Abstract
Purpose
We report on a primiparous woman who suffered recurrent seizure activity after repeated small doses of epidural morphine to highlight the neuroexcitation potential of neuraxial opioids in the epileptic patient.
Clinical features
Seizure activities as a complication of opioid administration have been reported in laboratory animals and humans. We report the case of a 30-yr-old primiparous woman with a history of epilepsy under carbamazepine treatment, who had epidural anesthesia for elective Cesarean section at 38 weeks gestation. Postoperatively, 1.5 mg of morphine were administered epidurally for pain control. Three hours later the patient suffered from clonic movements of the right arm without loss of consciousness. One day later, she again received 1 mg of epidural morphine twice at a 12-hr interval and similar seizure episodes recurred eight hours after each dose. A relation between the administration of morphine and seizure activity was suspected and the use of opioids for pain control was stopped. The patient was discharged on the fifth postoperative day and, more than one year after the last episode, she remains free of any seizure activity.
Conclusion
Our report indicates that even a remote history of epilepsy carries a pro-convulsant potential in the peripartum period, even following the administration of small doses of epidural morphine.
Résumé
Objectif
Présenter une primipare qui a souffert ďépilepsie récurrente, après avoir reçu de petites doses répétées de morphine péridurale, pour souligner le potentiel neuroexcitateur des opioïdes neuraxiaux chez ľépileptique.
Éléments cliniques
Les crises ďépilepsie comme complication de ľadministration ďopioïde ont été constatées chez les animaux de laboratoire et chez les humains. Nous présentons le cas ďune primipare de 30 ans, épileptique traitée avec de la carbamazépine, qui a reçu une anesthésie péridurale pour une césarienne réglée à 38 semaines de grossesse. Après ľopération, elle a reçu 1,5 mg de morphine pour ľanalgésie péridurale. Trois heures plus tard, elle a souffert de mouvements cloniques du bras droit sans perte de conscience. Le lendemain, elle a reçu deux doses de 1 mg de morphine péridurale, à 12 h ďintervalle et des crises similaires sont survenues huit heures après chaque dose. Une relation entre la morphine et ľactivité épileptique a été présumée et ľadministration de morphine a été stoppée. La patiente a quitté ľhôpital au cinquième jour postopératoire et n’a subi aucune crise plus ďun an après le dernier épisode.
Conclusion
Notre article indique que même une histoire ancienne ďépilepsie comporte un potentiel pro-convulsivant en période postpartum, après ľadministration péridurale de petites doses de morphine.
Article PDF
Similar content being viewed by others
Avoid common mistakes on your manuscript.
References
Jayawardena B, Hill DJ. Myoclonic spasms after epidural diamorphine infusion. Anaesthesia 1991; 46: 473–4.
Shohami E, Evron S. Intrathecal morphine induces myoclonic seizures in the rat. Acta Pharmacol Toxicol (Copenh) 1985; 56: 50–4.
Gregory RE, Grossman S, Sheidler VR. Grand mal seizures associated with high-dose intravenous morphine infusions: incidence and possible etiology. Pain 1992; 51: 255–8.
Rozan JP, Kahn CH, Warfield CA. Epidural and intravenous opioid-induced neuroexcitation. Anesthesiology 1995; 83: 860–3.
Young GB, da Silva OP. Effects of morphine on the electroencephalograms of neonates: a prospective, observational study. Clin Neurophysiol 2000; 111: 1955–60.
De Conno F, Caraceni A, Martini C, Spoldi E, Salvetti M, Ventafridda V. Hyperalgesia and myoclonus with intrathecal infusion of high-dose morphine. Pain 1991; 47: 337–9.
Borgeat A, Biollaz J, Depierraz B, Neff R. Grand mal seizure after extradural morphine analgesia. Br J Anaesth 1988; 60: 733–5.
Bansinath M, Ramabadran K, Turndorf H, Shukla VK. Intracerebroventricular administration of kappaagonists induces convulsions in mice. Brain Res Bull 1991; 27: 75–9.
Crain SM, Shen KF. Opioids can evoke direct receptormediated excitatory effects on sensory neurons. Trends Pharmacol Sci 1990; 11: 77–81.
Werz MA, Macdonald RL. Opiate alkaloids antagonize postsynaptic glycine and GABA responses: correlation with convulsant action. Brain Res 1982; 236: 107–19.
Chen L, Huang LY. Sustained potentiation of NMDA receptor-mediated glutamate responses through activation of protein kinase C by a mu opioid. Neuron 1991; 7: 319–26.
Foote F, Gale K. Morphine potentiates seizures induced by GABA antagonists and attenuates seizures induced by electroshock in the rat. Eur J Pharmacol 1983; 95: 259–64.
Yaksh TL, Harty GJ. Pharmacology of the allodynia in rats evoked by high dose intrathecal morphine. J Pharmacol Exp Ther 1988; 244: 501–7.
Knill RL, Clement JL, Thompson WR. Epidural morphine causes delayed and prolonged ventilatory depression. Can Anaesth Soc J 1981; 28: 537–43.
Bromage PR, Camporesi EM, Durant PA, Nielsen CH. Nonrespiratory side effects of epidural morphine. Anesth Analg 1982; 61: 490–5.
Frenk H. Pro-and anticonvulsant actions of morphine and the endogenous opioids: involvement and interactions of multiple opiate and non-opiate systems. Brain Res 1983; 287: 197–210.
Bertran F, Denise P, Letellier P. Nonconvulsive status epilepticus: the role of morphine and its antagonist. Neurophysiol Clin 2000; 30: 109–12.
Frost JJ, Mayberg HS, Fisher RS, et al. Mu-opiate receptors measured by positron emission tomography are increased in temporal lobe epilepsy. Ann Neurol 1988; 23: 231–7.
Abboud TK. Maternal and fetal beta endorphin: effects of pregnancy and labour. Arch Dis Child 1988; 63: 707–9.
Smolen A, Smolen TN, van de Kamp JL. The effect of naloxone administration on pregnancy-associated seizures. Life Sci 1986; 38: 1899–905.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Shih, CJ., Doufas, A.G., Chang, HC. et al. Recurrent seizure activity after epidural morphine in a post-partum woman. Can J Anesth 52, 727–729 (2005). https://doi.org/10.1007/BF03016561
Accepted:
Issue Date:
DOI: https://doi.org/10.1007/BF03016561