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Skin Ischemia Caused by Subcutaneous Administration of Methylergonovine
Abstract Number: F 44
Abstract Type: Case Report/Case Series
Anesthesia providers play an active role in the treatment of uterine atony during cesarean deliveries. In the case presented, a patient received methylergonovine IM for uterine atony. Postoperatively she was found to have a skin reaction in the location of methylergonovine injection. Similar reactions have not been described in literature.
A 25 year-old at 40 weeks gestation underwent c-section for fetal intolerance to labor. Anesthesia was via a routine spinal and the case proceeded uneventfully. After delivery of the fetus, the obstetrician noted poor uterine tone despite oxytocin administration. Methylergonovine 0.2 mg IM was given for persistent atony.
Assessment of the patient postoperatively revealed a localized, raised, 7x10cm area of purple discoloration surrounded by erythema at the site of injection. The area was cool and non-indurated. She was treated conservatively with a warm compress and had near complete resolution in 24 hours.
Methylergonovine, an ergot alkaloid, has complex pharmacologic properties12. It is a selective antagonist of serotonergic receptors in smooth muscle, partial agonist of α-adrenergic receptors and weak antagonist of dopaminergic receptors in vessels1. It increases the strength, frequency and duration of uterine contractions.
Methylergonovine increases blood pressure after oral, IM and IV administration3. Side effects include hypertension, headache, nausea and vomiting. Serious complications attributed to administration of methylergonovine have also been reported.
Several case reports describe coronary vasospasm. IM,IV, and oral administration has led to myocardial infarction in susceptible patients45. There is, however, no reference in current literature describing cutaneous vasospastic effects in patients receiving methylergonovine. Our injection was likely into subcutaneous rather than IM. We postulate intense α-adrenergic stimulation in the vessels near the injection site caused the area to become acutely ischemic and present as described.
Infiltration of vasoconstrictive agents subcutaneously is known to cause tissue ischemia and necrosis. Treatment of vasoconstrictive agent infiltration includes elevation of the affected extremity, warm compress to promote vasodilation, saline washout, and local injection of an α-blocking agent such as phentolamine. We recommend proper visualization of the injection site and using an appropriate length needle to ensure delivery of methylergonovine into the intramuscular compartment.
1.MD Consult Drug Monograph: Methylergonovine. http://www.mdconsult.com/das/pharm/body/382508057-1336/0/full/1450.
2.Novartis Pharmaceuticals Corporation: Methergine®
3.Svanstrom MC, et al. Brit J Anaes 2008;100(5):683-689.
4.Liao, J., et al. The American Journal of Cardiology 1991;68:823–824.
5.Lin YH, et al. Acta Obstet Gynecol Scand 2005;84:1022.