Risk factors for obstetric morbidity in patients with uterine atony undergoing caesarean delivery

BACKGROUND

Uterine atony (UA) is recognized as a leading cause of postpartum haemorrhage. However, knowledge of risk factors of haemorrhage-related morbidity among patients diagnosed with UA is uncertain. We investigated risk factors for haemorrhage-related morbidity among patients undergoing Caesarean delivery with UA.

METHODS

We conducted a secondary analysis of data sourced from a 4-yr observational study at 19 US academic centres. Patients with UA were identified based on receiving methylergonovine or carboprost. Our primary outcome (haemorrhage-related morbidity) included a composite of intra- or postpartum transfusion; Caesarean hysterectomy; uterine or hypogastric artery ligation; intensive care admission for: pulmonary oedema, coagulopathy, adult respiratory distress syndrome, postoperative ventilation, or invasive line monitoring.

RESULTS

Among 57,182 patients who underwent Caesarean delivery, 2294 (4%) patients developed UA. Haemorrhage-related morbidity occurred in 450 (19.6%) patients with UA. The risk of haemorrhage-related morbidity was increased among African-Americans [adjusted odds ratio (aOR)=2.36; 95% confidence interval (CI)=1.73-3.23], Hispanics (aOR=1.4; 95% CI=1.04-1.9), women with multiple gestations (aOR=1.59; 95% CI=1.06-2.38), placenta praevia (aOR=4.89; 95% CI=3.04-7.87), patients with ASA class III (aOR=1.4; 95 CI=1.03-1.9), or ASA class IV (aOR=5.88; 95% CI=2.48-13.9), exposure to general anaesthesia (GA) (aOR=2.4; 95% CI=1.59-3.62) and combined general and regional anaesthesia (aOR=4.0; 95% CI=2.62-6.09), and ≥2 prior Caesarean deliveries (aOR=1.62; 95% CI=1.1-2.39).

CONCLUSIONS

Among patients with UA undergoing Caesarean delivery, the risk of haemorrhage-related morbidity is increased in African-Americans, Hispanics, patients with multiple gestations, placenta praevia, ASA class III or IV, ≥2 prior Caesarean deliveries and those undergoing GA.

[Two cases of congenital airway obstruction managed with ex utero intrapartum treatment procedures: anesthetic implications]

An ex utero intrapartum treatment (EXIT) procedure provides sufficient time to gain control of the potentially obstructed fetal upper airway while uterine placental circulation is maintained during cesarean section. We report 2 cases in which fetal congenital upper airway obstruction was managed without complications during EXIT procedures. We also discuss general considerations concerning the obstetric patient and the performance of intramuscular fetal anesthesia. Before the hysterotomy, sevoflurane at 1.5 minimum alveolar concentration was administered to assure sufficient uterine relaxation during EXIT. The 2 parturients remained hemodynamically stable during the procedure and uterine and placental perfusion was adequate. Nasotracheal intubation was possible in 1 fetus after a cervical mass was dissected. In the other, a tracheostomy was created. After the umbilical cord was clamped, the concentration of sevoflurane anesthetic gas was reduced and oxytocin and methylergometrine were administered to induce adequate uterine contractions within a few minutes. Both neonates survived the EXIT procedure with no complications.

[Effects of methylergometrine and oxytocin on blood loss and uterine contraction during cesarean section]

BACKGROUND

The effects of intravenous oxytocics on blood loss and uterine contraction during cesarean section were studied in 136 parturients.

METHODS

The subjects were randomized to receive either methylergometrine 0.2 mg bolus (MEM group; n = 34), oxytocin 10 IU over 30 seconds (OX 30 s group; n = 34), oxytocin 10 IU over 5 minutes (OX 5 m group; n = 34) or oxytocin 10 IU over 15 minutes (OX 15 m group; n = 34). The subjects received spinal anesthesia with 11-12 mg of intrathecal isobaric bupivacaine (0.5%). Additional intramyometrial prostaglandin F2alpha (PGF2alpha) was administered when obstetrician diagnosed uterine atony. We analyzed total amount of blood loss including amniotic fluid and number of parturients that received additional intramyometrial PGF2alpha to evaluate uterine contraction.

RESULTS

The amounts of blood loss in the OX 30 s and OX 5 m groups were significantly lower than in the MEM group, and the numbers of parturients received additional PGF2alpha in all the oxytocin treat ment groups were significantly lower than in the MEM group (P < 0.05). There were no significant differences in blood loss and uterine contractior among the oxytocin treatment groups.

CONCLUSIONS

Intravenous oxytocin 10 IU over 30 seconds to 15 minutes was effective to decrease blood loss and uterine contraction than intravenous methylergometrine 0.2 mg bolus.

Reinforcement in an in vitro analog of appetitive classical conditioning of feeding behavior in Aplysia: blockade by a dopamine antagonist

In a recently developed in vitro analog of appetitive classical conditioning of feeding in Aplysia, the unconditioned stimulus (US) was electrical stimulation of the esophageal nerve (En). This nerve is rich in dopamine (DA)-containing processes, which suggests that DA mediates reinforcement during appetitive conditioning. To test this possibility, methylergonovine was used to antagonize DA receptors. Methylergonovine (1 nM) blocked the pairing-specific increase in fictive feeding that is usually induced by in vitro classical conditioning. The present results and previous observation that methylergonovine also blocks the effects of contingent reinforcement in an in vitro analog of appetitive operant conditioning suggest that DA mediates reinforcement for appetitive associative conditioning of feeding in Aplysia.

