ORIGINAL ARTICLE
Effect of dexamethasone on prevention of postoperative
nausea, vomiting and pain after caesarean section:
a randomised, placebo-controlled, double-blind trial
Monica M.S. Cardoso, Alexandre O. Leite, Elisa A. Santos, Judymara L. Gozzani and Lgia A.S.T. Mathias
Context Spinal morphine is a common form of postoperative
analgesia after caesarean section, but it is associated with
postoperative nausea and vomiting.
Objective To evaluate the hypothesis that dexamethasone
reduces nausea and vomiting in patients undergoing caesarean
section under spinal anaesthesia with morphine.
Design Interventional, randomised, double-blinded, placebo-
controlled study to evaluate a preoperative single dose of
dexamethasone.
Setting Patients from a tertiary hospital in the city of Sao Paulo,
Sao Paulo, Brazil observed from 1 January through 30 June
2008.
Patients or other participants Seventy full-term pregnant
patients (American Society of Anesthesiologists 1 or 2)
were studied. Patients were randomly allocated into
two groups determined by a computerised table. Exclusion
criteria were contraindication to regional anaesthesia,
allergy to dexamethasone, opioids or local anaesthetics,
hypertension or diabetes originated during pregnancy and
use of any antiemetic drug received before surgery. Spinal
anaesthesia consisted of hyperbaric bupivacaine and
morphine.
Introduction
A low dose of spinal morphine is probably the most
common form of postoperative analgesia after caesarean
section. Its main advantages are its low cost and simpli-
city and the fact that a single spinal dose usually provides
high-quality postoperative analgesia for a full 24 h. How-
ever, dose-related side-effects, such as pruritus, nausea
and vomiting, may occur. Nausea and vomiting may be
extremely unpleasant after caesarean section and may
reduce the patients satisfaction, not only impairing the
quality of postoperative care but also jeopardising the
new mothers ability to take care of her baby.
Several strategies have been used to reduce the incidence
of nausea and vomiting after caesarean section under
regional anaesthesia combined with opioids. Research
has focused on various antiemetic agents, used either
alone or in combination with other drugs in varying
regimens. A single dose of dexamethasone administered
immediately before surgery has been shown to reduce the
incidence of nausea and vomiting in patients undergoing
From the Faculdade de Ciencias Medicas da Santa Casa de Sao Paulo, Sao Paulo,
Sao Paulo, Brazil
Correspondence to Dr Lgia A.S.T. Mathias, Alameda Campinas 139/41, Sao
Paulo, SP 01404-000, Brazil
E-mail: rtimao@uol.com.br
0265-0215 2013 Copyright European Society of Anaesthesiology
Copyright European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited.
Intervention Patients received either dexamethasone 10 mg in
100 ml of isotonic saline, intravenously or 100 ml of isotonic
saline (placebo) prior to surgery.
Main outcome Incidence of postoperative nausea and vomiting
in the first 24 h were rated and recorded. Pain scores at rest and
on movement were evaluated using a visual analogue scale.
Results During the first 24 hours, nausea occured in 12/35
(34.4%) patients receiving dexamethasone and in 32/35
(91.4%) receiving placebo (P < 0.001). During the same time
period, vomiting occured in 12/35 (34.4%) patients receiving
dexamethasone and in 29/35 (82.9%) receiving placebo
(P < 0.001). Pain at rest and pain on movement was lower in
patients who received dexamethasone at some time points
during the study period.
Conclusion Dexamethasone reduced the cumulative incidence
of nausea and vomiting after caesarean section under spinal
anaesthesia with morphine and lowered pain scores on the first
postoperative day.
Eur J Anaesthesiol 2013; 30:102105
Published online 2 October 2012
Keywords: anaesthesia, caesarean section, dexamethasone, morphine,
spinal
caesarean section under both epidural and spinal anaes-
thesia with 3 mg and 200 mg of morphine.14 Our current
protocol uses a much smaller dose of spinal morphine
(60 mg) in combination with systemic NSAIDs as part of a
multimodal approach for analgesia after caesarean sec-
tion. Reducing the morphine dose may contribute to a
reduced incidence of nausea and vomiting in the
postoperative period.
The purpose of the study was to evaluate whether a
single dose of dexamethasone given immediately before
surgery prevented nausea and vomiting in patients
undergoing caesarean under spinal anaesthesia utilising
a small dose of morphine.
Methods
This interventional, double-blinded and randomised,
placebo-controlled study protocol was approved by the
local Hospital Ethics Committee (Comite de Etica em
Pesquisa of Irmandade Santa Casa de Sao Paulo, Sao
Paulo, Sao Paulo, Brazil; Ethical Committee number:
269/07; Chairperson: Professor Dr Nelson Keiske Ono,
date of meeting: 11 July 2007). Full-term pregnant
patients (ASA physical status 1 or 2) undergoing elective
caesarean section under spinal anaesthesia were recruited
and written informed consent was obtained from all
DOI:10.1097/EJA.0b013e328356676b
 Dexamethasone for nausea and vomiting after caesarean section 103

