Post-partum myocardial ischemia due to intramuscular methylergonovine-induced coronary vasospasm: case report.

BACKGROUND: Methylergonovine is a vasoconstrictive agent historically used as a provocative agent in the lab for coronary vasospasm; it is also a first line uterotonic agent for management of postpartum hemorrhage. CASE PRESENTATION: A 29-year-old female with history of smoking and idiopathic thrombocytopenia received intramuscular methylergonovine after delivery of twins for intrauterine hemorrhage management. Subsequently, she had episodes of chest pain with high sensitivity Troponin I elevation to 1509 ng/L with accompanying septal T wave inversions, decreased left ventricular ejection fraction to 49% and basal septal wall hypokinesis. Computed tomography (CT) coronary angiogram showed patent coronary arteries and no coronary arterial dissection. The patient was conservatively managed with aspirin and metoprolol, and on follow up had fully recovered left ventricular function with resolution of wall motion abnormalities. Given this, coronary vasospasm due to intramuscular methylergonovine is the most likely cause of patient's chest pain and associated myocardial ischemia. CONCLUSIONS: Intramuscular, intrauterine, intravenous, and even oral methylergonovine can rarely cause coronary vasospasm leading to myocardial ischemia. Cardiologists caring for postpartum patients should be aware of these potential lethal complications; prompt identification and administration of sublingual nitroglycerin can prevent severe complications of arrythmias, heart block, or cardiac arrest.

Eclampsia with RCVS: Postpartum seizure provoked by methergine.

BACKGROUND: Eclampsia is a pregnancy complicationcharacterized bygeneralized tonic-clonicconvulsions.Not all seizures in pregnancy are eclamptic, and othercauses include epilepsy, infection,stroke,tumor, and ruptured aneurysm. CASE: A 19-year-old G1P0 presentedinlabor at term. She had a generalized tonic-clonicseizure one hour aftervaginaldelivery for which she received methergine for uterine atony. Seizure activity resolved with lorazepam and magnesium sulfate for presumed eclampsia.Brain imaging revealedvasoconstriction of theleftposterior cerebral artery and blood in the subarachnoid space,andshewas diagnosed with eclampsia with reversible cerebral vasoconstrictive syndrome (RCVS). CONCLUSION: RCVS isapregnancy-related cause of seizure that should remain on the differential for any patient presenting with a seizure in the peripartum period, especially with use of vasoconstrictive agents. Management is controversial but involves calcium channel blockers and magnesium sulfate, as well as avoidance of vasoconstrictive agents.

Second-degree atrioventricular block after administration of methylergometrine for treatment of uterine atony during cesarean section.

Mortality due to cardiovascular disease in pregnancy is a growing problem in developed countries, being nowadays the leading cause of maternal death. Within this group, the most common cause of death are congenital or acquired heart diseases, representing a challenge in the management of these patients, since the pregnancy-related physiological alterations can impair their basal condition and treatment. We present the case of a 34-year-old patient, without any relevant pathological antecedents, who developed a second-degree atrioventricular block, Mobitz type I, following the administration of methylergometrine during cesarean section due to failure to progress in labour. We emphasize the importance of considering the side effects of commonly used drugs in pregnant patients, despite rare possibility of some adverse reactions.

Pharmaco-vigilance of oral MethylErgometrine prescriptions for delayed and secondary postpartum haemorrhage.

Objectives The objectives of this study were to quantify the prescription of oral methergin tablets in a busy Women's Hospital, assess the stated indications for such prescription and highlight the issues and safety profile of Methergin use especially in the postpartum patient. Methods Review of prescription data for oral Methergin and the corresponding annual figures on primary and secondary postpartum hemorrhage. Results Over a period of 5 years, oral Methergin prescriptions for delayed and secondary postpartum hemorrhage constituted less than 1% of the overall prescription in Obstetrics and Gynaecology, which ranged between 1214 and 2085 per year. The numbers were too few to ascertain any relationship with both types of postpartum hemorrhage. Although stated on the relevant Patient Information leaflet, no local or regional guideline on its use exist. Conclusions Specific and random trend monitoring of medications for continuing safety profile, risk benefit issues, or unapproved indication, may help in identifying, preventing and mitigating any medication safety matters. Clinical pharmacists in collaboration with physicians are well placed in conducting such pharmacovigilance activities to improve medication safety.

New onset acute pulmonary edema after methylergonovine given during cesarean delivery of a patient with undiagnosed Raynaud's disease.

