← Dr. Chapa’s OBGYN Clinical Pearls 
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Back In September of 2021, ACOG released clinical consensus number one which was pharmacological stepwise multimodal approach for postpartum pain management. Now look, I, I'd want to give off any false errors here that like I can, you know, stomach a lot of pain. I don't, I'm, I'm the first to say I've got a pretty moderately low pain tolerance. So I do feel for our patients who have, you know, big abdominal incision to have their child delivered. I get that. However, you know, just handing out opioids like they're lollipops is not the way to go either. So back in September 2021, ACOG stated that NSAIDs with acetaminophen in a progressive stepwise multi, multimodal approach can be very, very effective. Effective to control pain without resorting to opioids. Okay, this was clinical consensus number one and we covered this when this came out. Now for vaginal birth, same deal. A stepwise multimodal approach to analgesia starting with NSAIDs or acetaminophen and then escalating if needed to an opioid is what is recommended however and I get this whole thing of patient satisfaction and scores in the hospitals and drives me nuts because you know, trying to do the right thing and make the patients happy. We can be over sedating patients when they gotta care for a child and, or hold a child or they're sleeping with a child in the hospital bed. You know, nothing is free. So again, opioids, I'm not anti opioids, I'm just against using opioids willy nilly without first putting in the effort for Tylenol and an nsaid. Okay, that's what we're gonna talk about in this episode. What is the best dose of of ketorolac? A very powerful NSAID and a favorite for any surgical discipline in the perioperative timeframe because Toradol post surgery is phenomenal. Now, you gotta be careful with it in certain patients. We're gonna get into that here in a minute and understand, you know, what about patients with preeclampsia with severe features? Well, the answer to that is, well, what makes them severe? Is it blood pressure? Because NSAIDs are unlikely to really affect blood pressure. It may increase it a little bit, but it's not going to push it into a whole other range. And that's why ACOG says, you know, NSAIDS can still be considered first line, even for those with hypertensive disorders in pregnancy. However, if they have altered kidney function, then that's an issue. Okay, so maybe you got to back that down. Use a very low dose. So that's a cautionary tale here. We're going to make this distinction between Acog's allowance of NSAIDs with hypertension versus NSAIDs effect in patients with hypertension on renal function. Those are two different things. All right? And the reason I want to clarify that is because, you know, I've had this discussion before. This was a couple of years back when I was talking to an OB hospitalist and like, oh, she has severe preeclampsia. Creatinine is like 1.1. But we gave her Toradol because ACOG says you can. Well, it says that you can based on blood pressure issues, but if you've got renal impairment, you could push that patient over the edge. So those are two different things. We're going to summarize that after the intro, but that's not even our main focus. The focus is what is the best dose post C section of ketorolac. Okay, that's Toradol. Not a sponsor of Ketorolac after C section. This is a new rct, even though it was small numbers. These are phenomenal authors from the Ohio State University. And this just came out in April 2026 in the green journals, Open access, sister journal. All right, so this is out of O N G Open. That is the green journals open access version. Okay, so we're going to talk about this brand new publication that just came out that randomized patients undergoing C section to either 60 milligrams of Toradol IV, that's the intervention group, or 30 milligrams that was the control of intravenous keto or lac in the OR at the end of surgery before they go to recovery. And we're gonna talk about what was the amount of opioids used in that first post op? 24 hour interval. And they calculated what's called the MME. I'm gonna tell you how to do that. It's very easy. I've taught residents how to do that. It's not a big deal. The morphe milli equivalent Milligram equivalent is a standardized way to look at a patient's opioid requirements. All right, so we're going to talk about this again. O and G Open just came out April in April 2026 out of the Ohio State University. The best dose for ketorolac after C section for pain prophylaxis. Let's talk about it coming up next. 