title: Analgesic efficacy and adverse effects of epidural morphine compared to parenteral opioids after elective caesarean section: a systematic review.
abstract: BACKGROUND
  The optimal effective dose of epidural morphine that provides postoperative analgesia after caesarean section with minimal side effects remains debated.
  
  
  OBJECTIVE
  We performed a systematic review to assess the analgesic efficacy and the incidence of adverse effects of epidural morphine after caesarean section compared to systemic analgesia with opioids.
  
  
  METHODS
  We searched Medline, Embase and Cochrane Collaboration Library databases. Studies were evaluated with the Modified Oxford Scale. Prospective randomized studies comparing analgesic efficacy and/or adverse effects of a single epidural morphine administration versus systemic opioids after elective caesarean section were included.
  
  
  RESULTS
  Ten studies (n=431) were selected. Epidural morphine increases the time until the first request for a rescue analgesic (Emax, 29.7 h; 95% confidence interval, 25.2-33.9) and decreases pain scores and postoperative morphine request during the first 24 h compared to systemic opioid analgesia. However, epidural morphine increases the incidence of pruritus (relative risk, 2.7; 95% CI, 2.1-3.6) and nausea (relative risk, 2.0; 95% CI, 1.2-3.3).
  
  
  CONCLUSIONS
  A single bolus of epidural morphine provides better analgesia than parenteral opioids but with an effect limited to the first postoperative day after caesarean section and with an increase in morphine side effects.
authors.affiliation: Département d'Anesthésie-Réanimation, Groupe Hospitalier Cochin Port Royal, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Université René Descartes, Paris, France. mariepierre.bonnet@9online.fr
authors.forename: Marie-Pierre
authors.initials: MP
authors.lastname: Bonnet
authors.forename: Alexandre
authors.initials: A
authors.lastname: Mignon
authors.forename: Jean-Xavier
authors.initials: JX
authors.lastname: Mazoit
authors.forename: Yves
authors.initials: Y
authors.lastname: Ozier
authors.forename: Emmanuel
authors.initials: E
authors.lastname: Marret
mesh_terms: D000328:Adult; D015360:Analgesia, Epidural / Q000009:adverse effects; D000701:Analgesics, Opioid / Q000008:administration & dosage* / Q000009:adverse effects; D000773:Anesthesia, Obstetrical / Q000009:adverse effects*; D002585:Cesarean Section / Q000009:adverse effects*; D005260:Female; D006801:Humans; D007263:Infusions, Parenteral / Q000009:adverse effects; D009020:Morphine / Q000008:administration & dosage / Q000009:adverse effects*; D010149:Postoperative Pain / Q000188:drug therapy* / Q000209:etiology; D011247:Pregnancy; D055815:Young Adult
chemical_list: D000701:Analgesics, Opioid; D009020:Morphine