Commonly used antiemetics for prophylaxis of postoperative nausea and vomiting after Caesarean delivery with neuraxial morphine: a network meta-analysis

Br J Anaesth. 2024 Jun;132(6):1274-1284. doi: 10.1016/j.bja.2024.03.010. Epub 2024 Apr 15.

Abstract

Background: Dopamine antagonists, 5-HT3 antagonists, and dexamethasone are frequently used in obstetrics to prevent postoperative nausea and vomiting (PONV). However, the superiority of any drug class is yet to be established. This network meta-analysis aimed to compare the efficacy of these antiemetics for PONV prophylaxis in women receiving neuraxial morphine for Caesarean delivery.

Methods: We searched PubMed, Embase, CENTRAL, Web of Science, and Wanfang Data for eligible randomised controlled trials. Primary outcomes were the incidences of postoperative nausea (PON) and postoperative vomiting (POV) within 24 h after surgery. We used a Bayesian random-effects model and calculated odds ratios with 95% credible intervals for dichotomous data. We performed sensitivity and subgroup analyses for primary outcomes.

Results: A total of 33 studies with 4238 women were included. In the primary analyses of all women, 5-HT3 antagonists, dopamine antagonists, dexamethasone, and 5-HT3 antagonists plus dexamethasone significantly reduced PON and POV compared with placebo, and 5-HT3 antagonists plus dexamethasone were more effective than monotherapy. In the subgroup analyses, similar results were seen in women receiving epidural morphine or intrathecal morphine alone but not in women receiving intrathecal morphine with fentanyl or sufentanil. However, most included studies had some concerns or a high risk of bias, and the overall certainty of the evidence was low or very low.

Conclusions: Combined 5-HT3 antagonists plus dexamethasone are more effective than monotherapy in preventing PONV associated with neuraxial morphine after Caesarean delivery. Future studies are needed to determine the role of prophylactic antiemetics in women receiving intrathecal morphine and lipophilic opioids.

Systematic review protocol: PROSPERO CRD42023454602.

Keywords: Caesarean delivery; antiemetics; network meta-analysis; neuraxial morphine; postoperative nausea and vomiting; prophylaxis.

Publication types

  • Meta-Analysis
  • Systematic Review
  • Review

MeSH terms

  • Analgesics, Opioid / administration & dosage
  • Analgesics, Opioid / therapeutic use
  • Antiemetics* / administration & dosage
  • Antiemetics* / therapeutic use
  • Cesarean Section* / adverse effects
  • Dexamethasone* / administration & dosage
  • Dexamethasone* / therapeutic use
  • Dopamine Antagonists / administration & dosage
  • Dopamine Antagonists / therapeutic use
  • Female
  • Humans
  • Morphine* / administration & dosage
  • Morphine* / therapeutic use
  • Network Meta-Analysis*
  • Postoperative Nausea and Vomiting* / prevention & control
  • Pregnancy
  • Randomized Controlled Trials as Topic
  • Serotonin 5-HT3 Receptor Antagonists / therapeutic use

Substances

  • Morphine
  • Antiemetics
  • Dexamethasone
  • Analgesics, Opioid
  • Dopamine Antagonists
  • Serotonin 5-HT3 Receptor Antagonists