Butorphanol use in laboring patients with preeclampsia or chronic hypertension (2022)


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Pregnancy Hypertension: An International Journal of Women's Cardiovascular Health

Volume 6, Issue 4,

October 2016

, Pages 288-290



The American College of Obstetricians and Gynecologists (ACOG) recommends against the use of butorphanol in patients diagnosed with preeclampsia or chronic hypertension secondary to a theoretical concern that the drug will further elevate blood pressures. No past study has examined the drug’s potential to elevate blood pressures in laboring patients.


In this retrospective cohort study all chronic hypertensive and preeclamptic patients who underwent an induction of labor and delivered a viable, singleton pregnancy between the dates of 1/1/2013 and 12/31/2014 at a single academic hospital were included.


The use of butorphanol in chronically hypertensive patients during labor was not associated with the presence of severe range blood pressures during labor (OR=0.92 95% CI: (0.04–19.34) P=0.96). In preeclamptic patients there was similarly no change in the frequency of severe range blood pressures with the use of the drug (OR=0.59 95% CI: (0.19–1.83) P=0.36).


In laboring patients with chronic hypertension or preeclampsia butorphanol is not associated with severe range blood pressures, and therefore it is a reasonable option for providing pain relief in these populations.

(Video) #Hypertension_in_pregnancy #mgso4 #Magnesium_sulphate #Labetalol || Pregnancy induce hypertension


Over four million births occur in the United States each year [1]. For the vast majority of these women labor pains are an unavoidable facet of delivery. Increasingly, more attention has been given to finding appropriate methods and protocols to alleviate labor pains [2]. Hospitals have attempted everything from increasing the number of in house anesthesia providers to establishing policies stating that “maternal request [alone] is a sufficient medical indication for pain relief during labor” [3], [4].

Multiple modalities for pain control in labor exist. The most common and most effective is regional anesthesia provided via an epidural catheter [5]. Epidural anesthesia results in decreased pain sensation below the T8 level. Unfortunately, with the decreased sensation of pain also comes a variable decrease in motor function. This loss of mobility and other potential side effects including hypotension, fever, and postdural puncture headaches cause some women to delay or even decline epidural placement despite their desire for pain management [3].

While not as effective in providing long term pain relief, narcotic medications provide laboring women [6] an alternative option for systemic analgesia. The intermittent dosing possible with narcotics results in many women feeling an increased sense of control over their labor, which is a quality some women desire [7]. A variety of opioid agonists and agonist-antagonists have been studied in labor with the most common ones being meperidine, nalbuphine, morphine, fentanyl and butorphanol [3].

Butorphanol is a synthetic opioid agonist-antagonist first approved by the FDA in 1978 [8]. Its rapid 1–2min onset makes it an attractive medication for women suffering from labor pain. It is both a partial μ- and partial κ-agonist, with numerous studies suggesting that at low doses it has predominate μ-activity. At higher doses many believe that a ceiling effect may be seen on its μ-receptor activity [16]. Because butorphanol only acts as a partial agonist at the μ-receptor, unlike morphine which acts as a complete agonist, many believe it poses less risk of physical dependence and respiratory depression than morphine [8]. It is important to note that, during labor, a potential side effect of butorphanol is a fetal sinusoidal pattern that is not associated with adverse outcomes [9].

The American College of Obstetricians and Gynecologists (ACOG) recommends against using butorphanol in chronic hypertensive and preeclamptic patients citing concerns that the drug could further elevate blood pressures in these populations [3]. ACOG’s concerns stem from a single paper, which postulates a theoretical risk based on controversial medical and pharmaceutical literature [10]. However, no research has been able to back up this theoretical concern. A literature review was unable to discern a single documented case of elevated blood pressure attributable to butorphanol. Further, multiple animal studies have failed to demonstrate blood pressure elevations following butorphanol’s use [11], [12], [13]. The sole human study to examine the cardiopulmonary effects of butorphanol came to a similar conclusion [14]. With the lack of research available to support the claim that butorphanol would further elevate blood pressures in preeclamptic and hypertensive women, a study was designed to examine just this. It was hypothesized that butorphanol’s use would not in fact result in an increased prevalence of severe range blood pressures in chronic hypertensive and preeclamptic laboring patients.

