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Title: The effects of antepartum depressive symptoms on post-cesarean opioid consumption

Authors: Zachary Walker MD, Victoria Jauk MPH, Callie Perkins BS, J. Morgan Jenkins, Allison Todd MSN, Yumo Xue MS, Lorie Harper MD, MSCI, Jeff M. Szychowski PhD, and Sara Mazzoni MD, MPH

Category: Medical/Surgical/Disease/Complications – Psychiatric

Objective: To test the hypothesis that antepartum depressive symptoms are associated with increased pain scores and opioid use during postpartum hospitalization.

Study Design: Retrospective cohort of English or Spanish-speaking women > 18 years who had prenatal care for a singleton gestation and delivered by cesarean (CS) at > 36 weeks within a tertiary center during 2017 where all women are screened for depression with an antenatal Edinburgh Depression Scale (EDS). Exclusions included fetal anomalies or death, sickle cell disease, substance misuse, chronic pain, and fibromyalgia. Women with no EDS scores recorded antenatally were excluded. Major depressive symptoms (MDS) were defined as a documented antenatal EDS>=12 and no MDS if EDS<12. MDS groups were compared with Student’s t-test, Wilcoxon rank sum tests, Chi-square, and exact tests where appropriate. Multiple linear regression modeled pain by MDS status controlling for smoking and anesthesia; model for opioid use included pain as well.

Results: Of the 891 patients reviewed, 676 (76%) had documented antenatal EDS scores, and 104 (15.4%) had MDS. Women with MDS were more likely to be single, use tobacco, and have general anesthesia for CS, but were otherwise similar (Table 1). Women with MDS reported higher daily and average pain scores (Table 2). In bivariate analyses, women with MDS used more morphine milligram equivalents (MME) each day during their postpartum hospitalization, leading to a higher total MME use (121mg (60.5-214.5) vs 75mg (28.5-133.5), p<0.001). However, when adjusted for pain, MME use was not statistically significant (p=0.15).

Conclusion: Our study supports an association between antepartum MDS and acute pain after CS leading to increased opioid use.  Given the current focus on opioid stewardship, further research into this association, exploration of tailored pain control, and determining whether treatment of antepartum MDS reduces postpartum pain, and therefore opioid use, will be of the utmost priority. 


Table 1. Maternal demographics and delivery characteristics
  EDS < 12
N = 572
 
EDS >= 12
N = 104
 
P value 
 Maternal age (years)   29.2 ± 6.1  28.9 ± 5.8  0.66
 Race / Ethnicity
   African-American
   White
   Hispanic
   Other
 
273 (47.7%)
196 (34.3%)
79 (13.8%)
24 (4.2%)
 
64 (61.5%)
27 (26.0%)
10 (9.6%)
3 (2.9%)
 
0.08
 BMI  35.4 ± 8.4  34.7 ± 7.6  0.43
 Insurance
   Private
   Public
 
236 (41.4%)
334 (58.6%)
 
33 (31.7%)
71 (68.3%)
 
0.06
 Married/Cohabitation  343 (60.0%)  46 (44.2%)  0.003
 Nulliparous  192 (33.6%)  26 (25.0%)  0.09
 Tobacco use  46 (8.1%)  19 (18.5%)  0.001
 Alcohol use 7 (1.2%) 2 (1.9%) 0.63
 Number of prenatal visits 11.6 ± 3.9 11.1 ± 4.0 0.22
 Previous cesarean 292 (51.1%) 56 (54.4%) 0.54
 Number of previous cesareans 1 (0-1) 1 (0-1) 0.92
 Labor before cesarean 259 (45.3%) 46 (44.2%) 0.84
 Labor type
    None
    Induced
    Spontaneous

263 (46.0%)
160 (28.0%)
149 (26.1%)

44 (42.3%)
29 (27.9%)
31 (29.8%)

0.70
 Anesthesia
    General
    Epidural
    Spinal
    Combined epidural/spinal

51 (8.9%)
219 (38.3%)
249 (43.5%)
53 (9.3%)

22 (21.2%)
29 (27.9%)
44 (42.3%)
9 (8.7%)
0.002
 Cesarean incision type
    Pfannenstiel
    Vertical

552 (96.5%)
20 (3.5%)

102 (98.1%)
2 (1.9%)

0.56
 Cesarean closure type
    Staple
    Suture

17 (3.0%)
555 (97.0%)

2 (1.9%)
102 (98.1%)

0.75
 Prior abdominal surgery 326 (57.0%) 58 (55.8%) 0.82
 Chorioamnionitis 57 (10.0%) 12 (11.5%) 0.63
 Endometritis 6 (1.1%) 3 (2.9%) 0.15
 Postpartum hemorrhage 94 (16.4% 16 (15.4%) 0.79
 Preeclampsia 51 (8.9%) 12 (11.5%) 0.40
 Wound complication 9 (1.6%) 2 (1.9%) 0.68
Data are presented as n(%), mean + standard deviation, or median (range)


Table 2: Maternal postpartum pain scores and opioid use
   EPDS < 12
N = 572
EPDS >= 12
N = 104
 
P value   Adjusted
P Value
 Average Daily Pain Score+        
    DOS 1.5 (0.5-2.7)   2.5 (1.3-3.7) <0.001  <0.001* 
    POD1 2.1 (1.0-3.4)   3.0 (1.6-4.1) <0.001  0.001* 
    POD2 2.0 (0.8-3.2)   2.7 (1.6-4.0) <0.001   <0.001*
    POD3  1.7 (0-3.2)  2.0 (0.4-3.6) 0.06   0.18*
    POD4  0 (0-3.5)  2.1 (0-5.5) 0.02  0.04* 
 Average Pain Score  1.7 (1.0-2.6)  2.4 (1.6-3.4)  <0.001  <0.001*
         
 Opioid use (mean MME in mg)        
   DOS 12 (0-29) 23.5 (8-46.3) <0.001 0.13
   POD1 30 (7.5-52.5) 45 (22.5-67.5) <0.001 0.04
   POD2 15 (0-37.5) 30 (15-52.5) 0.006 0.16
   POD3 15 (0-30) 22.5 (0-52.5) 0.001* <0.001
   POD4 0 (0-15) 7.5 (0-15) 0.14 0.16
 Total Meds Used 75 (28.5-133.5) 121 (60.5-214.5) <0.001 0.15
DOS = Day of Surgery, POD = Postoperative day
+ Data presented as median (IQ range)
* Controlled for tobacco use and type of anesthesia
Controlled for tobacco use, type of anesthesia, and pain score at day of medication