-. ,
Intravenous Nitroglycerin Uterine Inversion
for
Daniel A. Bayhi, MD, JD, RPh,* Cynthia D.A. Sherwood, MD,? Carol E. Campbell, MDT Department of Anesthesiology, Medical Center of Louisiana Louisiana State University Medical Center, New Orleans, LA.
Uterine inversion following vaginal delivery or during Cesarean section is rare. Cardiovascular instability resulting from blood loss is possible. This article describes the use of intravenous nitroglycerin as an alternative to the induction of general anesthesia and administration of volatile anesthetics to provide uterine relaxation.
Keywords: Cesarean nitroglycerin; uterus,
section; myometrium; relaxation of, inversion
of.
Introduction Uterine inversion following vaginal delivery is a rare complication. Uterine inversion during cesarean section is reported even less frequently. The potential for excessive blood loss with attendant cardiovascular instability could make this event an anesthetic emergency. Standard anesthetic intervention has included the induction of anesthesia and the administration of volatile anesthetics to relax uterine smooth muscle. This technique has allowed the obstetrician to revert the uterus. The induction of anesthesia in a full-stomach obstetric patient has its own set of potentially lethal complications. We report a case of uterine inversion occurring during
*Associate Professor tAssistant Professor Address reprint requests to Dr. Bayhi at the Department of Anesthesiology, Medical Center of Louisiana at New Orleans, Louisiana State University Medical Center, 1532 Tulane Avenue, New Orleans, LA 70140, USA. Received for publication May 14, 1992; cepted for publication July 21, 1992. 0 1992 Butterworth-Heinemann 1. Clin. Anesth. 4:487-488.
1992.
revised manuscript
ac-
at New Orleans,
cesarean section with spinal anesthesia treated with intravenous nitroglycerin without general anesthesia. Case Report A healthy 35-year-old gravida 3 para 1 at 39 weeks gestation was admitted for repeat cesarean section. She weighted 84 kg and was 162 cm tall. Her prenatal course was unremarkable except for a history of peptic ulcer disease. Her physical examination was within normal limits. Monitors used during the induction of continuous spinal anesthesia included electrocardiogram (ECG), arterial oxygen saturation, continuous fetal heart rate monitor, and noninvasive blood pressure (BP) monitor. The patient was given 30 ml of 0.3 M sodium citrate orally and 2,000 ml of lactated Ringer’s solution intravenously (IV). She was placed in a sitting position, and the second lumbar interspace was identified and anesthetized with 1% lidocaine. Continuous spinal anesthesia was begun with a 22-gauge Quincke-point needle through which bupivacaine 9 mg with dextrose 99 mg was injected. A 28-gauge styletted CoSpan catheter (Kendall Corp., Mansfield, MA) was inserted 2.5 cm without paresthesia. Clear cerebrospinal fluid was aspirated from the catheter within 1 minute. The patient was placed in the left uterine displacement position. The initial level of analgesia was T,O bilaterally. An additional dose of lidocaine 50 mg with dextrose 75 mg was injected via the catheter, and a T, level was obtained bilaterally prior to commencement of the cesarean section. BP dipped to 95/50 mmHg for less than 1 minute after initial positioning of the patient. This was successfully treated with ephedrine 25 mg IV. Uneventful delivery of a 3,400 g female child with Apgar scores of 919 occurred 12 minutes after skin incision. Uterine incision to delivery time was 2 minutes. Upon manual extraction of the placenta, an infusion of 30 units of oxytocin in 1 liter of lactated Ringer’s solution was started. During the manual extraction of the plaJ. Clin. Anesth., vol. 4, November/December
1992
487
Case Reports
centa, the uterus was unintentionally inverted. The oxytocin infusion was discontinued, and manual reversion failed after several minutes. The obstetrician requested immediate induction of general anesthesia and subsequent administration of volatile anesthetics for uterine relaxation. Alternatively, we suggested and administered nitroglycerin 200 pg IV. Within 1 minute, the uterus relaxed substantially, and uterine reversion was accomplished. Vital signs remained unchanged and stable during the inversion and administration of nitroglycerin. Oxytocin infusion was reinstituted following successful reversion. Total estimated blood loss was 1,000 ml. The patient remained stable throughout the remainder of the case.
