title: Side Effects and Efficacy of Neuraxial Opioids in Pregnant Patients at Delivery: A Comprehensive Review.
abstract: Neuraxial opioids are an integral part of obstetric anaesthesia and have contributed to greatly improved analgesia for labour and caesarean delivery, both intraoperatively and postoperatively. Despite these advantages, neuraxial opioids may be associated with a number of side effects, some of which (such as respiratory depression), although rare, may be associated with significant morbidity and mortality. The risk of respiratory depression appears to be increased with less lipophilic opioids such as morphine but can be reduced with careful patient selection and monitoring. Other side effects such as pruritus and nausea and vomiting appear to be dose-related and so can be limited by choosing the appropriate dose to optimise analgesia whilst limiting the adverse effects. Urinary retention, the potential neurotoxic effects of neuraxial opioids and the postulated effects on the foetus are also considered but currently it is felt there is not enough evidence to make strong recommendations with regard to specific drugs or dosage. This review aims to discuss the mechanism and incidence of these side effects as well as, where possible, their prevention.
authors.affiliation: Frimley Health NHS Foundation Trust, Portsmouth Road, Frimley, Surrey, UK. drsaraharmstrong@gmail.com.
authors.forename: Sarah
authors.initials: S
authors.lastname: Armstrong
authors.affiliation: University College London Hospitals, London, UK.
authors.forename: Roshan
authors.initials: R
authors.lastname: Fernando
mesh_terms: D000701:Analgesics, Opioid / Q000009:adverse effects* / Q000627:therapeutic use*; D002585:Cesarean Section / Q000009:adverse effects*; D005260:Female; D006801:Humans; D010146:Pain / Q000188:drug therapy*; D036801:Parturition / Q000187:drug effects*; D011247:Pregnancy
chemical_list: D000701:Analgesics, Opioid
references.citation: Br J Anaesth. 2003 May;90(5):665-70
references.pmid: 12697596
references.citation: J Med Assoc Thai. 2002 Sep;85 Suppl 3:S956-62
references.pmid: 12452235
references.citation: J Neurosci. 2011 Jan 26;31(4):1292-301
references.pmid: 21273414
references.citation: Anesth Analg. 2005 May;100(5):1472-6, table of contents
references.pmid: 15845709
references.citation: J Obstet Gynecol Neonatal Nurs. 2005 May-Jun;34(3):335-41
references.pmid: 15890832
references.citation: Anesth Analg. 1992 May;74(5):677-82
references.pmid: 1533106
references.citation: J Clin Anesth. 1992 Sep-Oct;4(5):390-3
references.pmid: 1389194
references.citation: Anesthesiology. 1994 Oct;81(4):1083
references.pmid: 7943823
references.citation: Anesth Analg. 2010 Nov;111(5):1238-41
references.pmid: 20881282
references.citation: Reg Anesth. 1996 Sep-Oct;21(5):424-9
references.pmid: 8896002
references.citation: Anesth Analg. 1983 Jul;62(7):666-72
references.pmid: 6859570
references.citation: Lancet. 1979 Aug 18;2(8138):356-7
references.pmid: 89412
references.citation: J Anesth. 2012 Oct;26(5):752-7
references.pmid: 22674156
references.citation: Int Breastfeed J. 2006 Nov 29;1:25
references.pmid: 17331266
references.citation: Anaesthesia. 2005 May;60(5):453-7
references.pmid: 15819765
references.citation: Anesth Analg. 2007 Sep;105(3):764-9
references.pmid: 17717237
references.citation: Lancet. 1979 Jun 30;1(8131):1410-1
