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Postpartum cardiac arrest secondary to ergometrine-induced coronary vasospasm
Abstract Number: SUN-48
Abstract Type: Case Report/Case Series
Ergometrine is a uterotonic and potent vasoconstrictor and is frequently used in obstetrics for prevention and management of postpartum haemorrhage. It has been used to provoke coronary artery spasm to investigate the role of vasoconstriction over thrombosis in acute coronary syndromes (ACS) in the context of variant angina. Despite its widespread use in obstetrics, such profound coronary vasospasm is very rare1, 2.
A healthy 28-year-old Chinese female delivered a healthy baby via spontaneous vaginal delivery under epidural anaesthesia and the care of a midwife. Active management of the third stage of labour was facilitated by an intramuscular injection of oxytocin 5 IU and ergometrine 500 mcg. Postpartum blood loss of 700mls was recorded. The patient became unresponsive with confirmed loss of cardiac output 45 minutes later. Cardiopulmonary resuscitation and vasoactive drugs successfully achieved return of spontaneous circulation within 5 minutes. Blood tests revealed a haemoglobin of 55 g/L and a lactic acidosis (pH 7.32, BE -9, Lac 5.6). An electrocardiogram (ECG) revealed marked ST depression in leads II, III, aVF and V2-V6, suggesting an infero-lateral myocardial infarction. An echocardiogram revealed only hypovolaemia. Troponin T levels were elevated at 796 ng/L (normal range 0-13).
Two litres of IV crystalloid and 2 units of packed red cells were transfused. Further investigation including CT pulmonary angiogram and a coronary angiogram were normal. Coronary artery vasospasm secondary to ergometrine was the diagnosis of exclusion. Standard ACS therapy resulted in resolution of ECG changes and full recovery.
Ergometrine can have profound systemic vasoactive actions. For this reason it is contraindicated in hypertensive and severe cardiac disorders. Although coronary artery spasm and myocardial ischaemia can occur in patients with normal coronary arteries there is no guidance as to which patients may be at increased risk. Recent studies, in non-pregnant patients, looking at the susceptibility of variant angina and coronary artery vasospasm in response to ergot alkaloids now suggest an increase in incidence in patients of Japanese ethnicity, when compared to Caucasians3. We believe this is the first such case, reported in the English medical literature, in a pregnant patient of chinese ethnicity. Further examination of the risk, of ergometrine administration to this patient group, is required.
1. Bateman BT, Huybrechts KF, Hernandez-Diaz S, Liu J, Ecker JL, Avorn J. Methylergonovine maleate and the risk of myocardial ischaemia and infarction. American journal of obstetrics and gynecology. 2013;209(5):459.e1-459.e13. doi:10.1016/j.ajog.2013.07.001.
2. Pristipino C, Beltrame JF, Finocchiaro ML, Hattori R, Fujita M, Mongiardo R, et al. Major racial differences in coronary constrictor response between Japanese and Caucasians with recent myocardial infarction. Circulation. 2000;101:1102–8.