Discussion Nitroglycerin, a potent vasodilator and smooth-muscle relaxant, has been established as efficacious in obstetric anesthesia to treat a retained placenta.‘,* Nitroglycerin has a rapid onset of action, a plasma half-life of approximately 2 minutes,5 and a short duration of action. It has been suggested for reduction of an inverted uterus.4 We present a case in which excellent relaxation of the inverted uterus was rapidly obtained, allowing speedy reversion of an otherwise inflexible uterus. The uterus promptly responded to the administration of oxytocin, and hemodynamic stability was maintained. Methods previously described for treatment of this rare obstetric predicament include induction of general anesthesia with administration of potent inhalational anesthetics4 or patiently waiting for the uterus to be manually reverted with continued firm pressure against the fundus from inside the uterus3 Tocolytic drugs such as terbutalinee and magnesium sulfate’ also have been advocated. General anesthesia subjects the full-stomach parturient to the risks of aspiration and hypoxia. The concentration of inhalation drug necessary to relax the refractory uterus may depress the cardiovascular system at a time when hemodynamics may be unstable. The manual reversion method not only is time-consuming but could contribute to the accumulation of “metabolic products,” which may lead to hemodynamic instability.8 The infusion of beta-mimetic drugs for tocolysis has been associated with serious untoward maternal hemodynamic and pulmonary events, including cardiovascular instability and pulmonary edema.g Beta-mimetic drugs consistently cause tachycardia and alterations in systolic and diastolic blood pressure.6 The vasodilator effects of the beta-mimetics, which have longer durations of action than nitroglycerin, may worsen concurrent hypotension and should be used cautiously.4 After bolus administration of magnesium, the patient may experience chest tightness, palpitations, tachycardia, hypotension, or nausea.4 Also, the administration of magnesium sulfate to parturients for tocolysis has been associated with side effects similar to those caused by beta-mimetics, including pulmonary edema, chest pain, 488
J. Clin.
Anesth.,
vol. 4, November/December
1992
and chest tightness. lo It has been shown that the frequency of serious side effects such as chest pain with or without ECG changes, chest pressure, and adult respiratory distress syndrome occurred more often if the magnesium sulfate and beta-mimetic drug were given concurrently .*I Therefore, if a patient happens to be receiving either a beta-mimetic drug or magnesium sulfate during parturition, the administration of the other drug for uterine inversion may be problematic. In such a case, nitroglycerin may be useful. Nitroglycerin has been used for the removal of a retained placenta. I,* Uterine relaxation occurred within 30 to 95 seconds. Vital signs were virtually unaffected in patients who received nitroglycerin. Even when bolus doses of nitroglycerin 500 pg were administered, only mild hypotension was noted and deemed clinically unimportant.’ Side effects such as headache, prolonged uterine relaxation, and palpitations were not noted. In the current case, the bolus dose of nitroglycerin 200 kg allowed swift reversion of the uterus. No significant changes in vital signs occurred. The patient received an adequate preload, and blood loss prior to inversion was not excessive. Also, early detection and rapid reversion could have accounted for the patient’s cardiovascular stability. Should inversion occur in a patient who is less than hemodynamically stable, rapid infusion of a fluid and titration of low doses of nitroglycerin may be appropriate.
References 1. Peng AT, (;orman RS, Shulman SM, DeMarchis E, Nyunt K, Blancato LS: Intravenous nitroglycerin for uterine relaxation in the postpartum patient with retained placenta [Letter]. Anesthesiology 1989;7 1: 172-3. 2. DeSimone CA, Norris MC, Leighton BL: Intravenous nitroglycerin aids manual extraction of a retained placenta [Letter]. Anesthesiology 1990;73:787. 3. Kates RA: Antianginal drug therapy. In: Kaplan JA, ed. CardiucAnesthesia. Vol. 1. Orlando, FL: Grune & Stratton, 1987:45165. 4. Datta S: Anesthetic and Obstetnc Management of High-Risk Pregnancy. St. Louis: Mosby Year Book, 1991:129-30; 465-66. 5. James FM, Wheeler AS, Dewan DM: Obstetric Anesthesza: The Complicated Patient. 2d ed. Philadelphia: F.A. Davis, 1988:3345. 6. Kovacs BW, DeVore GR: Management of acute and subacute puerperal uterine inversion with terbutaline sulfate. Am J Obstet Gynecol 1984;150:784-6. 7. Grossman RA: Magnesium sulfate for uterine inversion. J Reprod Med 1981;26:261-2. 8. Emmott RS, Bennett A: Acute inversion of the uterus at caesarean section. Implications for the anaesthetist. Anaesthesia 1988;43: 118-20. 9. Benedetti TJ: Maternal complications of parenteral beta-sympathomimetic therapy for premature labor. Am J Obstet Gynecol 1983;145:1-6. 10. Elliot JP: Magnesium sulfate as a tocolytic agent. Am J ObAtet Gynecol 1983;147:277-84. 11. Ferguson JE II, Hensleigh PA, Kredenster D: Adjunctive use of magnesium sulfate with ritodrine for preterm labor tocolysis. Am J Obstet Gynecol 1984; 148: 166-7 1.