Section snippets


Following approval from the institutional review board, over 3500 deliveries at a tertiary care academic hospital were analyzed for this study. All deliveries that transpired over a two year period from 1/1/2013 to 12/31/2014 were considered. Initial screening resulted in the identification of all pregnancies complicated by either chronic hypertension or preeclampsia. Chronic hypertension was defined as at least two elevated blood pressures (140 systolic or 90 diastolic) prior to 20weeks


During the study period, 66 women with chronic hypertension who met the inclusion criteria were identified. Of these patients the majority progressed through labor without butorphanol (no butorphanol n=58, versus butorphanol n=8). The maternal demographics of the cohorts who did and did not receive butorphanol were very similar (Table 1), with the two cohorts not differing in estimated gestational age (p=0.58), blood pressure values on admission (p=0.68 and p=0.52), or percentage of patients


To the knowledge of this study’s authors, this is the first study to specifically examine the effect of butorphanol on blood pressure in laboring chronic hypertensive and preeclamptic patients. In this retrospective cohort study butorphanol’s use was found to have no effect on the frequency of severe range hypertension in the cohorts receiving the drug. Where this study did note a statistical difference with butorphanol’s use, the drug’s use resulted in improved outcomes by decreasing NICU


As women have come to expect better pain control in labor, increased attention has been focused on developing and refining options to meet these demands. Butorphanol functions as one of several narcotics that can be utilized during labor. Based on the results of this study, the presence of maternal chronic hypertension or preeclampsia should not preclude the use of butorphanol in these populations.

References (16)

  • S. Commiskey et al.Butorphanol: effects of a prototypical agonist-antagonist analgesic on kappa-opioid receptors

    J. Pharmacol. Sci.


  • A. PalanisamyThe 2013 Gerard W. Ostheimer lecture: what’s new in obstetric anesthesia?

    Int. J. Obstet. Anesth.


    (Video) Hypertension in Pregnancy by Dr Langer Recorded on 9 2 16

  • J.A. Martin et al.

    National vital statistics reports births: final data for 2006

    Statistics (Ber).


  • E. Ogboli-Nwasor et al.

    Pain relief in labor: a survey of awareness, attitude, and practice of health care providers in Zaria

    Nigeria. J. Pain Res.


  • Gynecology AC of O and ACOG practice bulletin, Obstetric analgesia and anesthesia, No. 36, 2002, American College of...
  • B.A. Bucklin et al.

    Obstetric anesthesia workforce survey: twenty-year update



  • K.E. Nelson et al.

    Intravenous butorphanol, meperidine, and their combination relieve pain and distress in women in labor



  • D. Anderson

    A review of systemic opioids commonly used for labor pain relief

    J. Midwifery Women’s Heal.


There are more references available in the full text version of this article.

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Does butorphanol increase blood pressure? ›

The American College of Obstetricians and Gynecology state that butorphanol may increase blood pressure levels and should be avoided in patients with chronic hypertension or preeclampsia.

What is the drug of choice for preeclampsia? ›

The drug of choice for the prevention and control of maternal seizures in patients with severe preeclampsia or eclampsia during the peripartum period is i.v. magnesium sulfate. Its mechanism of action for the treatment of eclampsia is not well understood.

What is the drug of choice for hypertension in pregnancy? ›

Methyldopa is a drug of first choice for control of mild to moderate hypertension in pregnancy and is the most widely prescribed antihypertensive for this indication in several countries, including the US and the UK.

Which drug is contraindicated in a laboring mother with hypertension? ›

Some commonly prescribed antihypertensive drugs are contraindicated or best avoided before conception and during pregnancy (Table 1 ). These include ACE inhibitors, angiotensin receptor antagonists, diuretics and most beta blockers.

Why is butorphanol used in labor? ›

Butorphanol is a narcotic analgesic medication and an opioid agonist-antagonist. 2 Doctors may prescribe this medication to treat migraine headaches, relieve pain after surgery, or help with the pain during labor. Butorphanol is a narcotic analgesic medication and an opioid agonist-antagonist.

What is butorphanol used for? ›

Butorphanol nasal spray is used to relieve pain severe enough to require opioid treatment and when other pain medicines did not work well enough or cannot be tolerated. It belongs to the group of medicines called narcotic analgesics (pain medicines). Butorphanol acts on the central nervous system (CNS) to relieve pain.

What is the first drug of choice for hypertension? ›

There are three main classes of medication that are usually in the first line of treatment for hypertension: 1. Calcium Channel Blockers (CCB) 2. Angiotensin Converting Enzyme inhibitors (ACE inhibitors or ACE-I) and Angiotensin Receptor Blockers (ARBs) 3. Diuretics.