Evidence for possible involvement of 5-HT(2B) receptors in the cardiac valvulopathy associated with fenfluramine and other serotonergic medications

BACKGROUND

Serotonergic medications with various mechanisms of action are used to treat psychiatric disorders and are being investigated as treatments for drug dependence. The occurrence of fenfluramine-associated valvular heart disease (VHD) has raised concerns that other serotonergic medications might also increase the risk of developing VHD. We hypothesized that fenfluramine or its metabolite norfenfluramine and other medications known to produce VHD have preferentially high affinities for a particular serotonin receptor subtype capable of stimulating mitogenesis.

METHODS AND RESULTS

Medications known or suspected to cause VHD (positive controls) and medications not associated with VHD (negative controls) were screened for activity at 11 cloned serotonin receptor subtypes by use of ligand-binding methods and functional assays. The positive control drugs were (+/-)-fenfluramine; (+)-fenfluramine; (-)-fenfluramine; its metabolites (+/-)-norfenfluramine, (+)-norfenfluramine, and (-)-norfenfluramine; ergotamine; and methysergide and its metabolite methylergonovine. The negative control drugs were phentermine, fluoxetine, its metabolite norfluoxetine, and trazodone and its active metabolite m-chlorophenylpiperazine. (+/-)-, (+)-, and (-)-Norfenfluramine, ergotamine, and methylergonovine all had preferentially high affinities for the cloned human serotonin 5-HT(2B) receptor and were partial to full agonists at the 5-HT(2B) receptor.

CONCLUSIONS

Our data imply that activation of 5-HT(2B) receptors is necessary to produce VHD and that serotonergic medications that do not activate 5-HT(2B) receptors are unlikely to produce VHD. We suggest that all clinically available medications with serotonergic activity and their active metabolites be screened for agonist activity at 5-HT(2B) receptors and that clinicians should consider suspending their use of medications with significant activity at 5-HT(2B) receptors.

Modulation of contractions to ergonovine and methylergonovine by nitric oxide and thromboxane A2 in the human coronary artery

This study explored the modulatory effects of nitric oxide and thromboxane A2 on contractions to ergonovine and methylergonovine in human coronary arteries. To elucidate the different role of nitric oxide synthase in the response to the ergot alkaloids, the serotonin (5-HT) receptors involved in nitric oxide synthase in the response to the ergot alkaloids, the 5-HT receptors involved in nitric oxide release and the contraction of the vascular smooth muscle were characterized with more selective 5-HT-receptor agonists and antagonists. Rings of human coronary arteries from explanted hearts were suspended in organ chambers for isometric tension recording. After testing for contractile (potassium chloride, 60 mM) and endothelial function (substance P, 10(-8) M), respectively, they were exposed to ergot alkaloids or other agonists in the absence or presence of U 46619 (10(-9) M), or nitro-L-arginine (10(-4) M), or both. Ergonovine and methylergonovine were comparable, weak vasoconstrictors in untreated preparations. Contractions to ergonovine were augmented by U 46619, but not by nitro-L-arginine. Contractions to methylergonovine were augmented only by combining U 46619 and nitro-L-arginine. Serotonin and methylergonovine, but not ergonovine, elicited endothelium-dependent, nitric oxide-mediated relaxations. Nonselective 5-HT(1B/1D)-receptor stimulation caused both contractions and relaxations; selective 5-HT1B stimulation caused relaxations only. In the human coronary artery, contractions to ergonovine are not dependent on NO release but are synergistically augmented by thromboxane. Methylergonovine causes similar effects on the vascular smooth muscle, but contractions are inhibited by the release of NO from the endothelium. The 5-HT receptor on the endothelium appears to be different from the receptor on the vascular smooth muscle, which mediates the contractile response to the ergot alkaloids.

Use of methergine for the prevention of postoperative endometritis in non-elective cesarean section patients

OBJECTIVE

Methergine increases constriction of uterine musculature which may facilitate sloughing of endometrial debris, close uterine vessels, and prevent post-cesarean endometritis. The objective of this study was to evaluate the efficacy of methergine in preventing endometritis in patients undergoing non-elective cesarean section delivery.

METHODS

Eighty patients undergoing non-elective cesarean section were enrolled in a prospective randomized clinical trial of methergine (41) versus no methergine (39) administration during the postpartum period. The hospital records were abstracted after discharge to compare the postpartum course.

RESULTS

There were no significant demographic differences between the two groups. The women receiving methergine had a significant reduction in the rate of postoperative endometritis (10% vs. 36%, P < 0.005). In addition, the mean postoperative hemoglobin was significantly higher in the methergine treated group (P < 0.001).

CONCLUSIONS

The use of methergine postpartum in women undergoing non-elective cesarean sections significantly reduces the incidence of postoperative endometritis and blood loss.