participants. Patients were invited to participate during
their admission to a pre-partum room. Patients were
excluded if they had any contraindication to receiving
regional anaesthesia; were allergic to dexamethasone, to
opioids or local anaesthetics; presented with pregnancy-
induced hypertension or diabetes; or had received any
antiemetic drug in the 24 h prior to the scheduled
caesarean section.
Patients were randomly allocated into two groups using a
computer-generated table and received a single dose of
dexamethasone 10 mg in 100 ml 0.9% saline immediately
prior to surgery or placebo (100 ml 0.9% saline).
Spinal anaesthesia was administered with 15 mg of hyper-
baric bupivacaine and 60 mg of morphine. Patients
received 10 ml kg
1 of lactated Ringers solution. Blood
pressure was measured every 3 min until delivery and
hypotension was treated with a 0.2 mg bolus of metar-
aminol. Hypotension was defined as any decrease in the
SBP from the control value defined as the mean of three
measurements obtained immediately before the admin-
istration of spinal anaesthesia. After their infants were
delivered, patients received ketoprofen 100 mg, dipyrone
2 g and oxytocin 15 IU intravenously. Starting 6 h after
delivery, patients received diclofenac 75 mg orally every
8 h and dipyrone 2 g every 6 h.
The study was double-blinded and the anaesthesiologist
who was responsible for the postoperative evaluations
was not present during surgery. The evaluations were
performed every hour for the first 3 h and then at 6, 12 and
24 h following the administration of spinal morphine.
The primary endpoint was the incidence of nausea and
vomiting in the first 24 h after surgery. Patients who had
a nausea score more than 1 (0 no nausea; 1 mild;
2 moderate; and 3 severe nausea) or who had two
or more episodes of vomiting were treated with dimen-
hydrinate 50 mg and pyridoxine 10 mg. Pain was evalu-
ated using a visual analogue scale (VAS) (0 no pain and
10 worst pain possible) at rest and on movement. To

Fig. 1

Enrolment
Assessed for eligibility (n = 455)

Excluded (n = 324)
Not meeting inclusion criteria (n = 324)
Declined to participate (n = 0)
Other reasons (n = 0)

Randomised (n = 131)

Excluded as not the first patient

on the day (n = 61)

Allocation
Allocated to dexamethasone (n = 35) Allocated to saline infusion (n = 35)
Received dexamethasone (n = 35) Received saline infusion (n = 35)
Did not receive dexamethasone (n = 0) Did not receive saline infusion (n = 0)

Follow-up
Lost to follow-up (n = 0) Lost to follow-up (n = 0)
Discontinued intervention (n = 0) Discontinued intervention (n = 0)

Analysis
Analysed (n = 35) Analysed (n = 35)
Excluded from analysis (n = 0) Excluded from analysis (n = 0)

Study flow diagram for 70 patients undergoing elective caesarean section under spinal anaesthesia with low-dose morphine.

