|LETTERS TO EDITOR
|Year : 2020 | Volume
| Issue : 2 | Page : 150-151
Is intramyometrial carboprost troublesome?
Shankey Garg, Sanjay Kumar, Shalvi Mahajan
Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
|Date of Submission||16-Jan-2020|
|Date of Acceptance||14-Mar-2020|
|Date of Web Publication||20-Aug-2020|
Dr. Shalvi Mahajan
Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Garg S, Kumar S, Mahajan S. Is intramyometrial carboprost troublesome?. J Obstet Anaesth Crit Care 2020;10:150-1
Postpartum hemorrhage (PPH) is a common complication and major cause of maternal mortality after delivery. We hereby report a case of a young healthy primigravida female who developed a life-threatening cardiovascular change following intramyometrial injection of carboprost for atonic uterus during cesarean section.
A 24 years old primigravida, 37 weeks of gestation with breech, was planned for elective lower segment cesarean section. Pre-Anesthesia checkup was unremarkable. With standard ASA monitoring, the subarachnoid block was given in sitting position, using a midline approach with 8 mg of 0.5% bupivacaine (hyperbaric) and 25 mcg fentanyl (total volume 2.3 mL) and anesthesia level was achieved up to the T6 dermatome. Oxytocin 25 IU IV infusion was started at 5 IU.h − 1 as per institutional protocol after the delivery of the baby. The uterine contraction was inadequate after the initial measures and intramyometrial carboprost 250 mcg (Carboprost Tromethamine, 250 mcg, Neon Laboratories Limited) was administered after negative aspiration for blood. After 1–2 min, the patient complained uneasiness and headache. She developed tachycardia (heart rate-140/min), ST-segment depression in 5-lead ECG, and blood pressure (BP) increased to 210/120 mmHg without a drop in oxygen saturation [Figure 1]. She was managed symptomatically with IV esmolol 20 mg and labetalol 10 mg. After 4–5 min, the heart rate decreased to 90/min and BP to 105/61 mmHg. ST-segment depression resolved gradually. Arterial blood gas was performed during this event, showed pH 7.37, pO2 436.7 mmHg, pCO2 30.4 mmHg, Hco3-17.4, BE-6.8, Na 138.4 mEq/L, K 3.5 mEq/L with blood sugar (RBS) 71 mg/dL. Dextrose 5% 100 mL was given and repeat measurement of RBS was 128 mg/dL. Despite this event, the adequate uterine contraction was achieved and the rest of the surgery was uneventful. The patient was comfortable and kept in the postanesthesia recovery unit for monitoring. 12-lead ECG was done postoperatively which showed no ST-T changes. The rest of the hospital course was uneventful.
|Figure 1: Hemodynamics and ST-segment changes following intramyometrial carboprost administration|
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Carboprost is a synthetic prostaglandin F2 alpha and is FDA approved for second-line oxytocic agent following oxytocin and ergometrine. It can be administered intramuscular or intramyometrial or intravascular to control PPH. Intramyometrial injection is preferred over the intramuscular because of its early onset of action (5 min vs 15 min) by causing direct contraction of uterine smooth muscles. Intravascular use of carboprost has a very limited role due to its multiple side effects like nausea, vomiting, diarrhea, bronchospasm, and hypertension.
Our patient developed hypertension with significant ST wave changes which resolved after symptomatic treatment. It may be due to accidental intravascular administration of carboprost during intramyometrial injection due to increased vascularity of uterus despite negative aspiration for blood. PF2-alpha exerts its action through G-protein coupled F Prostanoid receptors (FP), present in the medial layer of resistance vessels and cardiac myocytes which lead to hypertension and tachycardia.
However, there is limited literature related to cardiac complications following its intramuscular (intramyometrial use). We found one similar case report by Mahey, observed increase in heart rate (175/min) and blood pressure (220/135 torr) without a change in oxygen saturation and carbon dioxide levels with intramyometrial injection of dinoprost for management of PPH. Both dinoprost and carboprost are PG F2 alpha agonists. In another case report, Cares et al. mentioned the sudden collapse and death of two healthy young females following intra-amniotic use of PGF2alpha as an abortifacient. Sachet et al. studied the systemic effects of IV infusion of PGF2α in pregnant patients and observed a 40% increase in cardiac output, 25% increase in femoral arterial pressure, 125% increase in pulmonary artery pressure with no significant change in the heart rate.
To conclude, both obstetricians and anesthesiologists should be more vigilant while injecting intramyometrial carboprost for hemodynamic changes resulting in life-threatening complications.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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