[Immediate collateral coronary circulation after a methylergometrin test]

The development of a collateral coronary circulation has been well studied by angiography in two main clinical situations: myocardial infarction (by durable coronary occlusion) and angina (due to significant coronary artery stenosis), but only rarely in spastic angina. The authors report the case of severe spasm at the site of non-significant stenosis after a methylergometrine test, with immediate contro-lateral collateral circulation in a patient with a short history of spastic angina without myocardial infarction. This observation demonstrates that collateral circulation may develop very rapidly in spastic angina (without basal ischaemia in the absence of significant coronary stenosis), because this patient only had seven ten-minute episodes of clinical ischaemia. As collateral circulation may mask clinical and electrical signs in spastic angina, this case suggests that angiographic control should be systematic during the methylergometrine test.

Drugs and uterine motility

Nurses who care for pregnant and laboring women are faced with an increasingly frequent use of pharmaceutical agents that facilitate initiation of labor (uterotropins), augment labor (uterotonics), or potentially stop labor (tocolytics). The choice of the drug, administration, side effects, and complications varies. Knowledge about uterine physiology helps the clinician understand the action of these agents. Knowledge of the differences and similarities among oxytoxics, ergots, prostaglandins, and the various drugs used as tocolytics is essential for safe and effective care of women and their fetuses who may be exposed to these agents.

Dopaminergic synapses mediate neuronal changes in an analogue of operant conditioning

Feeding behavior in Aplysia can be modified by operant conditioning in which contingent reinforcement is conveyed by the esophageal nerve (E n.). A neuronal analogue of this conditioning in the isolated buccal ganglia was developed by using stimulation of E n. as an analogue of contingent reinforcement. Previous studies indicated that E n. may release dopamine. We used a dopamine antagonist (methylergonovine) to investigate whether dopamine mediated the enhancement of motor patterns in the analogue of operant conditioning. Methylergonovine blocked synaptic connections from the reinforcement pathway and the contingent-dependent enhancement of the reinforced pattern. These results suggest that dopamine mediates at least part of the neuronal modifications induced by contingent reinforcement.

Ergot alkaloids. Current status and review of clinical pharmacology and therapeutic use compared with other oxytocics in obstetrics and gynaecology

Ergot alkaloids are well known preparations. Ergot alkaloids used in obstetrics and gynaecology are ergometrine (ergonovine; EM), methylergometrine (methergine; ME) and bromocriptine. The pharmaceutical properties of ME EM) are critical. To guarantee stability, ME and EM ampoules should be stored in a cool, dark place. ME and EM tablets are unstable in all conditions and they show an unpredictable bioavailability, which prevents oral use of the drugs for any purpose. ME and EM are known for their strong uterotonic effect and, compared with other ergot alkaloids, for their relatively slight vasoconstrictive abilities. ME and EM do have a place in the management of the third stage of labour as they are strong uterotonics. They act differently from oxytocin and prostaglandins, and have different adverse effects. Oxytocin should be used as prophylaxis or a the drug of first choice; next, ME or EM should be used, and if none of these drugs produce the desired effects, prostaglandins should be used to control bleeding. Ergot alkaloid use in gynaecology has been limited and today is discouraged even in essential menorrhagia. It is suggested that EM and ME be used (parenterally) only in first trimester abortion curettage, to reduce blood loss. Bromocriptine has been used for lactation suppression. However, alternatives such as cabergoline, which possess fewer adverse effects, are now available and therefore preferred for this indication. In sum, there is no place for the prophylactic use of ME and EM in obstetrics or gynaecology. They can be used for therapeutic purposes in the third stage of labour. During use, the practitioner must be alert for adverse effects.

The angiotensin II type 1 receptor gene polymorphism is associated with coronary artery vasoconstriction

OBJECTIVES

This study sought to assess the potential association of the angiotensin-converting enzyme (ACE) and angiotensin II type 1 (AT1) receptor gene polymorphisms on coronary vasomotion in humans.

BACKGROUND

Abnormal coronary vasomotion plays a role in the clinical expression of coronary atherosclerosis. The components of the renin-angiotensin system are important determinants of vasomotor tone. Furthermore, epidemiologic evidence suggests that these components are involved in the pathogenesis of coronary artery disease. Indeed, two genetic polymorphisms of the ACE and AT1 receptor genes were synergistically associated with the occurrence of myocardial infarction. The influence of these genetic polymorphisms on the risk of myocardial infarction may be related, at least in part, to a deleterious effect on coronary vasomotion.

METHODS

We studied the response of angiographically normal human coronary arteries after intravenous injection of methylergonovine maleate, a potent vasoconstrictor whose effects have been previously explored in various aspects of coronary artery disease. We characterized the ACE and AT1 receptor genotypes in a consecutive series of 140 patients with normal coronary arteries. Coronary vasomotion was assessed with quantitative coronary angiography.

RESULTS

No effect of the ACE gene polymorphism was detected. Conversely, the patients carrying the AT1 receptor CC genotype (n = 13) had significantly greater vasoconstriction in distal coronary vessels (p < 0.009).

CONCLUSIONS

The AT1 receptor gene polymorphism is associated with coronary vasomotion in humans.

Uterine evacuation by vaginal misoprostol after second trimester pregnancy interruption

BACKGROUND

The purpose was to study the capacity of vaginal misoprostol in combination with methylergometrine to achieve complete evacuation of the uterus without ensuing surgical evacuation of the uterine cavity.

METHODS

We performed this trial on 228 women seeking pregnancy interruption. Vaginal misoprostol was given in a dosage of 800 micrograms in early second trimester. All women received concomitant treatment with peroral methlyergometrine from the moment of misoprostol application every 8 hours until uterine evacuation. Follow-up was continued until the first menstruation after interruption.