Intravenous Nitroglycerin Uterine Inversion
for
Daniel A. Bayhi, MD, JD, RPh,* Cynthia D.A. Sherwood, MD,? Carol E. Campbell, MDT Department of Anesthesiology, Medical Center of Louisiana Louisiana State University Medical Center, New Orleans, LA.
Uterine inversion following vaginal delivery or during Cesarean section is rare. Cardiovascular instability resulting from blood loss is possible. This article describes the use of intravenous nitroglycerin as an alternative to the induction of general anesthesia and administration of volatile anesthetics to provide uterine relaxation.
Keywords: Cesarean nitroglycerin; uterus,
section; myometrium; relaxation of, inversion
of.
Introduction Uterine inversion following vaginal delivery is a rare complication. Uterine inversion during cesarean section is reported even less frequently. The potential for excessive blood loss with attendant cardiovascular instability could make this event an anesthetic emergency. Standard anesthetic intervention has included the induction of anesthesia and the administration of volatile anesthetics to relax uterine smooth muscle. This technique has allowed the obstetrician to revert the uterus. The induction of anesthesia in a full-stomach obstetric patient has its own set of potentially lethal complications. We report a case of uterine inversion occurring during
*Associate Professor tAssistant Professor Address reprint requests to Dr. Bayhi at the Department of Anesthesiology, Medical Center of Louisiana at New Orleans, Louisiana State University Medical Center, 1532 Tulane Avenue, New Orleans, LA 70140, USA. Received for publication May 14, 1992; cepted for publication July 21, 1992. 0 1992 Butterworth-Heinemann 1. Clin. Anesth. 4:487-488.
1992.
revised manuscript
ac-
at New Orleans,
cesarean section with spinal anesthesia treated with intravenous nitroglycerin without general anesthesia. Case Report A healthy 35-year-old gravida 3 para 1 at 39 weeks gestation was admitted for repeat cesarean section. She weighted 84 kg and was 162 cm tall. Her prenatal course was unremarkable except for a history of peptic ulcer disease. Her physical examination was within normal limits. Monitors used during the induction of continuous spinal anesthesia included electrocardiogram (ECG), arterial oxygen saturation, continuous fetal heart rate monitor, and noninvasive blood pressure (BP) monitor. The patient was given 30 ml of 0.3 M sodium citrate orally and 2,000 ml of lactated Ringer’s solution intravenously (IV). She was placed in a sitting position, and the second lumbar interspace was identified and anesthetized with 1% lidocaine. Continuous spinal anesthesia was begun with a 22-gauge Quincke-point needle through which bupivacaine 9 mg with dextrose 99 mg was injected. A 28-gauge styletted CoSpan catheter (Kendall Corp., Mansfield, MA) was inserted 2.5 cm without paresthesia. Clear cerebrospinal fluid was aspirated from the catheter within 1 minute. The patient was placed in the left uterine displacement position. The initial level of analgesia was T,O bilaterally. An additional dose of lidocaine 50 mg with dextrose 75 mg was injected via the catheter, and a T, level was obtained bilaterally prior to commencement of the cesarean section. BP dipped to 95/50 mmHg for less than 1 minute after initial positioning of the patient. This was successfully treated with ephedrine 25 mg IV. Uneventful delivery of a 3,400 g female child with Apgar scores of 919 occurred 12 minutes after skin incision. Uterine incision to delivery time was 2 minutes. Upon manual extraction of the placenta, an infusion of 30 units of oxytocin in 1 liter of lactated Ringer’s solution was started. During the manual extraction of the plaJ. Clin. Anesth., vol. 4, November/December
1992
487
Case Reports
centa, the uterus was unintentionally inverted. The oxytocin infusion was discontinued, and manual reversion failed after several minutes. The obstetrician requested immediate induction of general anesthesia and subsequent administration of volatile anesthetics for uterine relaxation. Alternatively, we suggested and administered nitroglycerin 200 pg IV. Within 1 minute, the uterus relaxed substantially, and uterine reversion was accomplished. Vital signs remained unchanged and stable during the inversion and administration of nitroglycerin. Oxytocin infusion was reinstituted following successful reversion. Total estimated blood loss was 1,000 ml. The patient remained stable throughout the remainder of the case.
