Intravenous Versus Intramuscular Administration of Methylergonovine for Uterine Contraction in Cesarean Sections
| Status: | Not yet recruiting |
|---|---|
| Conditions: | Women's Studies |
| Therapuetic Areas: | Reproductive |
| Healthy: | No |
| Age Range: | Any |
| Updated: | 4/6/2019 |
| Start Date: | May 2019 |
| End Date: | December 2020 |
| Contact: | Karen Lindeman, MD |
| Email: | klindema@jhmi.edu |
| Phone: | 410.955.8408 |
How's the Tone? Intravenous Versus Intramuscular Administration of Methylergonovine for Uterine Contraction in Cesarean Sections
Insufficient uterine tone resulting in atony can potentiate hemorrhage and adverse outcomes
for the parturient. Oxytocin is the first pharmacologic agent used, followed by
methylergonovine, carboprost, and misoprostol. The American Congress of Obstetricians and
Gynecologists (ACOG) recommends the sequential use of oxytocin, followed by methylergonovine,
carboprost, misoprostol, then surgical intervention for cases of refractory uterine atony.
Many studies have examined the effect and dosage of intravenous uterotonics, including
oxytocin.
Although there are anecdotal reports of using intravenous bolus or rapid infusion of
methylergonovine, no randomized trial has compared efficacy and side effects of these two
routes of administration. Investigators hypothesize that intravenous methylergonovine reduces
the time to adequate uterine tone (the tone at which the uterus is adequately contracted to
prevent atony after delivery of neonate), decreases the total dose of methylergonovine to
contract the uterus, and therefore produces fewer side effects of hypertension, nausea, and
vomiting. Reducing the time to achieve adequate uterine tone is likely to decrease postpartum
hemorrhage.
for the parturient. Oxytocin is the first pharmacologic agent used, followed by
methylergonovine, carboprost, and misoprostol. The American Congress of Obstetricians and
Gynecologists (ACOG) recommends the sequential use of oxytocin, followed by methylergonovine,
carboprost, misoprostol, then surgical intervention for cases of refractory uterine atony.
Many studies have examined the effect and dosage of intravenous uterotonics, including
oxytocin.
Although there are anecdotal reports of using intravenous bolus or rapid infusion of
methylergonovine, no randomized trial has compared efficacy and side effects of these two
routes of administration. Investigators hypothesize that intravenous methylergonovine reduces
the time to adequate uterine tone (the tone at which the uterus is adequately contracted to
prevent atony after delivery of neonate), decreases the total dose of methylergonovine to
contract the uterus, and therefore produces fewer side effects of hypertension, nausea, and
vomiting. Reducing the time to achieve adequate uterine tone is likely to decrease postpartum
hemorrhage.
The United States is one of the few modern countries in which maternal peripartum mortality
continues to rise. One of the three most important causes of maternal mortality is severe
hemorrhage. Controlling postpartum uterine tone remains an important role for the obstetric
anesthesiologist. Insufficient uterine tone resulting in atony can potentiate hemorrhage and
adverse outcomes for the parturient. Oxytocin is the first pharmacologic agent used, followed
by methylergonovine, carboprost, and misoprostol. The American Congress of Obstetricians and
Gynecologists (ACOG) recommends the sequential use of oxytocin, followed by methylergonovine,
carboprost, misoprostol, then surgical intervention for cases of refractory uterine atony.
Many studies have examined the effect and dosage of intravenous uterotonics, including
oxytocin.
Methylergonovine maleate is a semi-synthetic ergot alkaloid. Methylergonovine(200 mcg) is
administered intramuscularly when oxytocin has been administered but has not contracted the
uterus sufficiently. It is not without side effects, however. Due to its vasoconstrictive
properties, methylergonovine has been shown to elevate blood pressures and is avoided in
preeclamptic patients who may not tolerate abrupt increases in blood pressures. Although
there are anecdotal reports of using intravenous bolus or rapid infusion of methylergonovine,
no randomized trial has compared efficacy and side effects of these two routes of
administration. Investigators hypothesize that intravenous methylergonovine reduces the time
to adequate uterine tone (the tone at which the uterus is adequately contracted to prevent
atony after delivery of neonate), decreases the total dose of methylergonovine to contract
the uterus, and therefore produces fewer side effects of hypertension, nausea, and vomiting.
Reducing the time to achieve adequate uterine tone is likely to decrease postpartum
hemorrhage.
continues to rise. One of the three most important causes of maternal mortality is severe
hemorrhage. Controlling postpartum uterine tone remains an important role for the obstetric
anesthesiologist. Insufficient uterine tone resulting in atony can potentiate hemorrhage and
adverse outcomes for the parturient. Oxytocin is the first pharmacologic agent used, followed
by methylergonovine, carboprost, and misoprostol. The American Congress of Obstetricians and
Gynecologists (ACOG) recommends the sequential use of oxytocin, followed by methylergonovine,
carboprost, misoprostol, then surgical intervention for cases of refractory uterine atony.
Many studies have examined the effect and dosage of intravenous uterotonics, including
oxytocin.
Methylergonovine maleate is a semi-synthetic ergot alkaloid. Methylergonovine(200 mcg) is
administered intramuscularly when oxytocin has been administered but has not contracted the
uterus sufficiently. It is not without side effects, however. Due to its vasoconstrictive
properties, methylergonovine has been shown to elevate blood pressures and is avoided in
preeclamptic patients who may not tolerate abrupt increases in blood pressures. Although
there are anecdotal reports of using intravenous bolus or rapid infusion of methylergonovine,
no randomized trial has compared efficacy and side effects of these two routes of
administration. Investigators hypothesize that intravenous methylergonovine reduces the time
to adequate uterine tone (the tone at which the uterus is adequately contracted to prevent
atony after delivery of neonate), decreases the total dose of methylergonovine to contract
the uterus, and therefore produces fewer side effects of hypertension, nausea, and vomiting.
Reducing the time to achieve adequate uterine tone is likely to decrease postpartum
hemorrhage.
Inclusion Criteria:
- All patients admitted for elective cesarean section
- All laboring patients for planned vaginal delivery as these women may have an
unplanned cesarean delivery for maternal or for fetal indications
- Patients not in labor but admitted for non-elective cesarean section
- Administration of oxytocin prior to administration of methylergonovine, in accordance
to the ACOG guideline for postpartum hemorrhage
- Obstetrician's request for methylergonovine intraoperatively to the anesthesiologist
Exclusion Criteria:
- Fetus not considered to be of viable gestational age by obstetrical team
- Patients with hypertension (either chronic or pregnancy-induced, including
preeclampsia)
- Patients with coronary artery disease, established and diagnosed by medical internist
or cardiologist
- Patients taking CYP3A4 inhibitors
- Patients taking beta blockers.
- Patients with contraindications to any of the uterotonic agents for whatever medical
reason (allergies, for example)
- Surgeon request for administration of methylergonovine earlier than per protocol due
to clinical situation as abovementioned
- Maternal or obstetrician refusal
- Patients who require obstetrical intervention before 30 minutes has elapsed
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