Myocardial infarction and mortality caused by methylergonovine

Obstetric anesthesia considerations in pregnancy-associated myocardial infarction: a focused review

Pregnancy-associated myocardial infarction (PAMI) is a rare but serious complication that can occur either during pregnancy or postpartum. The etiologies of PAMI are atherosclerosis, spontaneous coronary artery dissection, coronary thrombosis, coronary embolism, and coronary vasospasm. Therapy of acute PAMI depends largely on the ECG presentation, hemodynamic stability, and suspected etiology of myocardial infarction. Anesthetic management during delivery in patients with PAMI should consist of early and carefully titrated neuraxial analgesia and anesthesia, maintenance of normal sinus rhythm, preservation of afterload, and monitoring for and avoiding myocardial ischemia. To improve the care of women with PAMI, a multidisciplinary team of cardiologists, maternal fetal medicine specialists, obstetric providers, neonatologists, and anesthesiologists must work collectively to manage these complex patients.

Care for the Obstetric Patient with Complex Cardiac Disease

The prevalence of cardiac disease-related maternal morbidity and mortality is on the rise in the United States. To ensure safe management of pregnancy in patients with cardiovascular disease, pre-delivery evaluation by a multidisciplinary Pregnancy Heart Team should occur. Appropriate anesthetic, cardiac, and obstetric care are essential. Risk stratification tools evaluate the etiology and severity of cardiovascular disease to determine the appropriate hospital type and location for delivery and anesthetic management. Intrapartum hemodynamic monitoring may need to be intensified, and neuraxial analgesia and anesthesia are generally appropriate. The anesthesiologist must be prepared for obstetric and cardiac emergencies.

Acute Coronary Syndromes in Women: A Narrative Review of Sex-Specific Characteristics

Acute coronary syndromes (ACSs) encompass a spectrum of life-threatening cardiovascular conditions, including unstable angina (UA) and myocardial infarction. While significant progress has been made in the understanding and management of ACS over the years, it has become increasingly evident that sex-based differences play a pivotal role in the pathophysiology, presentation, and outcomes of these conditions. Despite this recognition, the majority of clinical research in the field has historically focused on male populations, leading to a significant knowledge gap in understanding the unique aspects of ACS in women. This review article aims to comprehensively explore and synthesize the current body of literature concerning the sex-specific characteristics of ACS, shedding light on the epidemiology, risk factors, clinical presentation, diagnostic challenges, treatment strategies, and prognosis in women. By elucidating the distinct aspects of ACS in women, this review intends to foster greater awareness and improved clinical management, ultimately contributing to enhanced cardiovascular care for female patients.

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.

Methylergometrine-Induced Myocardial Infarction in the Setting of a Cesarean Delivery

A 30-year-old female with no significant past medical history presented to our labor and delivery ward for induction of labor. Due to failure to progress, she was proceeded to cesarean delivery. Intraoperatively, it was noted that her uterus was hypotonic; she required supplemental methylergometrine to control the bleeding from the uterine atony. However, within three minutes of intramuscular (IM) administration, she complained of chest pain. She then subsequently developed pulmonary edema in the postoperative care unit, which required supplemental oxygen. She was found to have elevated troponin and brain natriuretic peptide (BNP), along with radiologic features of fluid overload suggestive of congestive cardiac failure, which all lead to the diagnosis of non-ST myocardial infarction. The patient had a normal computed tomography (CT) pulmonary angiogram, echocardiogram, and serial electrocardiograms (ECGs). She was successfully discharged from the hospital on postoperative day 4 with resolution of her symptoms and improving cardiac enzymes. Cardiology outpatient follow-up was arranged.

Obstetric Anesthesia and Heart Disease: Practical Clinical Considerations

Maternal morbidity and mortality as a result of cardiac disease is increasing in the United States. Safe management of pregnancy in women with heart disease requires appropriate anesthetic, cardiac, and obstetric care. The anesthesiologist should risk stratify pregnant patients based upon cardiac disease etiology and severity in order to determine the appropriate type of hospital and location within the hospital for delivery and anesthetic management. Increased intrapartum hemodynamic monitoring may be necessary and neuraxial analgesia and anesthesia is typically appropriate. The anesthesiologist should anticipate obstetric and cardiac emergencies such as emergency cesarean delivery, postpartum hemorrhage, and peripartum arrhythmias. This clinical review answers practical questions for the obstetric anesthesiologist and the nonsubspecialist anesthesiologist who regularly practices obstetric anesthesiology.

Diagnostic Angiograms and Percutaneous Coronary Interventions in Pregnancy

Cardiovascular disease is the leading indirect cause of maternal mortality in the UK. Pregnancy increases the risk of acute MI (AMI) by three- to fourfold secondary to the profound physiological changes that place an extra burden on the cardiovascular system. AMI is not always recognised in pregnancy and there is concern among both clinicians and patients regarding catheter-based interventions due to fears of foetal irradiation and risks to the foetus. This article evaluates the current state of knowledge on AMI in pregnancy with particular emphasis on pregnancy-associated spontaneous coronary artery dissection and percutaneous coronary intervention as the revascularisation procedure for AMI. Special considerations that must be made in patients requiring percutaneous coronary intervention for pregnancy-associated spontaneous coronary artery dissection and the current recommendations on arterial access, methods of minimising radiation and stent selection are discussed.