RESULTS

Complete uterine evacuation was achieved in 173/228 cases (76%) [group 1]. The remaining 55 women [group 2] underwent manual evacuation of placental remnants trapped in the cervix. In seven of these women a conventional curettage was carried out due either to ultrasound evidence of placental remnants or due to uterine bleeding. The interval between misoprostol application and fetal expulsion averaged 14.9 hours (s.d. 9.6) in group 1 and 21.0 hours (s.d. 14.5) in group 2 (p=0.006).

CONCLUSIONS

Misoprostol, in combination with methylergometrine, is a remarkably efficient drug in achieving uterine evacuation also in the absence of surgical evacuation of the uterine cavity. The present study provides justification for a more expectant attitude after vaginal misoprostol treatment for pregnancy interruption. The avoidance of close to 80% of otherwise conventional curettages would seem to represent a major advantage, particularly in settings where manpower and material resources are scarce.

Oral administration of methylergometrine shows a late and unpredictable effect on the non-pregnant human menstruating uterus

OBJECTIVE

To study the pharmacodynamic and pharmacokinetic properties of oral and intravenous methylergometrine upon uterine motility during menstruation.

STUDY-DESIGN

Intra-uterine pressure was measured in six volunteers with a fluid-filled sponge-tipped catheter during menstruation. Methylergometrine was given orally (0.5 mg) or intravenously (0.2 mg) in a cross-over design.

RESULTS

After intravenous administration, a fast increase of the frequency of uterine contractions and basal tone occurred with a decrease of amplitude, lasting at least 30 min. Oral administration had a late and less marked effect on uterine motility. An intravenous dose administered 24 h after an oral dose had no effect on uterine motility. Pharmacokinetic data, such as the maximum plasma concentration (Cmax), the time at which Cmax is reached (tmax) and the half-life of absorption (t1/2abs) also demonstrated large individual variations after oral administration.

CONCLUSIONS

Oral administration of methylergometrine had an unpredictable and late effect on uterine motility on the menstruating uterus, probably due to an unpredictable bioavailability, in contrast with the fast and predictable effect after intravenous administration.

Dose-response curve of angiographically smooth human epicardial vessel segments to intracoronary injections of isosorbide dinitrate

The coronary vasodilator properties of isosorbide dinitrate are well established but the doses generally used (1,000-2,000 micrograms) are still empirical. We studied, with the use of quantitative coronary arteriography (CAESAR System), the response of smooth vessel segments (greater than 1.85 mm diameter), preconstricted with methylergometrine (400 micrograms i.v.), to intracoronary injections of graded doses (5-100 micrograms) of isosorbide dinitrate and the effects of these injections on systemic hemodynamic parameters in 10 patients undergoing diagnostic coronary angiography. Six further patients, in whom the injections of isosorbide dinitrate were replaced by equivalent volumes of normal saline, served as controls. Relative to the diameter 5 min after injection of methylergometrine, the diameter increased by a mean +/- SD of 9 +/- 7, 26 +/- 12, 33 +/- 15, 38 +/- 14, and 39 +/- 16% after injections of 5, 15, 60, 240, and 1,000 micrograms, respectively, of isosorbide dinitrate. After a cumulative dose of 80 micrograms, subsequent doses did not cause further significant increases in diameter. Injection of saline in the control group did not alter the coronary diameter. A significant fall in systolic arterial pressure, compared to the control group, occurred at a cumulative dose of 320 micrograms. The mean arterial pressure and heart rate were unchanged. Significant coronary vasodilation occurs with intracoronary doses of isosorbide much smaller than those currently employed. Cumulative doses of 320 micrograms or more cause systemic hemodynamic changes without producing additional coronary vasodilation. During interventional cardiac procedures, where systemic hypotension is undesirable, the use of smaller doses of intracoronary isosorbide dinitrate than currently employed may be feasible and should be investigated further.

[Response of coronary arteries to the intracoronary injection of isosorbide dinitrate. Dose-response curve]

The coronary vasodilator properties of isosorbide dinitrate (ISDN) are well known but the dosage remains empirical. The aim of this study was to construct a dose-response curve to ISDN with respect to vasoconstriction induced by ergometrine. The heart rate, aortic pressure and coronary angiography were analysed before and 3 and 5 minutes after I.V. injection of 0.4 mg of methylergometrine and 3 minutes after intracoronary injection of 5, 15, 60, 240 and 1,000 micrograms of ISDN in 10 patients with an average age of 53.2 +/- 10.8 years (ISDN group). Six other patients with an average age of 56.5 +/- 12.8 years comprised the control group and only received ergometrine. The coronary diameters were measured by quantitative coronary angiography using the CAESAR system of automatic contour detection. Three coronary segments with angiographically normal appearances and a resting diameter greater than or equal to 1.85 mm were analysed in each patient. With respect to the maximal constriction observed 5 minutes after the injection of methylergometrine, the percentage increase in coronary diameter was 9 +/- 7%, 26 +/- 12%, 33 +/- 15%, 38 +/- 14% and 39 +/- 16% after 5, 15, 60, 240 and 1,000 micrograms of ISDN respectively (p less than 0.005 vs control). A plateau effect was observed after a cumulative dose of 80 micrograms and administration of higher doses of 240 and 1,000 micrograms only caused mild nonsignificant additional increase in vessel diameter. In comparison with the control group, the systolic blood pressure only fell significantly with doses greater than 240 micrograms of ISDN (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison between the influence of methylergometrine and oxytocin on the incidence of retained placenta in the third stage of labour

Twenty randomly selected birth centres were questioned about their oxytocic use in the third stage of labour and incidence of retained placenta in relation to the number of vaginal deliveries during 1987. Ten centres used either methylergometrine or oxytocin routinely. Of 6,906 vaginal deliveries treated with 0.2 mg methylergometrine immediately after birth, 187 (2.7%) were complicated by retained placenta. Significantly fewer (p less than 0.001) of the 10,680 vaginal deliveries treated with 5-10 IU oxytocin were complicated by retained placenta (n = 192; 1.8%).