How is chronic hypertension treated in pregnancy? ›

For women with chronic hypertension who enter pregnancy not on antihypertensive treatment, ACOG recommends initiating antihypertensive treatment when blood pressures are consistently >160 mm Hg systolic and/or >105 mm Hg diastolic.

How do you manage chronic hypertension during pregnancy? ›

Medical treatment of chronic hypertension in pregnancy, that is, hypertension present before 20 weeks' gestation, is recommended at 160 mm Hg systolic or 110 mm Hg diastolic with labetalol or extended-release nifedipine, treating to 120 to 159 mm Hg systolic and 80 to 109 mm Hg diastolic.

What are the main classes of drug used to treat hypertension? ›

The classes of blood pressure medications include:
  • Diuretics.
  • Beta-blockers.
  • ACE inhibitors.
  • Angiotensin II receptor blockers.
  • Calcium channel blockers.
  • Alpha blockers.
  • Alpha-2 Receptor Agonists.
  • Combined alpha and beta-blockers.
Oct 31, 2017

What drugs are used to treat severe hypertensive episodes in pregnancy? ›

For emergency treatment in preeclampsia, IV hydralazine, labetalol and oral nifedipine can be used [1]. The ACOG Practice Bulletins also recommend that methyldopa and labetalol are appropriate first-line agents and beta-blockers and angiotensin-converting enzyme inhibitors are not recommended [21, 17].

What is first-line treatment for hypertension in pregnancy? ›

Background: Hydralazine, labetalol, and nifedipine are the recommended first-line treatments for severe hypertension in pregnancy.

Which drug is contraindicated for hypertension? ›

Your doctor or pharmacist can suggest OTC medicines that are safe for you. Some common types of OTC medicines you may need to avoid include: Decongestants, such as those that contain pseudoephedrine. Pain medicines (NSAIDs), such as ibuprofen and naproxen.

Can you have preeclampsia with chronic hypertension? ›

Preeclampsia happens when a woman who previously had normal blood pressure suddenly develops high blood pressure* and protein in her urine or other problems after 20 weeks of pregnancy. Women who have chronic hypertension can also get preeclampsia. Preeclampsia happens in about 1 in 25 pregnancies in the United States.

Why is butorphanol given in pregnancy? ›

Butorphanol may be harmful to an unborn baby. Tell your doctor if you are pregnant. Butorphanol is sometimes used during early labor, but using it just before childbirth can cause breathing problems in a newborn. Butorphanol passes into breast milk and may harm a nursing baby.

Which drug is used during labor? ›

Misoprostol and oxytocin are the most commonly used agents for cervical ripening and labor induction.

What pregnancy category is butorphanol? ›

US FDA pregnancy category C: Animal reproduction studies have shown an adverse effect on the fetus and there are no adequate and well-controlled studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks.

What is the best treatment for preeclampsia? ›

Medications to treat severe preeclampsia usually include: Antihypertensive drugs to lower blood pressure. Anticonvulsant medication, such as magnesium sulfate, to prevent seizures. Corticosteroids to promote development of your baby's lungs before delivery.

What is the proper treatment for eclampsia? ›

Eclampsia Treatment

Immediate treatment, usually in a hospital, is needed to stop the mother's seizures, treat blood pressure levels that are too high, and deliver the fetus. Magnesium sulfate (a type of mineral) may be given to treat active seizures and prevent future seizures.

What are the top 5 blood pressure medications? ›

In terms of dollar sales, there are 5 top high blood pressure medications.
  • the angiotensin II receptor blocker valsartan (Diovan) in the lead for high blood pressure medications,
  • the beta-blocker metoprolol,
  • the generic combination of valsartan and HCTZ,
  • olmesartan (Benicar), and.
  • olmesartan and HCTZ (Benicar HCT).

Is labetalol used in preeclampsia? ›

Labetalol, a combined alpha and beta blocker, has been used for many years to safely treat hypertension in preeclamptic women, and is now known to reduce CPP in women with preeclampsia.


1. Preeclampsia and Eclampsia, Animation
(Alila Medical Media)
2. Hypertension in Pregnancy - Diagnosis and Management: Nice guideline June2019-Guideline no. ng133.
(Priyata Lal)
(Naveen Malhotra Secretary ISA NHQ)
4. Preeclampsia/Eclampsia - Dr. Fragneto
(University of Kentucky Department of Anesthesiology)
5. Ricci Nursing Management of Difficult Labor and Birth and Selected Nursing Conditions Chapter 20/21
(Leah Elliott)
6. Physiology of Pregnancy - Dr. Fragneto
(University of Kentucky Department of Anesthesiology)

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