European Journal of Anaesthesiology 2013, Vol 30 No 3

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 104 Cardoso et al.

evaluate pain with movement, patients were asked to Table 2 The effect of dexamethasone on the incidence of nausea,
vomiting and pain at rest and with movement following caesarean
cough while in the recovery room and asked to sit in bed section under spinal anaesthesia
while in the ward. Breakthrough pain (>3 on the VAS or
Dexamethasone Control
when indicated as such by the patient) was treated with group group
tramadol 100 mg infused over 20 min. (n U 35) (n U 35) P

Fishers exact test was used to compare the incidence of At 1 h

nausea, vomiting, pain at rest and pain with movement at Nausea 6 (17%) 11 (31%) NS
Vomiting 6 (17%) 11 (31%) NS
multiple time points. The time to event analysis was Pain at rest 3 (9%) 9 (26%) NS
performed using KaplanMeier curves and the log-rank Pain with movement 5 (14%) 15 (43%) 0.001
At 2 h
test, considering nausea or vomiting as a unique event Nausea 4 (11%) 9 (26%) NS
and pain at any time within the first 24 h of treatment as Vomiting 4 (11%) 6 (17%) NS
an event. The sample size was determined prospectively; Pain at rest 4 (11%) 11 (31%) NS
Pain with movement 6 (17%) 14 (41%) NS
with 33 patients per group. A reduction in the incidence At 3 h
of nausea and vomiting from 35% to 10% at any time Nausea 1 (3%) 6 (17%) NS
Vomiting 1 (3%) 6 (17%) NS
within the first 24 h of treatment could be determined Pain at rest 6 (17%) 14 (41%) NS
with a statistical power of 85% (b0.85), assuming stat- Pain with movement 6 (17%) 14 (41%) NS
istical significance at 0.05 (a0.05). At 6 h
Nausea 1 (23%) 2 (6%) NS
Vomiting 1 (3%) 2 (6%) NS
Pain at rest 2 (6%) 12 (34%) 0.005
Results Pain with movement 4 (11%) 16 (46%) 0.003
Seventy full-term pregnant patients were studied (Fig. 1) At 12 h
from 1 January to 30 June 2008. Only patients who were Nausea 0 2 (6%) NS
Vomiting 0 2 (6%) NS
scheduled as the first procedure of the day were included. Pain at rest 4 (11%) 10 (29%) NS
The groups comprised 35 patients each and patient Pain with movement 4 (11%) 15 (43%) 0.006
characteristics were similar in the two groups (Table 1). At 24 h
Nausea 0 2 (6%) NS
The incidence of nausea and vomiting was similar Vomiting 0 2 (6%) NS
Pain at rest 5 (14%) 10 (29%) NS
between the two groups during the periods of obser- Pain with movement 5 (14%) 15 (43%) 0.01
vation. At 6 h pain at rest was lower in the group who
Values are number (proportion).
received dexamethasone. Pain with movement was lower
among patients who received dexamethasone at 1, 6, 12
and 24 h (Table 2). The cumulative incidence of nausea patients who underwent caesarean section under spinal
and vomiting for the period in the post-anaesthesia care anaesthesia, including spinal morphine, did not prevent
unit (up to 3 h after surgery) and in the ward (between 3 nausea and vomiting during the postoperative period. Wu
and 24 h after surgery) was lower in the patients who et al.1 observed a benefit when dexamethasone was used
received dexamethasone (Table 3). in combination with droperidol, and Nortcliffe et al.2
found that 50 mg of intravenous cyclizine alone was
better than dexamethasone. Both of the studies used a
Discussion much higher dose of morphine than we use in our current
Our results indicate a lower cumulative incidence of practice (200 vs. 60 mg) which may explain the difference
nausea and vomiting with dexamethasone, although in the incidence of nausea and vomiting between their
the incidence was not lower at all time points. Dexa- studies and ours (33 vs. 10%, respectively).
methasone also reduced pain scores at rest and with
movement during the first postoperative day. Jokela et al.5 reported similar findings with regard to
1 2 improved postoperative pain control; they found that
Wu et al. and Nortcliffe et al. found that a single dose
of dexamethasone administered to full-term pregnant dexamethasone 10 mg administered intravenously
immediately before induction of anaesthesia in patients
undergoing laparoscopic hysterectomy reduced oxyco-
Table 1 Patient characteristics and postoperative nausea and done consumption during the first two postoperative
vomiting-related variables for 70 patients undergoing elective
caesarean section under spinal anaesthesia hours. However, it should be emphasised that the study
population, the anaesthetic technique and the surgical
Dexamethasone Control
group (n U 35) group (n U 35) procedure were different from those in our study. These
differences may explain why they observed a major
Age (years) 28.2 (5.4) 26.1 (5.3)
Weight (kg) 86.0 (6.3) 86.0 (6.5)
benefit only during the first 2 h, whereas in our study
Height (cm) 166.1 (3.9) 165.8 (3.4) dexamethasone was advantageous during the first 24 h. It
Previous PONV 17 19 is known that pregnancy may significantly modify the
Smoker 7 8
pain modulation process after a surgical procedure. The
Values are mean (SD) and number. PONV, postoperative nausea and vomiting. outcome measures also varied between the two studies:

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 Dexamethasone for nausea and vomiting after caesarean section 105
Table 3 Incidence of nausea and vomiting in the post-anaesthesia care unit, ward and first 24 h in dexamthasone and control groups
Nausea (n U 35)
Dexamethasone Control
PACU (0 to 3 h) 11 26
Ward (3 to 24 h) 1 6
Total (0 to 24 h) 12 32
PACU, postanaesthesia care unit.
Jokela et al. used a reduction in the oxycodone consump-
tion of patients who were using patient-controlled analge-
sia pumps, whereas we evaluated pain using VAS pain
scores at rest and on movement. Other studies have also
demonstrated the potential benefits of steroids for
improving the quality of postoperative analgesia, both
at rest and with movement, which is of special interest in
the obstetric population, as mothers generally want to
take care of their babies. Wu et al. also demonstrated that
the VAS scores during rest or with movement between
6 and 24 h postoperatively were lower in patients who
received dexamethasone.1 The analgesic effects of
steroids are mainly provided through peripheral inhi-
bition of phospholipase enzymes which decreases the
products of the cyclooxygenase and lipoxygenase path-
ways in the inflammatory response.6 These character-
istics make dexamethasone a suitable drug for the
treatment of pain, both at rest and on movement.7
The potential side-effects of steroids used during the
postoperative period remain a concern. One of the major
problems is impaired wound healing during the acute
postoperative period. However, meta-analyses indicate
that a single dose of dexamethasone does not increase
infection or other complications.8,9 Another concern is
respiratory depression after the use of intrathecal mor-
phine as constituent of a spinal anaesthesia. Although
there was no specific protocol to address this side-effect,
the dose used was considered to be small enough to carry
a low risk of respiratory depression.10,11
Our study included only a small number of participants
when the total number in our hospital is considered. The
service is in a tertiary referral hospital and the majority of
patients admitted had pregnancy-related problems or
were hospitalised for some time prior to their due date.
In addition, although patients may have declared an
understanding of the protocol, some were not included
because they were considered illiterate by the investi-
gator who interviewed them (M.M.C.S.). Thus, there was
a risk of a type II error because the study did not have
sufficient power to detect a statistically significant differ-
ence between the groups.
Copyright European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited.
Vomiting (n U 35)
P Dexamethasone Control P
<0.001 11 23 <0.01
NS 1 6 NS
<0.001 12 29 <0.001
In conclusion, although we observed a trend towards a
lower incidence of postoperative nausea and vomiting in
the dexamethasone group, this effect was significant only
when considering the cumulative incidence. It was also
associated with reduced pain scores during the first
postoperative day.
Acknowledgements
Assistance with the study: the authors would like to thank
Dr Joaquim Vieira for his assistance with the study.
Financial support and sponsorship: this work was supported by the
Department of Anaesthesiology, Santa Casa de Misericordia, Sao
Paulo, Brazil.
Conflicts of interest: none declared.
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