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fulfill our life calling and our mission. This is Dr. Chapa's OBGYN no Spin podcast. Look, Toradol I think we can all agree is a phenomenal medication. I mean it just really works very well for post op pain across disciplines. I mean it just does very potent nsaid. The question though that has always lingered in terms of upstairs obstetrics is what's the best dose? Because obviously this thing goes through the kidneys, it's renally excreted and because of pregnancy changes, at least the thought makes sense that you would need a higher dose. Whereas maybe a 15 milligrams is not enough. Super under dosing, 30 milligrams. Maybe the question is, is the traditional 60 milligrams in this case this was given IV. Does that work better than something that's lower dose? Okay, so we really don't have a lot of this data. So. So good for these authors from the Ohio State University from putting this together. Okay, now I want to do this very quickly because I don't want to belabor this, but the big issue here is not to get confused with some of the contraindications. We're going to talk about this. Who they excluded from this as a research protocol, which actually makes a lot of sense. I'm okay with this. Okay. I do have one question about one of their restrictions. Some of the patients were eliminated if they had preeclampsia with severe fever features, but that's not broken up into what made them severe. In other words, was it just hypertension alone because ACOG says you can do that, just monitor blood pressure. Was it elevation in liver enzyme, which is okay because this is renally cleared, or were they severe because they had a creatinine of 1.2 at that level or above? Okay, that's the question is was it just everybody who was preeclamptic was severe because that may have robbed some of them of good medication. However, if that creatinine is high, and I don't like to use NSAIDs or ketorolac if their creatinine is greater than 1.0, that's pretty high. But that's not clear here. And I want to give this a little bit more of this distinction, this clarification between ACOG's allowance of NSAIDs with any hypertensive disorder in pregnancy? Because it's going to be okay with the caveat that that's different than keto relax potential effect on the kidney. Okay, so I want to get into that in just a minute. I'm just going to read a couple of excerpts from ACOG's multimodal stepwise progressive protocol on the consensus statement. And then just quickly touch on Practice bulletin number 222. That's the one on gestational hypertension and preeclampsia that talks about NSAIDS in these patients. All right, but before I get into that very quickly, remember this is an rct. It's at a single academic center. And the numbers are kind of small, but it still gives us very good information. Although I'm going to say it right here and the authors say it themselves. It would be nice later, somebody else down the road if we could repeat this to make sure that what they saw is legit. In other words. Quote Although the effect size was small, I'm reading from their conclusion. Haven't even given you the results yet, but I just, I'm just jumping a little bit ahead to let you know that we need more study here. Quote however, although the effect size was small, future studies may better address the clinical utility of ketorolac loading dose, end quote. So we're going to talk about what they found here. Is 60 milligrams better than 30 in terms of their opioid requirements in that first 24 hour post op interval. And remember, this was measured using M. I'm going to tell you how to calculate this. This is an easy way to take an oral opioid and then convert that into MMEs, or if you don't know what that is, I mentioned that in the intro it is morphine milligram equivalents because every medication has a different conversion for its morphine milligram equivalents within the first 24 hours after delivery. All right, so this is helpful to know. How can we make patients more comfortable without resorting to opioids? We're going to talk about this now. The patient that were recruited had to be at least 18. They had to be obviously undergoing a C section and they had to have regional anesthesia. These were not under general as part of their exclusions. I'm gonna get into that in a minute. They also could not have an allergy, obviously to NSAIDs. They can't have peptic ultra disease and they had to have normal renal clearance. All right, so if they were at risk for decreased renal clearance, including pre gestational diabetes with nephropathy or preeclampsia with severe features, they were kicked out. Okay, so no peptic ulcer disease, no allergy to NSAIDs, and if they were at risk for decreased renal clearance like nephropathy or preeclampsia with severe features, they kicked them out. Now that's one of the things here, as I mentioned just a little while ago. I'm not going to belabor this or say it again, but you know, just because you're, you're preeclampsia with severe features does not mean you cannot use an nsaid. If you have preeclampsia with severe features and you've got some potential for acute renal injury, then maybe that's separate. But they just said no, it's the, you know, throwing out