references.pmid: 87874
references.citation: Anaesthesia. 2006 Jan;61(1):29-31
references.pmid: 16409339
references.citation: Br J Anaesth. 2015 Mar;114(3):469-76
references.pmid: 25567476
references.citation: Acta Anaesthesiol Scand. 2010 Jul;54(6):764-9
references.pmid: 20236094
references.citation: Can J Anaesth. 1989 Mar;36(2):165-85
references.pmid: 2565167
references.citation: Can Anaesth Soc J. 1982 Jul;29(4):359-63
references.pmid: 7104806
references.citation: Anesth Analg. 1999 Aug;89(2):378-83
references.pmid: 10439751
references.citation: Anesthesiology. 1999 Feb;90(2):437-44
references.pmid: 9952150
references.citation: Int J Obstet Anesth. 2005 Jan;14(1):22-5
references.pmid: 15627534
references.citation: Cancer J. 2001 May-Jun;7(3):219-27
references.pmid: 11419030
references.citation: Acta Anaesthesiol Scand. 2010 Nov;54(10):1265-9
references.pmid: 21039348
references.citation: Anesth Analg. 2007 Mar;104(3):679-83
references.pmid: 17312229
references.citation: Anesth Analg. 1997 Dec;85(6):1288-93
references.pmid: 9390596
references.citation: Cochrane Database Syst Rev. 2012 Mar 14;(3):CD009234
references.pmid: 22419342
references.citation: Rev Bras Anestesiol. 2007 Feb;57(1):39-51
references.pmid: 19468617
references.citation: Anesth Analg. 2003 Jul;97(1):247-52, table of contents
references.pmid: 12818975
references.citation: N Engl J Med. 2009 Oct 1;361(14):1376-85
references.pmid: 19797284
references.citation: Anesth Analg. 2009 Jul;109(1):174-82
references.pmid: 19535708
references.citation: Anesth Analg. 1996 Oct;83(4):776-81
references.pmid: 8831320
references.citation: Anesthesiology. 1991 Jun;74(6):1153-5
references.pmid: 2042770
references.citation: Int J Obstet Anesth. 2011 Apr;20(2):110-7
references.pmid: 21194921
references.citation: Anesth Analg. 1984 Jan;63(1):8-14
references.pmid: 6691568
references.citation: Anaesthesia. 1993 Oct;48(10):856-61
references.pmid: 8238826
references.citation: Int J Obstet Anesth. 2010 Jul;19(3):273-7
references.pmid: 20627690
references.citation: J Bone Joint Surg Am. 2006 Feb;88(2):273-81
references.pmid: 16452737
references.citation: Anesth Analg. 1997 Jun;84(6):1256-61
references.pmid: 9174303
references.citation: Nurs Womens Health. 2015 Apr-May;19(2):154-63
references.pmid: 25900586
references.citation: Anesthesiology. 1981 Feb;54(2):136-40
references.pmid: 7008655
references.citation: Anesthesiology. 1991 Dec;75(6):1025-34
references.pmid: 1835823
references.citation: Reg Anesth Pain Med. 1998 Jul-Aug;23(4):418-23
references.pmid: 9690596
references.citation: Anesth Analg. 1990 Feb;70(2):168-71
references.pmid: 2301748
references.citation: Int J Obstet Anesth. 2005 Jul;14(3):230-41
references.pmid: 15935649
references.citation: Curr Opin Anaesthesiol. 2013 Jun;26(3):288-95
references.pmid: 23563797
references.citation: Br Med J. 1980 Aug 2;281(6236):351-3
references.pmid: 6893559
references.citation: Int J Obstet Anesth. 2010 Jul;19(3):246-53
references.pmid: 20171873
references.citation: Obstet Gynecol. 2013 Mar;121(3):615-23
references.pmid: 23635626
references.citation: Acta Anaesthesiol Sin. 1997 Dec;35(4):209-16
references.pmid: 9553236
references.citation: Anesth Analg. 2011 Aug;113(2):251-8
references.pmid: 21642610
references.citation: Anesth Analg. 2013 Feb;116(2):399-405
references.pmid: 23302971
references.citation: Int J Obstet Anesth. 2010 Jan;19(1):10-5