Discussion Nitroglycerin, a potent vasodilator and smooth-muscle relaxant, has been established as efficacious in obstetric anesthesia to treat a retained placenta.‘,* Nitroglycerin has a rapid onset of action, a plasma half-life of approximately 2 minutes,5 and a short duration of action. It has been suggested for reduction of an inverted uterus.4 We present a case in which excellent relaxation of the inverted uterus was rapidly obtained, allowing speedy reversion of an otherwise inflexible uterus. The uterus promptly responded to the administration of oxytocin, and hemodynamic stability was maintained. Methods previously described for treatment of this rare obstetric predicament include induction of general anesthesia with administration of potent inhalational anesthetics4 or patiently waiting for the uterus to be manually reverted with continued firm pressure against the fundus from inside the uterus3 Tocolytic drugs such as terbutalinee and magnesium sulfate’ also have been advocated. General anesthesia subjects the full-stomach parturient to the risks of aspiration and hypoxia. The concentration of inhalation drug necessary to relax the refractory uterus may depress the cardiovascular system at a time when hemodynamics may be unstable. The manual reversion method not only is time-consuming but could contribute to the accumulation of “metabolic products,” which may lead to hemodynamic instability.8 The infusion of beta-mimetic drugs for tocolysis has been associated with serious untoward maternal hemodynamic and pulmonary events, including cardiovascular instability and pulmonary edema.g Beta-mimetic drugs consistently cause tachycardia and alterations in systolic and diastolic blood pressure.6 The vasodilator effects of the beta-mimetics, which have longer durations of action than nitroglycerin, may worsen concurrent hypotension and should be used cautiously.4 After bolus administration of magnesium, the patient may experience chest tightness, palpitations, tachycardia, hypotension, or nausea.4 Also, the administration of magnesium sulfate to parturients for tocolysis has been associated with side effects similar to those caused by beta-mimetics, including pulmonary edema, chest pain, 488
J. Clin.
Anesth.,
vol. 4, November/December
1992
and chest tightness. lo It has been shown that the frequency of serious side effects such as chest pain with or without ECG changes, chest pressure, and adult respiratory distress syndrome occurred more often if the magnesium sulfate and beta-mimetic drug were given concurrently .*I Therefore, if a patient happens to be receiving either a beta-mimetic drug or magnesium sulfate during parturition, the administration of the other drug for uterine inversion may be problematic. In such a case, nitroglycerin may be useful. Nitroglycerin has been used for the removal of a retained placenta. I,* Uterine relaxation occurred within 30 to 95 seconds. Vital signs were virtually unaffected in patients who received nitroglycerin. Even when bolus doses of nitroglycerin 500 pg were administered, only mild hypotension was noted and deemed clinically unimportant.’ Side effects such as headache, prolonged uterine relaxation, and palpitations were not noted. In the current case, the bolus dose of nitroglycerin 200 kg allowed swift reversion of the uterus. No significant changes in vital signs occurred. The patient received an adequate preload, and blood loss prior to inversion was not excessive. Also, early detection and rapid reversion could have accounted for the patient’s cardiovascular stability. Should inversion occur in a patient who is less than hemodynamically stable, rapid infusion of a fluid and titration of low doses of nitroglycerin may be appropriate.
References 1. Peng AT, (;orman RS, Shulman SM, DeMarchis E, Nyunt K, Blancato LS: Intravenous nitroglycerin for uterine relaxation in the postpartum patient with retained placenta [Letter]. Anesthesiology 1989;7 1: 172-3. 2. DeSimone CA, Norris MC, Leighton BL: Intravenous nitroglycerin aids manual extraction of a retained placenta [Letter]. Anesthesiology 1990;73:787. 3. Kates RA: Antianginal drug therapy. In: Kaplan JA, ed. CardiucAnesthesia. Vol. 1. Orlando, FL: Grune & Stratton, 1987:45165. 4. Datta S: Anesthetic and Obstetnc Management of High-Risk Pregnancy. St. Louis: Mosby Year Book, 1991:129-30; 465-66. 5. James FM, Wheeler AS, Dewan DM: Obstetric Anesthesza: The Complicated Patient. 2d ed. Philadelphia: F.A. Davis, 1988:3345. 6. Kovacs BW, DeVore GR: Management of acute and subacute puerperal uterine inversion with terbutaline sulfate. Am J Obstet Gynecol 1984;150:784-6. 7. Grossman RA: Magnesium sulfate for uterine inversion. J Reprod Med 1981;26:261-2. 8. Emmott RS, Bennett A: Acute inversion of the uterus at caesarean section. Implications for the anaesthetist. Anaesthesia 1988;43: 118-20. 9. Benedetti TJ: Maternal complications of parenteral beta-sympathomimetic therapy for premature labor. Am J Obstet Gynecol 1983;145:1-6. 10. Elliot JP: Magnesium sulfate as a tocolytic agent. Am J ObAtet Gynecol 1983;147:277-84. 11. Ferguson JE II, Hensleigh PA, Kredenster D: Adjunctive use of magnesium sulfate with ritodrine for preterm labor tocolysis. Am J Obstet Gynecol 1984; 148: 166-7 1.
