Metoclopramide for nausea and vomiting prophylaxis during and after Caesarean section

1. Dr Shaikh Mohd Mudassir
DNB Anaesthesia
Saifee Hospital, Mumbai.

2.  Intra and post operative nausea and vomiting(IONV& PONV)
are common during caesarean delivery.
 Incidence of IONV has been reported to be 60-80% as per
various studies.

3.  Multifactorial
 Progesterone induced reduction in lower
esophageal sphincter(LOS) tone.
 Increased intra gastric pressure.
 Hypotension
 Exteriorization of uterus.
 Visceral stimulation.
 Use of neuraxial opiods

5.  Prokinetic drug.
 Increases tone of lower esophageal sphincter
 Increase gastric and small intestinal motility
 Relaxation of pylorus and duodenum during stomach
contraction
 Antidopaminergic action at chemoreceptor trigger zone
 At higher doses has antiserotonergic activity

6. 11 RCT S included in final analysis
13 RCTS considered for inclusion
46 PUBLICATIONS ASSESSED FOR
INCLUSION
COMBINING SEARCH DATABASES
RESULTED IN 475 PUBLICATIONS
LITERATURE SEARCH
Databases:medline, central, Google scholar and EMBASE
429 excluded:
269 duplicates
115 metoclopramide not used
17 reviews
12 case reports
11 abstracts
2 surveys
1 non human studies
1 letter to editor
1 commentary
33 excluded:
12 non caesarean
8 no control group
7 general anesthesia
3 end points different than PONV
2 Persian
1 anesthesia not std
2 excluded:
1 combined nausea vomiting results
1 duplicate publication

7.  Total 11 studies were included in final analysis.
 Total number of patients were 702(349 received
metoclopramide and 353 received placebo)
 Spinal anesthesia was used in nine studies and
epidural in two studies
 Metoclopramide was used in a dose of 10mg
before block placement in 4 studies and after
clamping umbilical cord in seven studies

8.  In three studies where perinorm was given before block
placement, there was statistically significant reduction in
incidence of ION& IOV(RR 0.27;95% CI 0.16,0.45)

9. In six studies where perinorm was used after delivery, four used spinal
anesthesia and two used epidural anesthesia. Pooled results from these
six studies showed statistically significant reduction in incidence of post
delivery ION & IOV in metoclopramide group(RR 0.38;95% CI 0.20,0.75).

10. •Only one study where perinorm was given before block placement reported
on use of rescue antiemetic with no difference between the groups.
• In two studies where perinorm was given after clamping the cord there was
statistically significant reduction in use of rescue antiemetic treatment when
compared to placebo.

11.  Three studies reported on early post operative nausea and
vomiting. Spinal was used in two studies and epidural in one
study. combining results of all three studies showed
statistically significant reduction in incidence of PON & POV in
metoclopramide treated patients.
 Extra pyramidal side effects were evaluated in six studies,
with no reported occurrence in any patients.
 Sedation was studied in three studies with no difference in
the two groups.
 Anxiety scores were similar in both study and control groups

12.  This meta-analysis suggests that the
administration of metoclopramide causes a
significant reduction in the incidence of IONV &
PONV in women undergoing cesarean section
under neuraxial anesthesia with no significant side
effects.
 In general surgical population the anti emetic
effects of metoclopramide in a dose of 10mg are
uncertain with 50% studies reporting this dose to
be no better than placebo. Higher doses of 20-
50mg ,however were reported to be effective.

13. •The reasons for this difference are unclear, but may be related to the
impact of physiological changes in pregnancy. Metoclopramide increases
the tone of lower esophageal sphicter,which is reduced during pregnancy
which accounts for higher incidence of reflux in these patients. since
reflux is associated with nausea the increase in LOS with metoclopramide
might account for its effective anti emetic effect in this patient
population.
•Furthermore its Prokinetic effect decreases gastric volume.

14.  The review suggests that the
administration of metoclopramide
in a dose of 10mg is effective,
safe and cost effective for the
prophylaxis against IONV&PONV
in parturient undergoing LSCS
under neuraxial anesthesia.

15. Thank