references.pmid: 19954964
references.citation: Acta Anaesthesiol Belg. 2009;60(2):109-22
references.pmid: 19594093
references.citation: Anesth Analg. 2001 Mar;92(3):665-8
references.pmid: 11226098
references.citation: Br J Anaesth. 2012 Mar;108(3):374-83
references.pmid: 22307240
references.citation: Anesth Analg. 1996 Oct;83(4):742-6
references.pmid: 8831313
references.citation: Eur J Anaesthesiol. 2013 Mar;30(3):102-5
references.pmid: 23022704
references.citation: Br J Anaesth. 2008 Sep;101(3):311-9
references.pmid: 18611915
references.citation: Anesth Analg. 1983 Jul;62(7):641-7
references.pmid: 6859567
references.citation: Can J Anaesth. 2003 Aug-Sep;50(7):679-88
references.pmid: 12944442
references.citation: Reg Anesth. 1991 Mar-Apr;16(2):84-8
references.pmid: 2043531
references.citation: Anesth Analg. 1997 Nov;85(5):1088-90
references.pmid: 9356104
references.citation: Anesth Analg. 2012 Apr;114(4):813-22
references.pmid: 22344239
references.citation: Drugs. 2011 Oct 1;71(14):1807-19
references.pmid: 21942973
references.citation: Anesthesiology. 2003 Jul;99(1):174-87
references.pmid: 12826858
references.citation: Can J Anaesth. 1990 Sep;37(6):636-40
references.pmid: 2208533
references.citation: Anesth Analg. 2000 Jul;91(1):172-5
references.pmid: 10866907
references.citation: Anesthesiology. 1990 Feb;72(2):233-7
references.pmid: 2105673
references.citation: J Infect Dis. 2002 Oct 15;186 Suppl 1:S3-28
references.pmid: 12353183
references.citation: Anesth Analg. 2008 Dec;107(6):2073-8
references.pmid: 19020161
references.citation: Anaesth Intensive Care. 1995 Aug;23(4):433-7
references.pmid: 7485932
references.citation: Anaesthesia. 2005 Dec;60(12):1168-72
references.pmid: 16288613
references.citation: Curr Opin Anaesthesiol. 2009 Jun;22(3):327-9
references.pmid: 19352174
references.citation: Anesthesiology. 1993 Jul;79(1):49-59; discussion 25A
references.pmid: 8342828
references.citation: Can J Anaesth. 1998 Sep;45(9):880-3
references.pmid: 9818112
references.citation: Anesth Analg. 1992 Nov;75(5):747-52
references.pmid: 1416128
references.citation: BJOG. 2002 Mar;109(3):274-81
references.pmid: 11950182
references.citation: Br J Anaesth. 1997 Mar;78(3):311-3
references.pmid: 9135312
references.citation: Anaesthesia. 2000 Oct;55(10):1008-13
references.pmid: 11012498
references.citation: Br J Anaesth. 1984 Dec;56(12):1351-60
references.pmid: 6548639
references.citation: Anesthesiology. 1994 Jun;80(6):1209-15
references.pmid: 8010467
references.citation: Anesth Analg. 1990 Oct;71(4):367-70
references.pmid: 2205128
references.citation: J Pain Res. 2014 Nov 06;7:615-26
references.pmid: 25395870
references.citation: Int J Obstet Anesth. 2005 Oct;14(4):279-83
references.pmid: 16143507
references.citation: Anesthesiology. 1999 Dec;91(6):1919-27
references.pmid: 10598635
references.citation: Anaesthesia. 2007 Jul;62(7):750
references.pmid: 17567364
references.citation: Anesth Analg. 1998 Mar;86(3):598-612
references.pmid: 9495424
references.citation: Acta Anaesthesiol Scand. 2003 Jan;47(1):13-9
references.pmid: 12492791
references.citation: Anesthesiology. 2004 Jun;100(6):1497-503
references.pmid: 15166570
references.citation: Anesth Analg. 2000 May;90(5):1162-6
references.pmid: 10781472
references.citation: Int J Obstet Anesth. 2010 Apr;19(2):204-8
references.pmid: 20202820