Effect of methylergometrine maleate (methergin) on electrical and mechanical activities of pregnant human myometrium

The effect of methylergometrine maleate (methergin) on electrical and mechanical activities of pregnant human isthmic myometrium was examined. Methergin (10(-8)-10(-6) g/ml) enhanced plateau potential and contraction, however, the effects were not prominent. Plateau potential and contraction were also potentiated after pretreatment with 10(-7) g/ml phentolamine (alpha-blocker), however 10(-7) g/ml methergin further increased these effects. It is suggested that methergin might potentiate contractions by changing the pattern of action potentials and not by alpha-adrenoceptor.

Regulation of placental 15-hydroxyprostaglandin dehydrogenase activity by obstetric drugs

The in vitro effects of obstetric drugs on 15-hydroxyprostaglandin dehydrogenase activity were investigated. Enzyme activity was inhibited by indomethacin, methylergometrine maleate, Solcoseryl, conjugated estrogen and progesterone, and was activated only by isoxsuprine-HCL. Methylergometrine maleate and isoxsuprine-HCl, which have opposite functions on uterine muscle, also exerted contrary effects on enzyme activity. Inhibitory and stimulatory effects of these drugs suggested that they could directly regulate uterine activity and also indirectly influence the uterus due to their effects on prostaglandin catabolism in vivo.

Methylergometrine antagonizes 5 HT in the temporal artery

Methylergometrine, the main metabolite of methysergide, has 40-times greater 5 HT antagonistic potency than methysergide in isolated segments of human temporal artery. It is suggested that methylergometrine is the "active" drug when methysergide is used in migraine prophylaxis, and that the two compounds should be compared in prophylactic trials in migraine.

The effect of labetalol on contractility of human myometrial preparations

Because of results in animal experiments which demonstrated a partial beta 2-adrenoceptor activity of labetalol on rat uterine smooth muscle the present study was conducted in human preparations. The following results were obtained: 1. Rhythmic uterine contractions with a defined steady-state amplitude and frequency were elicited spontaneously and after methylergometrine. 2. Labetalol reduced amplitude of contractions dose-dependently after 3 h of incubation. Frequency was unaffected. 3. The tocolytic effect of labetalol is apparent only at high concentrations, above those used in the treatment of hypertension. 4. Neither beta 2-specific adrenoceptor blockade with ICI 118,551 nor alpha-blockade with phentolamine changed amplitude of contraction, either alone or in combination with labetalol. 5. Labetalol has little tocolytic effect on human myometrium in vitro. This effect is unrelated to alpha- or beta-antagonism, but seems to depend on a direct smooth muscle depressant effect. In conclusion, from the present in vitro experiments using human myometrial preparations, it seems unlikely that labetalol would interfere with the normal process of labor when used for the treatment of pregnancy hypertension.

[Effects of routine administration of methylergometrin during puerperium on involution, maternal morbidity and lactation]

The objective of the prospective randomized study reported here, based on 880 puerperae, was to study the effects of methylergometrin on involution, puerperal morbidity, and lactation. Over 4 weeks 444 mothers were given 0.125 mg of methylergometrin 3 times a day, while 436 were given the same dose of placebo. The following differences were found: in the treated group involution of the uterus was accelerated in the first few days following birth, but after 4 weeks there were no longer any significant differences. Post-partum pains were almost twice as intense in the treated group as in the untreated group. It proved impossible to reduce the number of cases of infection (lochiostasis, axillary temperature over 37.5 degrees C) by administering Methergin during the puerperium; following spontaneous births there were actually more cases of endometritis in the treated group. The number of patients with severe afterbleeding after spontaneous birth was also higher in this group. Lactation among untreated puerperae averaged 880 g during the first six days, while among treated patients it was only 563 g. Even after 4 weeks there were still differences in the quantity of milk produced. The incidence of infection and afterbleeding was significantly lower in mothers who breast-fed their children, irrespective of whether they had taken Methergin or not. We therefore consider that routine treatment of puerperae with methylergometrin is no longer justified; we continue to advocate breast-feeding, not least in view of the fact that it reduces maternal morbidity.

Methylergometrine, an active metabolite of methysergide

In conscious dogs methysergide (MS) caused constriction of the saphenous vein at about 3000 times lower doses than methylergometrine (MT) when infused locally, but it elicited only a short-lasting venoconstrictor response when injected systemically intravenously. MS and MT proved to be equally active venoconstrictor agents when administered orally. Analysis of canine plasma by high-performance liquid chromatography showed that after both oral and intravenous administration of MS large amounts of MT appeared in the plasma, whereas only low and transient levels of MS could be detected. It is suggested that one of the first steps in metabolism of MS is demethylation at position 1 of the indole, leading to the formation of MT, which may be a main active principle of the therapeutic effectiveness of MS in the interval treatment of migraine headache.

