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Objective To evaluate the efficacy of intramuscular methylergonovine maleate as prophylaxis against excessive bleeding when given after dilation and evacuation (D&E) at 20–24 weeks. Study design We performed a randomized, double-blinded, placebo-controlled trial in patients without excessive bleeding requiring intervention after D&E completion. We administered study treatment within one minute of the end of the procedure. We primarily compared outcomes using a composite of indicators of excessive post-procedure blood loss (post-procedure measured blood loss exceeding 125 mL, uterine massage or compression for at least two minutes, administration of additional uterotonic medication, intrauterine balloon tamponade, uterine re-aspiration, blood transfusion, uterine artery embolization, hospital admission for bleeding, or major surgery). Secondary outcomes included individual indicator occurrences, satisfaction, and side effects. Results From March 3, 2015 to March 31, 2017, we randomized 284 participants (n = 140 methylergonovine, n = 144 placebo), five before we registered the trial with clinicaltrials.gov. Baseline characteristics were similar between groups. The composite outcome occurred in 78 (56%) methylergonovine and 75 (52%) placebo participants (p = 0.5). Methylergonovine recipients required more intrauterine balloon use (n = 20 [14%]) versus placebo (n = 10 [7%]), p = 0.04. We also observed a non-significant trend towards more uterotonic administration (n = 56 [40%] versus n = 43 [30%], p = 0.07) and hospital admissions for bleeding (n = 4 [3%] versus n = 0, p = 0.06) in the methylergonovine group compared to placebo. Conclusion We observed no improvement in the composite outcome for excessive bleeding with prophylactic post-procedure methylergonovine. In addition, individual excessive bleeding outcomes occurred more frequently in the methylergonovine group, potentially indicating harm with its prophylactic use after D&E. Implications When administered prophylactically immediately after dilation and evacuation abortion at 20–24 weeks, methylergonovine increases uterine bleeding. Given the lack of data for effectiveness as a prophylactic agent and our findings indicating harm, we do not recommend its use for post-operative prophylaxis.

A 30-year-old female with no significant past medical history presented to our labor and delivery ward for induction of labor. Due to failure to progress, she was proceeded to cesarean delivery. Intraoperatively, it was noted that her uterus was hypotonic; she required supplemental methylergometrine to control the bleeding from the uterine atony. However, within three minutes of intramuscular (IM) administration, she complained of chest pain. She then subsequently developed pulmonary edema in the postoperative care unit, which required supplemental oxygen. She was found to have elevated troponin and brain natriuretic peptide (BNP), along with radiologic features of fluid overload suggestive of congestive cardiac failure, which all lead to the diagnosis of non-ST myocardial infarction. The patient had a normal computed tomography (CT) pulmonary angiogram, echocardiogram, and serial electrocardiograms (ECGs). She was successfully discharged from the hospital on postoperative day 4 with resolution of her symptoms and improving cardiac enzymes. Cardiology outpatient follow-up was arranged.

BackgroundThe world’s understanding of COVID-19 continues to evolve as the scientific community discovers unique presentations of this disease. This case report depicts an unexpected intraoperative coagulopathy during a cesarean section in an otherwise asymptomatic patient who was later found to have COVID-19. This case suggests that there may be a higher risk for intrapartum bleeding in the pregnant, largely asymptomatic COVID-positive patient with more abnormal COVID laboratory values.CaseThe case patient displayed D-Dimer elevations beyond what is typically observed among this hospital’s COVID-positive peripartum population and displayed significantly more oozing than expected intraoperatively, despite normal prothrombin time, international normalized ratio, fibrinogen, and platelets.ConclusionThere is little published evidence on the association between D-Dimer and coagulopathy among the pregnant population infected with SARS-CoV-2. This case report contributes to the growing body of evidence on the effects of COVID-19 in pregnancy. A clinical picture concerning for intraoperative coagulopathy may be associated with SARS-CoV-2 infection during cesarean sections, and abnormal COVID laboratory tests, particularly D-Dimer, may help identify the patients in which this presentation occurs.

Objective Our objective was to document current practices of abortion providers on the use of medications to decrease bleeding during surgical abortion. Study design We emailed surveys to 336 abortion providers through a professional listserv to elicit information on their use of medications to prevent and treat bleeding during first- and second-trimester surgical abortion. Results One hundred sixty-eight (50%) providers responded to our survey. The majority were obstetrician-gynecologists (83%) working in an academic practice (66%). Most completed a fellowship in family planning (87%) and currently perform abortions up to 22 or 24 weeks of gestation (63%). Seventy-two percent routinely used prophylactic medications for bleeding. Providers who routinely used medications to prevent bleeding most commonly chose vasopressin (83%). Providers preferred methylergonovine as a treatment for excessive bleeding in the second trimester, followed by misoprostol. Conclusion We found that most providers routinely use medications to prevent bleeding and use several different regimens to treat bleeding during abortion. Implications We found that surgical abortion providers use a range of medications to prevent and treat hemorrhage at the time of surgical abortion. Scant evidence is available to guide abortion providers on the use of medications to decrease hemorrhage during surgical abortion. To provide evidence-based recommendations for the prevention and treatment of clinically significant bleeding, researchers should target the most commonly used interventions.