references.citation: Anaesthesia. 2014 May;69(5):458-67
references.pmid: 24738803
references.citation: J Surg Orthop Adv. 2014 Spring;23(1):9-12
references.pmid: 24641892
references.citation: Can J Anaesth. 1999 Sep;46(9):856-60
references.pmid: 10490154
references.citation: J Clin Anesth. 2003 May;15(3):234-9
references.pmid: 12770663
references.citation: Am J Surg. 2009 Sep;198(3):456-9
references.pmid: 19716889
references.citation: Acta Anaesthesiol Scand. 2006 Mar;50(3):364-7
references.pmid: 16480472
references.citation: Eur J Obstet Gynecol Reprod Biol. 1991 Nov 26;42(2):89-94
references.pmid: 1765214
references.citation: Cochrane Database Syst Rev. 2012 Sep 12;(9):CD007579
references.pmid: 22972112
references.citation: Anesth Analg. 1982 Jun;61(6):490-5
references.pmid: 7200737
references.citation: Anesthesiology. 1994 Oct;81(4):899-920
references.pmid: 7943841
references.citation: Anesth Analg. 1989 Apr;68(4):530-3
references.pmid: 2522749
references.citation: Anesth Analg. 2005 Apr;100(4):1150-8
references.pmid: 15781537
references.citation: Obstet Gynecol. 1984 Mar;63(3):409-13
references.pmid: 6700866
references.citation: Eur J Pharmacol. 1984 Feb 17;98(2):235-40
references.pmid: 6325218
references.citation: Br J Anaesth. 2007 Feb;98(2):241-5
references.pmid: 17210732
references.citation: Acta Anaesthesiol Scand. 1988 Apr;32(3):253-9
references.pmid: 3364150
references.citation: Anesth Analg. 2002 Feb;94(2):409-14, table of contents
references.pmid: 11812709
references.citation: Anesth Analg. 1988 Apr;67(4):318-23
references.pmid: 3354864
references.citation: Anesth Analg. 1985 Aug;64(8):786-91
references.pmid: 4014743
references.citation: Anesth Analg. 1987 Sep;66(9):887-93
references.pmid: 3113291
references.citation: Can J Anaesth. 1989 Jul;36(4):388-91
references.pmid: 2569364
references.citation: Int J Obstet Anesth. 2013 Jan;22(1):36-41
references.pmid: 23159009
references.citation: J Pharmacol Exp Ther. 1984 Nov;231(2):254-60
references.pmid: 6092610
references.citation: J Anaesthesiol Clin Pharmacol. 2013 Jul;29(3):303-7
references.pmid: 24106351
references.citation: J Pain Symptom Manage. 2001 Feb;21(2):151-68
references.pmid: 11226766
references.citation: Obstet Gynecol. 1994 Dec;84(6):931-6
references.pmid: 7970472
references.citation: Can Anaesth Soc J. 1986 Jan;33(1):115-6
references.pmid: 3948041
references.citation: Anesthesiology. 2005 May;102(5):1014-22
references.pmid: 15851890
references.citation: Anesth Analg. 2013 Sep;117(3):677-85
references.pmid: 23921652
references.citation: Anesth Analg. 2007 Nov;105(5):1413-9, table of contents
references.pmid: 17959975
references.citation: Anesthesiology. 2009 Feb;110(2):218-30
references.pmid: 19194148
references.citation: Br J Anaesth. 1990 Feb;64(2):243-5
references.pmid: 2317428
references.citation: Anesth Analg. 1988 Feb;67(2):137-43
references.pmid: 3277478
references.citation: J Neurosurg Spine. 2005 Jan;2(1):17-22
references.pmid: 15658121
references.citation: Anesthesiology. 1998 Aug;89(2):364-70
references.pmid: 9710394
references.citation: Anesth Analg. 2000 Apr;90(4):887-91
references.pmid: 10735794
references.citation: Anesth Analg. 2008 Oct;107(4):1308-12
references.pmid: 18806045
references.citation: Semin Pediatr Infect Dis. 2005 Oct;16(4):271-81
references.pmid: 16210107
references.citation: Anaesthesia. 1996 Sep;51(9):871-3
