The menstrual cycle and nausea or vomiting after wisdom teeth extraction

T M . Ramsay MBChBFRCA 0 P.F. McDonald MBChbFRCA 0 E.B. Faragher Mscvss 0 0 From the Department of Anaesthesia, Royal Perth Hospital , Wellington Street, Perth, WesternAustralia, WA 6001 . Anaesthesia, Stepping Hill Hospital , Poplar Grove, Stockport, SK2 7JE, England . Acceptedf o r publication H th May , 1994 We have investigated 195 pre-menopausal women undergoing third molar extractions, in a prospective study, to assess the influence o f the day o f the menstrual cycle on the incidence o f postoperative nausea or vomiting. In the 95 patients taking the oral contraceptive pill the incidence o f postoperative nausea or vomiting was higher on days 9 to 15 o f the menstrual cycle (P < 0.05) than on days one to eight and days 16 to the end o f cycle. In the 100 patients who were not taldng the oral contraceptive pill the incidence o f postoperative nausea or vomiting was not higher on days 9 to 15. The strongest predictor for postoperative nausea or vomiting in our study was a previous episode o f postoperative nausea or vomiting (P < 0.005). Patients with a tendency to motion sickness did not h a ~ a higher incidence o f postoperative nausea or vomiting. Pour dvaluer l~nfluence de la journ$e du cycle menstruel sur lea naus~es ou les vomissements postop~ratoires, nous avons dtudi~ prospectivement 195 femmes postm~nopausiques souraises dune extraction de la troi~i~me molaire. Pour 95 patientea sous contraceptifs oraux, l'incidence des naus$es ou des vomissements postop$ratoires est plus dlevde aux ,/ours 9 ~ 15 du cycle menstruel (P < 0,05) comparativement aux jours un h huit et aujour 16jusqu'au demierjour du cycle menstruel. Chez les 100 patientes qui ne prennent pas de contraceptifs oraux, l'incidence des naus~es ou des vomissements postopdratoires n'est pas plus ~lev~e attx jours 9 ~ 15. Dana notre ~tude, lefacteur de prediction le plus important consiate en un ~pisode anMrieur de vomissements ou nausdes postop~ratoires (P < 0,1905). Les patientes ayant d$j~ une tendance au real des transports n'ont pas une incidence plus ~lev~e de naus~es ou vomissements postop~ratoires. - Methods The study was approved by the Hospital Ethics Committee. Informed written consent was obtained from each patient who agreed to take part in the study. We studied 195 women, aged between 16 yr and the menopause, who presented to the Perth Dental Hospital to undergo third molar extractions. Patients were excluded if they were amenorrhoeic, had an irregular menstrual cycle, had undergone hysterectomy or may have been pregnant. Those who had stopped or commenced taking oral contraceptive medication in the last month were excluded, but those established on oral eontracepfives were studied to assess difference between women with ovulatory and anovulatory cycles. Preoperatively, patients supplied information on the date of their last menstrual period, length of cycle and its regularity. Their previous anaesthetic history was taken with reference to associated nausea or vomiting, and any tendency to travel sickness of any kind was noted. Premedieation of papaveretum 0.2 mg- kg -I and hyoscine 0.04 ~g. kg-~ im was administered one hour before anaesthesia. Induction was with thiopentone 4-6 m g . k g -~ followed by succinylcholine or a nondepolarizing muscle relaxant to facilitate nasotracheal intubation. Patients received nitrous oxide in oxygen and supplementation with either enflurane or isoflurane as required. Their lungs were ventilated or they were allowed to breath spontaneously according to the anaesthetist's preference. No opioids were given during anaesthesia. Each patient received prochlorperazine 0.17 mg. kg- l / v at induction of anaesthesia. One litre of compound sodium lactate was infused over the first hour after induction and thereafter dextrose 5% was infused at 2 ml. k g - l . hr-t until full ambulation and return of the ability to take oral fluids. On recovery and at one, two and four hours after waking the patients were questioned by trained recovery room nurses who did not know the purpose of the study. The patients were asked whether they had felt any nausea or had retched or vomited during the previous time period. The administration of any simple or opioid analgesics and antiemetics was noted, the decision to give any particular agent being at the recovery nurse's discretion. Full ambulation was encouraged between the third and fourth hour and discharge home was approximately 4.5 hr after awakening. The patients were categorised by day of menstrual cycle into three groups: days one to eight (pre-ovulatory), days 9 to 15 (ovulatory) and days 16 to the end of cycle (postovulatory). Chi-squared analysis was used to compare the incidence of nausea or vomiting between the groups. Stepwise multiple logistic regression analysis was used to identify factors independently related to postoperative nausea or vomiting. Statistical significance was set at the 5% level. Results Two hundred and three patients were recruited into the survey of whom 195 had complete data and in whom the protocol had been followed. Mean age was 22.4 yr (SD = 5.14) and mean weight 62.33 kg (SD = 13.16). The menstrual history revealed that 95 (48.7%) patients were taking oral contraceptives. Mean length of menstrual cycle was 27.9 d (SD = 2.47). The overall incidence of nausea or vomiting was 18.5%. The incidence of postoperative nausea or vomiting was higher on days 9 to 15 (P < 0.05) (Table). When the 95 patients taking the oral contraceptive pill were analysed independently, the incidence of nausea or vomiting was higher in those patients on days 9 to 15. Seventyeight of the 95 patients on the oral contraceptive pill knew which preparation they were taking. Fifty-five (70%) of these 78 patients were taking the triphasic oral eontra Day of menstrual cycle *P < 0.05 compared with days 1-8 and days 16 to the end of cycle. ceptive pill and the remainder taking a standard combined preparation. In those patients who were not taking the oral contraceptive pill the incidence of postoperative nausea or vomiting was not higher in the ovulatory group (Table). Forty of the 119 patients who had undergone previous general anaesthesia had a history of postoperative emesis. The incidence of nausea or vomiting was 15/40 (37.5%) in these patients, compared with I 1/79 (13.9%) in patients with no previous history of postoperative emesis (P < 0.005). Seventy of the 195 patients claimed to have suffered from motion sickness. The incidence of nausea or vomiting was 12/70 (17.1%) in these patients, compared with 24/125 (19.2%) in patients who did not suffer from motion sickness (P:NS). In this study motion sickness was not a risk factor for postoperative nausea or vomiting. The incidence of nausea or vomiting in the patients who breathed spontaneously was 8/48 (16.7%), compared with 28/147 (19%) in the patients whose lungs were mechanically ventilated (P:NS). The incidence of nausea or vomiting in the patients who (...truncated)