Enhancement of the cyclic motor activity of the ovine small intestine by lysergic acid derivatives. Mechanism and significance

The effects of a variety of substances influencing the initiation of cyclic motor events at the gastroduodenal junction were studied in conscious sheep. A significant and long-lasting decrease in the frequency of cyclic events from approximately 100 min to 30-40 min was elicited by the intraduodenal bulb administration of the lysergic acid derivatives methylergonovine and methysergide. This effect was dose-dependent and occurred with smaller dosages than those effective when administered parenterally or more distal in the jejunum. Intraluminal administration of cyproheptadine, fonazine, and metergoline into the duodenal bulb increased the interval between phase III activity. At higher dosages, however, cyproheptadine and metergoline reduced the spiking activity of the antroduodenal junction, without significantly changing the cycle duration of the migrating myoelectric complex on the duodenal bulb or jejunum. After administration of cyproheptadine, fonazine, and metergoline, the cycling activity of the duodenojejunum was irregular for 1-2 days. These findings are compatible with a resetting of the enteric biological clock at a faster rhythm and suggest a selective action via an enteric serotoninergic mechanism involved in the normal pacing of the cyclic motor events of the gut.

13,14-Dihydro-15-keto-PGF2 alpha (PGFM) and sulprostone serum levels after application of sulprostone to postpartum women

13 ,14 -Dihydro-15-keto-PGF2 alpha (PGFM) serum levels were determined by radioimmunoassay in 101 postpartum women who were treated with 200 micrograms methergin, 5 I.U. oxytocin and 500 micrograms sulprostone, respectively, 30 min after expulsion of placenta. All patients had normal deliveries. The present radioimmunoassay system did not show cross-reactivity with sulprostone. In addition, radioimmunoassayable sulprostone serum levels were monitored. Covariance analysis of area under PGFM serum levels between time zero and 180 min after application of oxytocics was performed. A higher but statistically not significantly PGFM serum level was maintained in subjects treated with sulprostone. Sulprostone serum levels are rapidly attained after application. Decrease of radioimmunoassayable sulprostone indicates a half-life of 75 min. These data corroborate clinical findings of an accompanying paper and combine to suggest that sulprostone may be a useful alternative therapy in high-risk patients with severe postpartum atony and hemorrhage in whom prior preventive measures have failed.

[Hemodynamic and coronary effects of methylergometrin]

The methylergometrine test (ME) was performed during coronary angiography in 43 patients either by a single injection of 0,4 mg (34 cases) or by fractioned doses every 5 minutes of 0,1 mg, 0,2 mg, 0,3 mg, 0,4 mg (total 1 mg) (9 cases). Opacification of the coronary arteries was performed 1, 3 and 5 minutes after each injection; left ventricular pressures were recorded with a Millar catheter-tip transducer. The heart rate and first derivative of left ventricular pressure did not vary significantly after the 0,4 mg single dose ME. Left ventricular end systolic pressure rose by 11 p. 100 (p less than 0,001) and left ventricular end diastolic pressure from 18,3 to 23,1 mmHg (p less than 0,001). Myocardial oxygen consumption assessed by the TTI rose from 2873 +/- 896 to 3083 +/- 788 mmHg.s-1 .min (p less than 0,01), but myocardial contractility as assessed by the V max fell from 1,68 +/- 0,40 to 1,58 +/- 0,35 s-1 (p less than 0,001). The reduction in the calibre of the coronary lumen was identical after the single 0,4 mg dose and the 1 mg fractioned doses. In the later case, 50 p. 100 of the maximal response was observed after the first injection of 0,1 mg. After the single dose of 0,4 g ME the reduction in coronary lumen was very rapid over the first 3 minutes. Prolonged observation up to the 10th minute (7 patients) showed slight aggravation of the vasoconstriction between the 5th and 10th minutes, justifying an injection of a nitrate derivative before discontinuing surveillance. The vasoconstriction induced by ME seems to be within the physiological limits of vasoconstriction. The maximal overall decrease of the coronary diameter was 12,3 +/- 7,8 p. 100 and never exceeded 20 p. 100. There was a significant difference in the response of atheromatous patients in whom the vasoconstriction was greater in the presence of resting angina than in the absence of resting angina (16,4 +/- 8,7 p. 100 compared to 9,7 +/- 6,4 p. 100, p less than 0,01).

Inhibition of puerperal lactation by metergoline: interactions with methylergobasine maleate

Metergoline, a prolactin (PRL) lowering drug, is used in the puerperal period to inhibit lactation. Methylergobasine maleate (MEM), widely employed in the puerperium to promote uterine contractions, has also been reported to decrease PRL release and to reduce lactation. To evaluate the possible interactions of the two drugs, groups of 6-11 puerperae each received no treatment, metergoline alone (8 or 12 mg/day for 5 days), MEM alone (0.2 mg i.v. at delivery followed by 0.5 mg/day p.o. for 5 days) and metergoline plus MEM. Metergoline fully prevented lactation and significantly reduced PRL release, the higher dose inducing effects faster. MEM was without effect on PRL release and lactation, and did not modify the effect of metergoline.