the baby with the bathwater. And I respect that. I do. I get that from a research standpoint. But you know, I don't know. I would have loved to see maybe a sub analysis in patients with preeclampsia who have severe features. However, remember that the end result wasn't hypertension control and it wasn't urine output. It was just on MMEs for opioid use. So they just threw them out. Now, just to clarify, ACOG does say in its again, clinical consensus number one, NSAIDs may be used for the management of postpartum pain in all individuals, including those with hypertensive disorders of pregnancy and should be considered among first line agents. That's from 2021. Also separately in practice bulletin 222, that's the gestational hypertension and preeclampsia guidance. It states as a level A recommendation quote, non steroidal anti inflammatory medications should continue to be used preferentially over opioids and that postpartum patients on MAG for seizure prophylaxis for preeclampsia did not show any differences in blood pressure, anti hypertensive requirements or other adverse events when managed with NSAIDs. End quote. So it's okay, but that's talking about a blood pressure effect that does not have to do and that's not focused on its potential for renal safety. That's a different issue. So because there are some safety concerns and because heat ORLAC is, is renally excreted here, it's reasonable to exclude those that have a bump in their creatinine. All right, so again, these authors excluded everybody with preeclampsia with severe features, even if maybe their creatinine was normal. But they're like, let's just make it clean, we don't have any problems. So no to you, I would still use it as long as your creatinine is fine. So just know that's one of the issues here that, that you know, I have an issue with. But nonetheless, I understand that from a research standpoint. Now back to Exclusions. If they had chronic hypertension for more than five years, they were excluded. Again, a good population that they could have studied. But I understand that from a research protocol. But just because you have chronic hypertension doesn't mean that you've got, you know, jank kidneys. So they kicked them out. It was. It had no, nothing to do with a cutoff of creatinine. They just said chronic hypertension for more than five years, you're not involved. If they had chronic kidney disease, that makes sense. Or acute kidney injury, that made sense, then they kicked him out. Also, if they had opioid use disorder or chronic pain disorders, they kicked them out, which makes sense. And then lastly, if it was in an emergency C section or they used general, or they were considered hemodynamically unstable because of pph, you know, you got other, you know, stuff. Oops, almost said something else there. You've got other stuff to worry about first, like saving her life rather than, you know, what's going on with, you know, post opioid use. We can deal with that later. So they were excluded. I understand that. All right. Oh, last thing. Also, if they weighed less than 50kg, so we're talking about really small patients. I don't have a lot of those under 50 kg. They were excluded. Okay. So short of it is these patients who are undergoing C section were randomized to either get 30 milligrams of IV ketorolac, that's called the control group, or 60 milligrams of IV ketoriolac, that was called the intervention group. And it was a one to one ratio. Right. So it was similar numbers per camp. It was 92 total. So 46 in one arm in the control of 30 milligrams, and then 46 in the intervention group. Right. Now, the two study groups were single blinded. Okay, here's what that means. So the participants, the patients were unaware of the treatment that they were going to get. But. But the clinical teams were unmasked. Now, before you go, well, isn't that kind of a bias? Well, not really. Not if you have an independent research team who's doing the data collection. Okay. And that trained research team, they were blinded. Okay, so this is single blinded because the patients were blinded, but the clinical team were not. And right before they went from the OR to recovery, then the anesthesia staff gave them their medication according to their randomization. Okay? So this was done again, still in the or. Now, all of these patients underwent either spinal or combined spinal epidural, and they received intrathecal duramorph, which is pretty standard. Okay. That's intrathecal morphine. And then it was pretty easy. Hey, let's take a look at some pain scores. They also had toradol given on the schedule. Each one, the control and the intervention group had toradol given as a schedule up to 120 milligrams in the first 24 hours. Right. So they had the initial loading of 60 or they had the initial loading of 30. And then on the clock, you know, every X amount of hours, they received additional 30 milligrams up to the 120 cutoff for the 24 hour