Raynaud's disease is a medical condition in which arterial spasm causes episodes of reduced blood flow, in the setting of certain triggers such as cold weather. Patients with this condition are at risk of adverse reactions if they receive medications with vasoactive properties. Methylergonovine maleate is one drug used during cesarean delivery to treat postpartum hemorrhage due to uterine atony. By acting directly on uterine and vascular smooth muscle, it produces cardiovascular responses such as coronary vasospasm, myocardial infarction, and even cardiac arrest. However, pulmonary events have rarely been reported. We report our anesthetic management of a 36-year-old patient, with undiagnosed Raynaud's disease and undergoing cesarean delivery, who experienced new onset acute pulmonary edema after methylergonovine administration to manage postpartum hemorrhage.

Uterotonic Medications: Oxytocin, Methylergonovine, Carboprost, Misoprostol.

Uterine atony is a common cause of primary postpartum hemorrhage, which remains a major cause of pregnancy-related mortality for women worldwide. Oxytocin, methylergonovine, carboprost, and misoprostol are commonly used to restore uterine tone. Oxytocin is the first-line agent. Methylergonovine and carboprost are both highly effective second-line agents with severe potential side effects. Recent studies have called into question the effectiveness of misoprostol as an adjunct to other uterotonic agents, but it remains a useful therapeutic in resource-limited practice environments. We review the current role these medications play in the prevention and treatment of uterine atony.

Outcome of breastfed infants following post-partum methylergonovine treatment.

OBJECTIVE: To evaluate maternal and breastfed infant's outcome following post-partum maternal use of methylergonovine. METHODS: A prospective, controlled observational study design was used. Mothers who contacted Beilinson Teratology Information Service (BELTIS) were followed by phone interview. Data on lactation, neonatal symptoms and outcomes at the age of 1-3 years were obtained. Mothers' breastfeeding while treated with methylergonovine and their infants were compared to a matched control group of breastfeeding mothers using a drug known to be safe during lactation (amoxicillin). RESULTS: Follow-up was obtained for 38 of 42 women (90.5%). Of whom, six stopped breastfeeding because of concerns regarding drug treatment and three refused to participate. The remaining 29 women and infant pairs were compared to a control group of 58 women and their infants. Comparison showed no effect of methylergonovine on lactation and similarly showed no difference in rate of neonatal complications (p = 1). At time of follow-up there were no differences in growth or in adverse neurodevelopment outcomes (p = 0.26). CONCLUSIONS: No increase in adverse long-term outcomes was found in infants exposed to methylergonovine through breastfeeding. Our data in conjunction with previous estimates of very low drug exposure support continuation of breastfeeding in women requiring treatment with methylergonovine.

Exposure to methylergonovine maleate as a cause of sirenomelia.

BACKGROUND: Sirenomelia is a rare, but deadly condition characterized by fusion of the lower limbs, lower spinal column defects, severe malformations of the urogenital and lower gastrointestinal tract, and an aberrant abdominal umbilical artery. METHODS: The two main hypotheses, not mutually exclusive, that have been advanced to explain the pathogenesis of sirenomelia are the blastogenetic theory and the vascular disruption theory. RESULTS: We describe a case of sirenomelia, probably associated with the use of methylergonovine maleate, an ergot alkaloid, during the first weeks of pregnancy. CONCLUSION: On the basis of the mechanisms of vascular disruption and early administration of methylergonovine maleate at a critical stage of organogenesis, we conclude that exposure to methylergonovine maleate could be the cause of the development of sirenomelia. Birth Defects Research (Part A) 106:643-647, 2016. © 2016 Wiley Periodicals, Inc.

The Effect of the Combined Use of Methylergonovine and Oxytocin during Caesarean Section in the Prevention of Post-partum Haemorrhage.

We aimed to show to patients the benefit of post-partum haemorrhage prophylaxis treatment and the effectiveness as a uterotonic agent of the combined use of methylergonovine and oxytocin infusion in the prevention of haemorrhage during and after Caesarean section, by comparison with a control group which received oxytocin infusion only. Two groups of patients undergoing Caesarean section at the same clinic were included in the study. A combination of methylergonovine and oxytocin was administered to the first group during the intra-operative and post-operative periods. The second group did not receive methylergonovine and was administered only with oxytocin infusion in the intra-operative and post-operative periods. Pre-operative and post-operative haemogram readings were taken for all patients in each of the groups for comparison. No difference was found between the two groups with regard to mean ages and pre-operative haemogram values. The decrease in post-operative haemoglobin values for the group administered with methylergonovine maleate and oxytocin was found to be significantly greater than for the group administered with oxytocin only. Results indicated that prophylactic methylergonovine treatment was clearly successful for the patients and no adverse side effects were found. The routine use of methylergonovine and oxytocin infusion in combination during the intra-operative period of Caesarean section reduced the level of post-partum haemorrhage considerably. We believe that this procedure will also reduce the risk of uterine atony, but clearly, prospective studies will be necessary in future to confirm this assumption.