Effects of haloperidol, methylergometrine and phentolamine on the frog ERG

The effects of 3 x 10(--5) solutions of haloperidol (HAL), methylergometrine (ME) and phentolamine (PHA) in a dose of 27 microliters on the ERG of isolated frog eye cup preparations were examined. HAL induced a decrease in the amplitude of both the b- and d-waves which began about 20 min after the application. The dominating ME effect was a fast increase of the b-wave amplitude, while PHA did not induce any significant influences on the ERG.

Complete denervation of the heart (autotransplantation) for treatment of severe, refractory coronary spasm

A 49 year old man had severe refractory Prinzmetal's variant angina and angiographically documented coronary arterial spasm of a dominant circumflex artery. The spasm was provoked by methergine (an ergot alkaloid) and seemed resistant to various forms of medical therapy including administration of nitrates, nifedipine, verapamil, diltiazem and amiodarone. The attacks of angina at rest persisted at the rate of 7 to 15/day and were frequently associated with atrioventricular (A-V) block. After unsuccessful plexectomy performed in another institution, the patient underwent complete cardiac denervation (produced by autotransplantation). The follow-up data have interesting implications in relation to treatment of refractory variant angina, as well as possible mechanisms of coronary arterial spasm.

Pharmacoangiography of gynecologic tumors

Angiography was performed before and after intraarterial administration of prostaglandin F2 alpha, 8-lysine vasopressin, oxytocin, methylergometrine, noradrenalin, and bradykinin in 62 women with various pelvic tumors. It is concluded that the use of the vasoactive drugs in the doses tested did not improve the angiographic diagnosis in unselected cases of female pelvic tumors.

Pharmacologic induction of luteolysis in cynomolgus monkeys (Macaca fascicularis)

Earlier studies reported from this laboratory demonstrated the luteolytic effect of a 5-day sequential regimen of 3 days of estrogen overlapped with 3 days of PGF2 alpha administered during the midluteal phase to cynomolgus monkeys. In this study, a different regimen, containing estrogen, lower doses of PGF2 alpha, and methylergonovine maleate (MEM), was used. Individual components of this modified sequential regimen were not effective as luteolytic agents. When 3 days of estrogen (40 micrograms of depoestradiol cypionate [DEC] on the first day and 40 micrograms of estradiol benzoate [EB] on second and third day) was followed by 3 days of MEM (400 micrograms, twice daily) overlapping 1 day of estrogen treatment, there was a significant shortening of the length of the menstrual cycle (less than 26 days) in eight of 10 animals, with a concomitant decline in plasma levels of progesterone. When a low dose of MEM (100 micrograms, twice daily), which was completely ineffective in shortening cycle lengths with the same estrogen treatment, was administered alternately with PGF2 alpha (5 mg twice daily, 11 of 14 animals had shortened cycles, with an associated decline in levels of progesterone. PGF2 alpha and MEM without the estrogen pretreatment did not have a significant effect on cycle lengths or blood levels of progesterone, thus demonstrating a synergism between estrogen and the other compounds in inducing luteolysis. Since the agents used in these sequential regimens have potent effects on the uterus, the treatments were repeated in hysterectomized monkeys to determine whether the uterus was involved in the mediation of luteolysis. These treatments caused a significant drop in plasma levels of progesterone by the tenth day after the preovulatory estrogen peak, thus demonstrating that the uterus is not essential to the luteolytic action.

Inhibition of prolactin and lactation by methylergometrine hydrogenmaleate

Reports on the effect of methylergometrine hydrogenmaleate (MEM) on prolactin (PRL) secretion and lactation are still controversial. Therefore a prospective study was designed to follow the influence of MEM on post-partum PRL levels and milk production. MEM was given orally to 30 post-partum women from day 1 to day 7 in a daily dose of 0.6 mg. Thirty untreated women served as control. PRL plasma levels and milk yield were compared at day 1, 3 and 7. PRL levels were significantly lower in the treated group at day 7 (P less than 0.01), while the difference at day 3 was statistically not significant. Milk yield was significantly reduced at day 3 (P less than 0.05) and day 7 (P less than 0.01). These results indicate PRL inhibiting properties of MEM resulting consequently in reduced lactation.

[Effect of ergot alkaloid derivatives on milk secretion in the immediate postpartum period]

30 women received an intramuscular injection of 0.2 mg of methylergobasine immediately after delivery and then 3 tablets of 1 mg of ergotamine tartrate per mouth daily for 6 days post-partum. 28 women received no treatment after delivery. The selection of the two groups was random. The treatment with rye ergot derivatives did not have a significant effect on the quantity of milk that the infant took, nor on the infant's weight gain in the 6 first days of life.

Haemodynamic effects of oxytocin (syntocinon) and methyl ergometrine (methergin) on the systemic and pulmonary circulations of pregnant anaesthetized women

The haemodynamic effects of oxytocin (Syntocinon) and methyl ergometrin (Methergin) were studied in 9 healthy females in the first trimester of pregnancy. The patients were anaesthetized with sodium thiomebumal, pethidine and pancuronium bromide and ventilated on a Manley respirator. 10 i.u. oxytocin given as an i.v. bolus brought about a fall in femoral arterial pressure of 40%, systemic resistance 59% and pulmonary resistance 44% 30 sec after injection. However, the heart rate increased 31% and stroke volume 17%, so that the cardiac output increased by 54%. The pulmonary arterial pressure and wedge pressure were increased by 33% and 35%, respectively 150 sec after injection. No changes were seen in the haemodynamic parameters during infusion of 80 mU oxytocin for 10 min. 0.2 mg Methergin brought about an increase in the femoral arterial pressure of 11%, pulmonary arterial pressure 27% and wedge pressure 31%, with no changes in the other measured parameters. The use of oxytocic drugs in patients with compromised circulation is discussed.

