A systematic review and network meta-analysis of the use of gabapentinoids perioperatively at the time of cesarean for reducing opioid use.

Background Cesarean section (CS) is the world’s most common major surgical procedure. Subsequently, inadequate pain control contributes to post-partum depression, impaired bonding with infants, and is a risk factor for developing chronic pain syndromes. In light of this, there has been an increased interest in using gabapentin as part of pain-reducing strategies for patients undergoing CS. Objectives To systematically review and synthesize published data regarding the use of gabapentinoids as adjuncts to cesarean section (CS) pain control on opioid consumption, pain scores, and patient satisfaction. Study Design We searched Ovid MEDLINE, Ovid Embase, and Cochrane. The literature search was run on May 6th, 2024, around the main concepts for “Cesarean Section,” “Gabapentin,” and “Pregabalin” and adapted for each database as necessary, from their inception until May 2024. Study eligibility criteria were randomized controlled trials (RCTs) and observational studies that used gabapentin or pregabalin pre- and/or postoperatively at the time of CS. Studies were excluded if there was no comparison group that did not receive either of the drugs. Two reviewers evaluated all studies for eligibility, assessed risk of bias using standard tools, and extracted data for analysis. Network meta-analysis was performed using the random effects model approach due to the inclusion of multi-arm studies and the heterogeneity of studies. Results 11 studies (9 RCTs, 2 observational studies) were included, with generally low risk of bias. Only the observational studies used gabapentin as part of an enhanced recovery after CS protocol. A total of 597 participants received gabapentin or pregabalin and 498 were controls. When including all study designs, one pre-operative 600mg dose of gabapentin decreased post-CS opioid use (measured with milligram morphine equivalents (MME), -20.72, 95% confidence interval (CI) [-33.52, -7.23]). When limiting the analysis to RCTs, a single 300mg dose of either gabapentin or pregabalin reduced MMEs (-4.30, 95% CI [-8.25, -0.36]; -6.90, 95% CI [-8.51, -5.29], respectively). Pain scores were also lower with 600mg and 900mg doses of gabapentin (-1.01, 95% CI [-1.98, -0.04] and -2.50, 95% CI [-4.28, -0.71], respectively). Four studies reported patient satisfaction, with only the 300mg gabapentin dose improving satisfaction scores compared to placebo (mean difference: 1.35, 95% CI [0.45, 2.24]). Conclusions Limited evidence demonstrates that including gabapentin or pregabalin to programs of pain management for CS may decrease total MME requirements, decrease pain, and improve satisfaction.