=.123), and the percentage who used zero opioids was 45% in the intervention arm and 34% in the control arm (P=.399). The total number of opioid pills prescribed at discharge was fewer in the intervention arm than in the control arm (P=.029). Patient satisfaction with the intervention group and control group was similar. CONCLUSION: Our pilot study suggests that liposomal bupivacaine administered via surgical transversus abdominis plane block is worth critical evaluation as an adjunctive analgesic modality in an adequately powered randomized trial.

Detection of fetal growth restriction with preterm severe preeclampsia: experience at two tertiary centers.

Our objective was to determine if sonographic estimate of fetal weight (SEFW) can identify fetal growth restriction (FGR; birthweight < 10% for gestational age [GA]) among patients with preterm (28 to 32 weeks) severe preeclampsia (P SPE). At two centers, all singletons with reliable GA, P SPE, and SEFW within 3 weeks of birth were identified retrospectively. Intrauterine growth restriction was SEFW < or = 10% for GA. Likelihood ratio (LR) and guidelines by an Evidence-Based Medicine Working Group were used. At the two centers, IUGR was suspected in 20% (4 of 20) and 28% (5 of 18) of P SPE, and FGR was noted in 35% and 44%. At one center, suspected intrauterine growth restriction (IUGR) was associated with actual FGR in 50% of the cases and at center II, in 80%. The LR for IUGR to identify FGR was 3.0. We concluded that SEFW is not a useful diagnostic test in identifying FGR among patients with preterm SPE.