references.pmid: 8882255
references.citation: Knee Surg Sports Traumatol Arthrosc. 2004 Mar;12(2):155-8
references.pmid: 15024563
references.citation: Minerva Anestesiol. 2011 Aug;77(8):781-8
references.pmid: 21730925
references.citation: Anesthesiology. 1992 Jan;76(1):91-9
references.pmid: 1729942
references.citation: Clin Exp Dermatol. 2010 Jan;35(1):2-6
references.pmid: 19663845
references.citation: Anesthesiology. 2005 Dec;103(6):1211-7
references.pmid: 16306734
references.citation: Obstet Gynecol. 2009 Jan;113(1):41-7
references.pmid: 19104358
references.citation: Anesth Analg. 2013 Dec;117(6):1368-70
references.pmid: 24257387
references.citation: Anaesthesia. 2011 Mar;66(3):191-212
references.pmid: 21320088
references.citation: Anesth Analg. 1995 Oct;81(4):829-32
references.pmid: 7574018
references.citation: Can J Anaesth. 2012 Jul;59(7):681-703
references.pmid: 22535232
references.citation: Anesthesiology. 1995 Aug;83(2):300-8
references.pmid: 7631952
references.citation: Anesth Analg. 1993 Dec;77(6):1155-60
references.pmid: 8250307
references.citation: Life Sci. 1978 Oct 30;23(17-18):1797-804
references.pmid: 214653
references.citation: Anesth Analg. 2000 Oct;91(4):865-70
references.pmid: 11004039
references.citation: Anesth Analg. 2005 Apr;100(4):1065-74
references.pmid: 15781524
references.citation: Anaesth Intensive Care. 2002 Oct;30(5):698-9
references.pmid: 12413273
references.citation: Anaesthesia. 2010 Feb;65(2):145-53
references.pmid: 19912160
references.citation: Anesth Analg. 2007 Jul;105(1):176-83
references.pmid: 17578973
references.citation: Anesthesiology. 1998 Jul;89(1):79-85
references.pmid: 9667297
references.citation: J Obstet Gynaecol Res. 1999 Jun;25(3):209-13
references.pmid: 10467795
references.citation: Anaesthesia. 1996 Feb;51(2):173-5
references.pmid: 8779376
references.citation: Anesth Analg. 1984 Mar;63(3):319-24
references.pmid: 6703348
references.citation: Anaesthesia. 1987 Nov;42(11):1156-61
references.pmid: 2963561
references.citation: Anesth Analg. 1996 Mar;82(3):641-7
references.pmid: 8623975
references.citation: Int J Obstet Anesth. 1994 Jul;3(3):127-31
references.pmid: 15636934
references.citation: Anesth Analg. 2000 Sep;91(3):601-5
references.pmid: 10960384
references.citation: Anesth Analg. 2004 Apr;98(4):1153-9, table of contents
references.pmid: 15041616
references.citation: Reg Anesth Pain Med. 2005 Mar-Apr;30(2):134-9
references.pmid: 15765455
references.citation: Anesthesiology. 1992 Jul;77(1):162-84
references.pmid: 1609990
references.citation: Eur J Pain. 2010 Oct;14(9):894.e1-9
references.pmid: 20381390
references.citation: Reg Anesth. 1991 May-Jun;16(3):137-40
references.pmid: 1883770
references.citation: Can J Anaesth. 1997 Oct;44(10):1060-5
references.pmid: 9350364
references.citation: Br J Anaesth. 1991 Jun;66(6):645-50
references.pmid: 2064878
references.citation: Anaesthesia. 1996 Dec;51(12):1133-8
references.pmid: 9038449
references.citation: Anesth Analg. 2008 Sep;107(3):956-61
references.pmid: 18713913
references.citation: Reg Anesth Pain Med. 2001 Jul-Aug;26(4):306-9
references.pmid: 11464347
references.citation: Eur J Clin Pharmacol. 2005 Aug;61(7):517-22
references.pmid: 16021436
references.citation: Anesthesiology. 1986 Jan;64(1):54-66
references.pmid: 2867722
references.citation: Anesthesiology. 1983 Sep;59(3):175-81
references.pmid: 6881580