Ergometrine for postpartum hemorrhage and associated myocardial ischemia: Two case reports and a review of the literature

Ergometrine is recommended for use in the medical treatment of postpartum hemorrhage. Ergometrine can occasionally precipitate myocardial ischemia in the setting of significant anemia in women without preexisting cardiac risk factors, and it is important to recognize and treat myocardial ischemia in affected patients to prevent severe complications.

Acute myocardial infarction in pregnancy: Current diagnosis and management approaches

Acute myocardial infarction during pregnancy is a very uncommon condition; atherosclerotic coronary artery disease is by far the most common cause of an acute coronary syndrome in the general population. The causes of an acute coronary syndrome in the pregnant patient are wide and varied. This has important implications with respect to the diagnosis of the etiology and the subsequent management of the cause of the acute coronary syndrome. There are a number of diagnostic tools for the diagnosis of coronary artery disease but it is important to understand their role in pregnant patients. Spontaneous coronary artery dissection is one of the most common causes of acute coronary syndrome in pregnant patients. Understanding its pathophysiology and knowing the natural history of this condition is paramount in the management of this condition. The article also lists the various therapeutic modalities available to the clinician faced with an acute coronary syndrome in the pregnant patient. Finally, we discuss the delivery of the baby and post partum care of these complex patients.

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.

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.

Cardiac arrest with pulmonary edema in a non-parturient after ergonovine administration recovered with extracorporeal membrane oxygenation -A case report-

Ergonovine have been used for the prevention and treatment of postpartum or postabortion hemorrhage. Although this modality has been considered relatively safe in the obstetric patients, there were a few cardiac events associated with this drug in the post-delivery or post-abortion patients, especially in patients with cardiovascular risk factors. We experienced cardiac arrest in a non-parturient with no discernible risk factors. Although resuscitated, she also suffered from pulmonary edema with unstable hemodynamics and low oxygenation. To manage the patient, extracorporeal membrane oxygenation was used and she recovered successfully without cardiopulmonary complications. Therefore, we recommend that when ergonovine is chosen as a modality, special caution should be paid to the pulmonary events, as well as cardiac, especially when administered by intravenously even in patients with no cardiovascular risk factors. If cardiac events occur, extracorporeal membrane oxygenation or other measures, such as intra-aortic balloon pump can be helpful when conventional cardiopulmonary resuscitation is not effective.

Diagnosis and treatment of peripartum bleeding

Severe peripartum hemorrhage (PPH) contributes to maternal morbidity and mortality and is one of the most frequent emergencies in obstetrics, occurring at a prevalence of 0.5-5.0%. Detection of antepartum risk factors is essential in order to implement preventive measures. Proper training of obstetric staff and publication of recommendations and guidelines can effectively reduce the frequency of PPH and its resulting morbidity and mortality. Therefore, an interdisciplinary expert committee was formed, with members from Germany, Austria, and Switzerland, to summarize recent scientific findings. An up-to-date presentation of the importance of embolization and of the diagnosis of coagulopathy in PPH is provided. Furthermore, the committee recommends changes in the management of PPH including new surgical options and the off-label use of recombinant factor VIIa.

Postpartum Severe Sinus Bradycardia following Methylergonovine Administration

The case is reported of a 30-year-old multigravida, with insignificant history and stable vital signs, admitted to the labour room for normal vaginal delivery of twins. She received combined spinal epidural analgesia (bupivacaine plus fentanyl) for 3 h. Following uneventful delivery she received 0.2 mg methylergonovine maleate, intramuscularly. Nausea and vomiting occurred 70 min after placenta delivery, heart rate decreased, arterial blood pressure increased and there was chest pain. After excluding cardiac ischaemia, 0.5 mg atropine sulphate was administered intravenously. Chest pain improved but heart rate and blood pressure increased more than expected. The patient had mild headache and nausea, and antiemetic 4 mg ondansetron was given intravenously. Continuous monitoring for 4 h showed spontaneous chest pain relief and blood pressure improvement. In conclusion, serious delayed side-effects arising from methylergonovine maleate can occur in young, normal patients and close monitoring is required. Intravenous atropine sulphate following methylergonovine maleate administration may lead to severe hypertension and tachycardia.

Acute myocardial infarction associated with pregnancy

Acute myocardial infarction (AMI) during pregnancy or the early post-partum period is rare but has been shown to be associated with poor maternal as well as fetal outcome. Major changes in both diagnosis and treatment of AMI in the nonpregnant patient have lead to improved outcome which may also affect pregnant patients. The purpose of this paper is to review available information related to the pathophysiology and clinical profile and provide recommendations for the diagnosis and management of AMI occuring during pregnancy and the early post-partum period.

Modifying labor routines for the woman with cardiac disease

The childbearing woman with cardiac disease presents a unique challenge to healthcare providers. The physiologic adaptations that accompany pregnancy and labor predispose the woman with cardiac disease to cardiac decompensation. Ideally, these women are identified to perinatal nursing staff prior to admission to the hospital in labor or for obstetrical procedures in order to provide adequate time for review of the specific cardiac lesion and development of an interdisciplinary plan of care. This article provides a comprehensive review of typical intrapartum routines that require modification and discusses strategies for adapting labor management for the woman with cardiac disease.