Outcomes for 298 breastfed neonates whose mothers received ketamine and diazepam for postpartum tubal ligation in a resource-limited setting

Mary Ellen Gilder,Annabelle Carter,Verena I Carrara,Ferdinand Frederik Som Ling Tan,Aung Myat Min,Pan Aye,Hsa Eh,Rose Mcgready,Nay Win Tun,Chaisiri Angkurawaranon

doi:10.1186/s12884-021-03610-1

Abstract

BackgroundAnesthesia in lactating women is frequently indicated for time-sensitive procedures such as postpartum tubal ligation. Ketamine and diazepam are two of the most commonly used anesthetic agents in low resource settings, but their safety profile in lactating women has not been established.MethodsMedical records of post-partum tubal ligations between 2013 and 2018 at clinics of the Shoklo Malaria Research Unit were reviewed for completeness of key outcome variables. Logistic regression identified presence or absence of associations between drug doses and adverse neonatal outcomes: clinically significant weight loss (≥95th percentile) and neonatal hyperbilirubinemia requiring phototherapy.ResultsOf 358 records reviewed, 298 were lactating women with singleton, term neonates. There were no severe outcomes in mothers or neonates. On the first postoperative day 98.0% (290/296) of neonates were reported to be breastfeeding well and 6.4% (19/298) had clinically significant weight loss. Phototherapy was required for 13.8% (41/298) of neonates. There was no association between either of the outcomes and increasing ketamine doses (up to 3.8 mg/kg), preoperative oral diazepam (5 mg), or increasing lidocaine doses (up to 200 mg). Preoperative oral diazepam resulted in lower doses of intraoperative anesthetics. Doses of intravenous diazepam above 0.1 mg/kg were associated with increased risk (adjusted odds ratio per 0.1 mg/kg increase, 95%CI) of weight loss (1.95, 95%CI 1.13–3.35, p = 0.016) and jaundice requiring phototherapy (1.87, 95%CI 1.11–3.13, p = 0.017).ConclusionsIn resource-limited settings ketamine use appears safe in lactating women and uninterrupted breastfeeding should be encouraged and supported. Preoperative oral diazepam may help reduce intraoperative anesthetic doses, but intravenous diazepam should be used with caution and avoided in high doses in lactating women.

Highlights

Information about the safety of ketamine and diazepam in lactating women is limited, despite their designation as essential drugs by the WHO [1]
The findings provide reassurance about the safety for breastfed infants of ketamine use in lactating women: the incidence of weight loss and jaundice in infants of women exposed to high and low doses of ketamine were no different, and comparable to the general population
The available information strongly suggests that current practice of using ketamine in breastfeeding women is safe for neonates, and ketamine should be preferred over diazepam if possible

Summary

Introduction

Information about the safety of ketamine and diazepam in lactating women is limited, despite their designation as essential drugs by the WHO [1]. Due to the short half-life, minimal presence in breast milk, and limited oral bioavailability of many anesthetic agents, once a mother is awake and able to breastfeed her baby, breastfeeding after anesthesia is generally considered safe [2,3,4,5]. Breastfeeding confers a host of benefits to mother and child, especially in resource-limited settings [6], where breast milk is often the only safe source of neonatal nutrition. Postpartum tubal ligation under anesthesia is a safe and highly effective method of contraception for a woman whose family is complete, and contraceptive procedures are increasingly recognized as essential services [8]. Ketamine and diazepam are two of the most commonly used anesthetic agents in low resource settings, but their safety profile in lactating women has not been established

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