Cesarean Delivery in a Parturient with Left Ventricular Noncompaction Complicated by Acute Pulmonary Hypertension After Methylergonovine Administration for Postpartum Hemorrhage.

Left ventricular noncompaction is a rare congenital cardiomyopathy that is an arrest in the normal process of cardiac compaction, resulting in the development of multiple prominent trabeculations in the left ventricle. We report a case of a parturient with left ventricular noncompaction causing decompensated heart failure who underwent cesarean delivery that was complicated by an acute pulmonary hypertensive crisis.

Methylergonovine maleate and the risk of myocardial ischemia and infarction.

OBJECTIVE: The purpose of this study was to examine the risks of acute coronary syndrome (ACS) and acute myocardial infarction (AMI) that are associated with methylergonovine maleate (Methergine; Novartis Pharmaceuticals Corporation, Plantation, FL) use in a large database of inpatient delivery admissions in the United States. STUDY DESIGN: We conducted a retrospective cohort study using data from the Premier Perspective Database and identified 2,233,630 women who were hospitalized for delivery between 2007 and 2011 (approximately one-seventh of all US deliveries during this period). Exposure was defined by a charge code for methylergonovine during the delivery hospitalization. Study outcomes included ACS and AMI. Propensity score matching was used to address potential confounding. RESULTS: Methylergonovine was administered to 139,617 patients (6.3%). Overall, 6 patients (0.004%) who were exposed to methylergonovine and 52 patients (0.002%) who were not exposed to methylergonovine had an ACS. Four patients (0.003%) who were exposed to methylergonovine and 44 patients (0.002%) in the not-exposed group had an AMI. After propensity score matching, the relative risk for ACS that was associated with methylergonovine exposure was 1.67 (95% confidence interval [CI], 0.40-6.97), and the risk difference was 1.44 per 100,000 patients (95% CI, -2.56 to 5.45); the relative risk for AMI that was associated with methylergonovine exposure was 1.00 (95% CI, 0.20-4.95), and the risk difference was 0.00 per 100,000 patients (95% CI, -3.47 to 3.47). CONCLUSION: Despite studying a very large proportion of US deliveries, we did not find a significant increase in the risk of ACS or AMI in women who received methylergonovine compared with those who did not; estimates were increased only modestly or not at all. The upper limit of the 95% CI of our analysis suggests that treatment with methylergonovine would result in no more than 5 additional cases of ACS and 3 additional cases of AMI per 100,000 exposed patients.

Comparison the effects of oxytocin and methylergonovine in elective caesarean section under spinal anesthesia.

PURPOSE: In order to prevent postpartum hemorrhage in caesarean section under spinal anesthesia, patients routinely receive oxytocin. In this study we compared the efficacy of Methylergonovine and Oxytocin on hemodynamic stability and bleeding amount in caesarean section. MATERIALS AND METHODS: In this randomised controlled trial study, 80 patients candidate for elective caesarean section under spinal anesthesia divided to two groups: 40 patients in control group received oxytocin and 40 ones in case group received methylergonovine. RESULTS: There was no differences between groups in Mean age, baseline hemodynamic values, after spinal anesthesia and recovery (except diastolic blood pressure min 20), time of uterine atony, dizziness; nausea and vomiting. After drug administration (oxytocin and methylergonovine), systolic blood pressure in minutes 1, 10, 15 and diastolic blood pressure in minutes 1, 3, 20 increased in case group statistically more than control group. In control group, heart rate in minutes 1, 5 increased significantly more than the other group. Mean arterial blood pressure in minutes 1, 3, 5, 10, 15 reduced significantly more than in control group. Need to vasoconstrictor drug statistically was less in case group (p < 0.0001). CONCLUSION: Methylergonovine induced significantly more hemodynamic stability. Adverse effects were similar between two groups. We recommend the use of methylergonovine in patients with caesarean section under spinal anesthesia because of its hemodynamic stability and low need to vasoconstrictor drugs.