interval. That's pretty legit. That makes sense. That's not unusual. A lot of places have that kind of protocol. We have something kind of similar as well. So once again, they get a standard loading, either 60 or 30. And then on the clock scheduled up to 120 milligrams. And either the control or the intervention, they got additional 30 milligrams to keep the inflammation down and to try to prevent opioid use. Okay. By the way, this was given every six hours. Right. So in the control group, they had additional three doses of 30 milligrams. So that's 90 milligrams additional. That's in the control because they got 30. So they get another 90 up to get up to the 120 milligrams total. That was every six hours. And then in the intervention group, that's when they got 60 milligrams. They only had two additional doses of keto or lac at 30 milligrams every six hours. So they got the other 60 in addition to the 60 in the OR to get to their 120. Right. Makes sense. Pretty, pretty simple protocol. Makes sense to me. And then they calculated the amount of opioid doses that they got, not by straight. You know, lortabs are norco. They converted, they converted the oral medication with an online calculator. I mean, you can download, it's on MD calc. It's not a big deal. It's called the MME equivalent. All right, so the morphine milligram equivalent per day. There's a simple formula. You can calculate these and let me just tell you what they found. I'm trying to do this relatively quick. The short answer is, guys, it's not like mind blowing. A higher dose of keto orlac given in the OR before they go to recovery worked better. Right. So 60 milligrams actually did have a benefit in the reduction of MMEs. All right, so let me give you this, this result and then we're gonna kind of wrap it up. So according to this small numbers, and again, the effect size is still pretty small, but those that had the higher dose required less MMEs. Let me give you these numbers. Participants who had the intervention group, so 60 milligrams who had that loading dose had an average of 15 morphine milligram equivalents. But those who had 30 milligrams of keto or lac used double that. In other words, they had 30 morphine milligram equivalents. So 15 with the higher dose, 30 in the lower dose. Now that is good to know. It's not, you know, having a double use of opioids with a lower dose of ketorolac is pretty significant. And the authors found that that was a good thing. An initial loading dose of 60mg compared with 30mg of intravenous ketorolac after cesarean delivery results in lower post opioid use without an increase in treatment related adverse events. However, and I read this in the intro, the effect size was small and future studies may better address the clinical utility of keto or lac loading dose. Guys, I wanted to do this quickly because, you know, kudos to these authors for doing this RCT on two perioped ketorolac dosing regimens after C section to try to reduce opioids. Here's my take home message. Toradol, keto or lac rocks. It's great. I understand that some protocols give it im. I have no beef with that. This was given IV and excluding those who have the potential to have kidney issues, that's probably, you know, something you got to consider. This works great so that patients can feel more comfortable. Remember toradol? Remember acetaminophen? In the multimodal stepwise progressive approach that ACOG reminds us to do for the last five years because I came out in 2021 with opioids for rescue. Don't use that as first line, please use those as rescue. Then they get all constipated, they get extra nausea and they can get sedated. And that's an issue. Now, if your question has to do with breastfeeding, well, toradol and breastfeeding seems to be okay, right? I mean, even though there's a potential for some of that to enter the breast milk, it doesn't seem to be at any level that's considered worrisome. And even ACOG has that in its guidance quote. Acetaminophen and ibuprofen are first line analgesic for postpartum pain for individuals intending to provide breast milk to their infants. And there's even a section here on IV Ketarolac. Intravenous ketorlac is an acceptable component of postpartum multimodal therapy for women intended to provide breast milk to their neonates. And here's the last one. Although information about medication levels in breast milk is not available for IV ketorolac, quote, they are likely low in the immediate postpartum interval and without significant risk, end quote. So yes, you can give IM or IV tordal without a concern for breastfeeding in the immediate postpartum interval. And that's according to ACOG's clinical consensus. Number one podcast family, as always, we're thankful for you. We're glad you're part of our podcast community. And now that we've done all that, Michael, come on now, let's take it home. This is Dr. Chapma's obgyn no spin podcast.
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