title: A systematic review of the effects of adding neostigmine to local anesthetics for neuraxial administration in obstetric anesthesia and analgesia.
abstract: BACKGROUND
  Drugs used in obstetric patients must accomplish two goals: efficacy and safety for both mother and fetus. Neostigmine has been co-administered epidurally and intrathecally with local anesthetics and other adjuncts in the obstetric setting. The aim of this meta-analysis was to assess the efficacy and incidence of adverse events related to the use of neostigmine in obstetric anesthesia.
  
  
  METHODS
  A meta-analysis of randomized-controlled human trials was conducted using the data sources Google Scholar and PubMed (updated 1 November 2014). Inclusion criteria were: random allocation to treatment; comparison of neostigmine or neostigmine with local anesthetics and/or other adjuvants versus placebo or placebo with local anesthetics and/or other adjuvants; and approval by an ethics committee.
  
  
  RESULTS
  The use of neostigmine as an adjuvant in neuraxial anesthesia is associated with a reduction in the dose of local anesthetic during labor analgesia and postoperative analgesia following cesarean section: mean reduction of local anesthetic (ropivacaine or bupivacaine) vs. control -4.08 (95% CI -6.7 to -1.5) mg/h (P=0.002). The risk of nausea was increased vs. control with intrathecal neostigmine (OR 8.99 [95% CI 4.74 to 17.05], P <0.001) but not with epidural neostigmine (OR 0.97 [95% CI 0.46 to 2.05], P=0.94). Use of neuraxial neostigmine was associated with a decrease in the risk of pruritus but there was no increase in the incidence of hypotension, dizziness or sedation and no effect on the incidence of abnormal fetal heart rate patterns or Apgar scores.
  
  
  CONCLUSIONS
  Neuraxial administration of neostigmine significantly reduces local anesthetic consumption without serious adverse side effects to the mother or fetus. However, neostigmine is only recommended for epidural administration as intrathecal use significantly increases the incidence of maternal nausea and vomiting.
authors.affiliation: UOC Anesthesia and Intensive Care, AOU Sassari, Department of Surgical and Medical Sciences, University of Sassari, Italy. Electronic address: andreapcossu@yahoo.it.
authors.forename: A P
authors.initials: AP
authors.lastname: Cossu
authors.affiliation: UOC Anesthesia and Intensive Care and, Pain Therapy Service, AOU Cagliari, Department of Medical Sciences "M. Aresu", University of Cagliari, Italy.
authors.forename: L M
authors.initials: LM
authors.lastname: De Giudici
authors.affiliation: UOC Anesthesia and Intensive Care and, Pain Therapy Service, AOU Cagliari, Department of Medical Sciences "M. Aresu", University of Cagliari, Italy.
authors.forename: D
authors.initials: D
authors.lastname: Piras
authors.affiliation: UOC Anesthesia and Intensive Care and, Pain Therapy Service, AOU Cagliari, Department of Medical Sciences "M. Aresu", University of Cagliari, Italy.
authors.forename: P
authors.initials: P
authors.lastname: Mura
authors.affiliation: University of Sassari, Italy.
authors.forename: M
authors.initials: M
authors.lastname: Scanu
authors.affiliation: University of Sassari, Italy.
authors.forename: M
authors.initials: M
authors.lastname: Cossu
authors.affiliation: UOC Anesthesia and Intensive Care and, Pain Therapy Service, AOU Cagliari, Department of Medical Sciences "M. Aresu", University of Cagliari, Italy.
authors.forename: M
authors.initials: M
authors.lastname: Saba
authors.affiliation: UOC Anesthesia and Intensive Care and, Pain Therapy Service, AOU Cagliari, Department of Medical Sciences "M. Aresu", University of Cagliari, Italy.
authors.forename: G
authors.initials: G
authors.lastname: Finco
authors.affiliation: UOC Anesthesia and Intensive Care, AOU Sassari, Department of Surgical and Medical Sciences, University of Sassari, Italy.
authors.forename: L
authors.initials: L
authors.lastname: Brazzi
mesh_terms: D016362:Analgesia, Obstetrical / Q000379:methods*; D000773:Anesthesia, Obstetrical / Q000379:methods*; D000779:Anesthetics, Local / Q000008:administration & dosage* / Q000009:adverse effects; D005260:Female; D006801:Humans; D007278:Injections, Spinal; D009388:Neostigmine / Q000008:administration & dosage* / Q000009:adverse effects; D011247:Pregnancy
chemical_list: D000779:Anesthetics, Local; D009388:Neostigmine
keywords: Cesarean section; Labor analgesia; Neostigmine; Neuraxial anesthesia