Reversible cerebral vasoconstriction syndrome with limb myoclonus following intravenous administration of methylergometrine.

Neurological deficits associated with methylergometrine have been reported primarily as a result of reversible cerebral vasoconstriction syndromes (RCVS). RCVS are characterized by reversible multifocal vasoconstrictions of the cerebral arteries heralded by acute severe headache with or without neurological deficits. Here, we present the first case of suspected RCVS with transient limb myoclonus following the intravenous administration of methylergometrine during cesarean section. A 31-year-old woman who received slowly infused intravenous methylergometrine during a cesarean section suddenly reported severe occipital headache after 40 min, followed by apnea and unconsciousness for 8 min. A second administration of methylergometrine to treat the weakness of her uterine contractions resulted in a repeated loss of consciousness within minutes and the development of limb myoclonus. No abnormalities were detected by brain computerized tomography, magnetic resonance imaging, and electroencephalogram. She fully recovered spontaneously within 12 h. We consider that the transient limb myoclonus in our patient appeared as a result of RCVS caused by the intravenous administration of methylergometrine.

Exacerbation of acetazolamide-responsive sodium channel myotonia by uterotonic agents.

The symptoms of myotonia can worsen during pregnancy and tocolysis with ritodrine has been associated with rhabdomyolysis. We describe a patient with myotonia who developed hypertonus immediately following the administration of uterotonic agents. A 24-year-old, G2P1 at 31 weeks of gestation with a history of acetazolamide-responsive myotonia presented with premature rupture of membranes. During cesarean delivery she experienced significant hypertonus of the upper limbs, shoulders, fingers, and mouth immediately after intravenous administration of oxytocin 5 IU and methylergometrine maleate 0.2mg. The mechanism underlying increased muscle tone in response to these drugs remains unclear. Anesthesiologists should be especially attentive to the administration of uterotonic drugs during the management of pregnant myotonia patients.

Hipertensión pulmonar poscapilar tras administración de antiinflamatorios no esteroideos y antihipertensivos / Congestive pulmonary hypertension following the admi- nistration of NSAIDs and anti-Hypertension drugs

La hipertensión arterial sistémica produce un aumento de la presión en las cavidades izquierdas cardiacas que, de forma retrógrada, puede conducir a una hipertensión pulmonar. Entre las causas reconocidas de hipertensión arterial sistémica se encuentran un número importante de fármacos de uso habitual. Presentamos el caso de una mujer puérpera que desarrolló HTA yHTP y proponemos como causa de las mismas, la administración demetilergometrina e ibuprofeno, que después se perpetuó por la asociación de metildopa y labetalol (AU)

The systemic hypertension produces an increase in pressure of left cardiac cavities that can lead to pulmonary hypertension. Many drugs are recognized cause of systemic hypertension. We report the case of a puerperae woman who developed pulmonary and systemic hypertension and we propose the administration of methylergometrine and ibuprofen and then methyldopa and labetalol as the cause of hypertension (AU)

Comparison of sublingual misoprostol, intravenous oxytocin, and intravenous methylergometrine in active management of the third stage of labor.

OBJECTIVE: To compare the efficacy and adverse effects of sublingual misoprostol, intravenous oxytocin, and intravenous methylergometrine in active management of the third stage of labor (AMTSL). METHODS: A double-blind randomized trial of 300 women with a healthy singleton pregnancy allocated into 4 groups to receive either: 400 microg or 600 microg of sublingual misoprostol, 5 IU of intravenous oxytocin, or 200 microg of intravenous methylergometrine. The primary outcome measure was blood loss in the third and fourth stage of labor; secondary measures were duration of the third stage of labor, changes in hemoglobin levels, and adverse effects. RESULTS: Patients who received 600 microg of misoprostol had the lowest blood loss (96.05+/-21.1 mL), followed by 400 microg of misoprostol (126.24+/-49.3 mL), oxytocin (154.7+/-45.7 mL), and methylergometrine (223.4+/-73.7 mL) (P<0.01). Shortest mean duration of the third stage of labor (5.74 minutes) was with 600 microg of misoprostol, while methylergometrine had the longest (6.83 minutes) (P<0.05). Pyrexia was observed in the misoprostol groups, and raised blood pressure in the methylergometrine group (P<0.001). The 24-hour postpartum hemoglobin level was similar among the groups (P>0.05). CONCLUSION: Administration of 600 microg of sublingual misoprostol was more effective than 400 microg of misoprostol, intravenous oxytocin, and intravenous methylergometrine for AMTSL.