Pharmacokinetics of methylergometrine (methylergonovine) in the rabbit and man

Methylergometrine concentrations in human and rabbit plasma were determined by a new radioimmunoassay after a single intravenous injection (0.2 mg in man and 0.05, 0.1 and 0.2 mg/kg in rabbits). Both in man and in the rabbit methylergometrine disappeared quickly from the plasma with a mean T1/2alpha of 1.8 and 1.2-1.7 min. respectively. Similarly, the T1/2beta-values were 32.1 and 27.3-93.2 min. tthe mean maximal response in the rabbit uterus in situ after 0.05, 0.1 and 0.2 mg/kg intravenously dose was found at 40 sec., 26 sec., and 26 sec. after the drug administration, respectively, and the dose response curve was quite steep. A significant correlation was found between the dose and response.

[The uterotropismus of halothane, chloroform or methoxyflurane in clinical use (author's transl)]

To perform episiotomy, 89 women after childbirth were anaesthetized with either halothane (50 patients), methoxyflurane (24 patients) or chloroform (15 patients). The activity of the uterus was registered tocodynamographically. To examine the alternate influence of narcotics and uterotonica, 57 patients were pre-medicated with sintocinon and methergin i.m. as a prophylaxis. The second group (32 patients) received no premedication to stimulate labor activity, however in 18 cases towards the end of narcosis oxytocin and methergin were given i.v. In addition to these examinations 5 vaginal deliveries were anaesthetised with halothane only. Concerning our own experimental study it can be observed: 1. The relaxative properties of halothane wich suppresses completly the activity of myometrium during the deep stages of anaesthesia are superior to chloroform and methoxyflurane. 2. More rapid relaxation of the uterus with halothane compared with chloroform and methoxyflurane. 3. After the use of halothane a quicker return of the activity of the uterus compared with chloroform and methoxyflurane. 4. The value of a prophylaxis with uterotonica can be demonstrated by a comparatively reduced slowing-down of labour-activity during anaesthesia. 5. In every one of the cases, an interuption of the labour-suppressing, caused by the anaesthesia, can be obtained by injecting intravenously oxytocin or methergin. 6. During vaginal delivery, compared to the post placentar phase, there is no need for higher concentrations of halothane to be used to suppress labour contractions. The discussion deals with the intensity of reduction of the uterus contraction caused by the above mentioned narcotics, the dangers of the atony of the uterus, and the indications and contra-indications of obstetrical anaesthesia with halothane or methoxyflurane.

Lack of effect of methyl-ergonovine on postpartum lactation

There is little information about the action of ergot derivatives other than bromocriptine (CB 154) on plasma prolactin and milk secretion in human beings. In a recent report it has been suggested that ergonovine might interfere with lactation when administered post partum. The present study shows that methyl-ergonovine (Methergine), a closely related compound, has no action on prolactin or milk secretion as measured in a group of 10 breast feeding mothers in comparison with another 10 untreated puerperas.

Effect of methylergonovine on puerperal prolactin secretion

Serum prolactin concentration was measured by radioimmunoassay in 29 women, in the first 1 1/2 hours postpartum. Fourteen women received 0.2 mg methylergonovine maleate (Methergine) intramuscularly after the delivery of the placenta. Fifteen women who served as controls received only saline. The rise in serum prolactin concentration seen in the control women (266.4 ng/ml +/- 40.8 SE) was significantly greater than that seen in methylergonovine-treated patients (141.0 ng/ml +/- 29.0. SE).

Effect of methylergobasine maleate on serum gonadotrophin and prolactin in humans

Intramuscular injection of 0.2 mg methylergobasine maleate3) (Methergin, Sandoz) in women on day 3 post-partum, in regularly menstruating women and in adult men, is followed within 30 to 75 min by a 50% decrease in serum prolactin concentration: the levels remain low until 180 min and increase between 180 and 240 min. The amplitude of the decrease is the same when prolactin is measured in terms of the same serum prolactin standard by a homologous ovine assay and by a homologous human assay. However, in the case of regularly menstruating women and of men serum prolactin concentration is some three times higher when estimated by the ovine assay than when estimated by the human assay. This difference between assay results obtained by the two radioimmunoassay methods could be due to heterogeneity of serum prolactin. However, non-specific effects of serum are not excluded. In regularly menstruating women and in men, intramuscular injection of 0.2 mg methylergobasine maleate is followed within 45 to 75 min by a 50% decrease in immunoreactive serum LH concentration without concomtant change in immunoreactive FSH. The depression of LH secretion lasts for 1 to 2 h. The circulating levels of HCG in post-partum women are not modified after intramuscular injection of Methergin. In humans as in animals and in in vitro studies, inhibition of prolactin and LH release induced by ergot drugs are likely due to both an indirect effect via the hypothalamus and to a direct effect on the pituitary cells.