Uterine atony is a common cause of primary postpartum hemorrhage, which remains a major cause of pregnancy-related mortality for women worldwide. Oxytocin, methylergonovine, carboprost, and misoprostol are commonly used to restore uterine tone. Oxytocin is the first-line agent. Methylergonovine and carboprost are both highly effective second-line agents with severe potential side effects. Recent studies have called into question the effectiveness of misoprostol as an adjunct to other uterotonic agents, but it remains a useful therapeutic in resource-limited practice environments. We review the current role these medications play in the prevention and treatment of uterine atony.

Objectives The objectives of this study were to quantify the prescription of oral methergin tablets in a busy Women’s Hospital, assess the stated indications for such prescription and highlight the issues and safety profile of Methergin use especially in the postpartum patient. Methods Review of prescription data for oral Methergin and the corresponding annual figures on primary and secondary postpartum hemorrhage. Results Over a period of 5 years, oral Methergin prescriptions for delayed and secondary postpartum hemorrhage constituted less than 1% of the overall prescription in Obstetrics and Gynaecology, which ranged between 1214 and 2085 per year. The numbers were too few to ascertain any relationship with both types of postpartum hemorrhage. Although stated on the relevant Patient Information leaflet, no local or regional guideline on its use exist. Conclusions Specific and random trend monitoring of medications for continuing safety profile, risk benefit issues, or unapproved indication, may help in identifying, preventing and mitigating any medication safety matters. Clinical pharmacists in collaboration with physicians are well placed in conducting such pharmacovigilance activities to improve medication safety.

Objective To characterize the use of the drug misoprostol for treatment of postpartum hemorrhage in pregnant women. Methods A descriptive observational study was carried out with secondary data from pregnant women who used misoprostol to treat postpartum hemorrhage in a reference public maternity, from July 2015 to June 2017. Clinical and sociodemographic profiles of pregnant women, how misoprostol was used and success rate in controling postpartum hemorrhage were characterized. Results A total of 717 prescriptions of misoprostol were identified. Of these, 10% were for treatment of postpartum hemorrhage. The majority of pregnant women were young adults, married, with complete high school education, white, residing in urban areas, multiparous (68.1%) and 25% had previous cesarean sections. The mean gestational age was 39 weeks and 51.4% had a cesarean section. There was prophylactic use of oxytocin in 47.2% of women. Treatment of postpartum hemorrhage was successful in 84.7% of women. Of these, 79.2% also used oxytocin and 54.2% methylergonovine. Only 13.5% of pregnant women had less than five prenatal visits, and the main cause of postpartum hemorrhage was uterine atony. There were 13 complications after hemorrhage, 15.3% required blood transfusion and there was one case of maternal death. Conclusion Misoprostol showed to be effective and safe for treating postpartum hemorrhage.

Previous case reports describe the inadvertent administration of methylergonovine to newborns resulting in rare, life-threatening events including neonatal death. To our knowledge, no case reports exist detailing inadvertent methylergonovine administration in the emergency medicine literature. A newborn infant presented to the emergency department (ED) at hour five of life following methylergonovine administration with periods of apnea and cyanosis. The infant required intubation, mechanical ventilation, and a seven day neonatal intensive care stay. This rare case describes the potential for this error to occur in the community and heightens the vigilance of emergency medicine providers when caring for newborns in their first hours of life.

Patient: Male, Newborn Final Diagnosis: Accidental methylergonovine poisoning Symptoms: Respiratory distress Medication: — Clinical Procedure: — Specialty: Pediatrics and Neonatology Objective: Diagnostic/therapeutic accidents Background: Methylergonovine is an ergot alkaloid used to treat post-partum hemorrhage secondary to uterine atony. Mistaking methylergonovine for vitamin K with accidental administration to the neonate is a rare iatrogenic illness occurring almost exclusively in the delivery room setting. Complications of ergot alkaloids in neonates include respiratory depression, seizures, and death. Case Report: A term infant was inadvertently given 0.1 mg of methylergonovine intramuscularly in the right thigh. The error was only noted when the vial of medication was scanned, after administration, identifying it as methylergonovine rather than vitamin K. The local poison center was notified, and the infant was transferred to the neonatal intensive care unit for observation. Two hours after transfer, the infant was noted to have oxygen desaturations and required oxygen via nasal cannula. Supplemental oxygen was continued for 4 hours until the neonate was able to maintain normal oxygen saturations in room air. Feeding was started by 10 hours of life, and the infant was discharged home in good condition after a 72-hour stay without further complications. Conclusions: Because of the potential for serious adverse events, vigilance is required to prevent accidental administration of methylergonovine to the neonate as a result of possible confusion with vitamin K in the early post-partum period.

Background Sirenomelia is a rare, but deadly condition characterized by fusion of the lower limbs, lower spinal column defects, severe malformations of the urogenital and lower gastrointestinal tract, and an aberrant abdominal umbilical artery. Methods The two main hypotheses, not mutually exclusive, that have been advanced to explain the pathogenesis of sirenomelia are the blastogenetic theory and the vascular disruption theory. Results We describe a case of sirenomelia, probably associated with the use of methylergonovine maleate, an ergot alkaloid, during the first weeks of pregnancy. Conclusion On the basis of the mechanisms of vascular disruption and early administration of methylergonovine maleate at a critical stage of organogenesis, we conclude that exposure to methylergonovine maleate could be the cause of the development of sirenomelia. Birth Defects Research (Part A) 106:643–647, 2016. © 2016 Wiley Periodicals, Inc.

Background: Intravenous dihydroergotamine (DHE) is frequently used during inpatient hospitalizations or outpatient infusion therapies for 3–5 days in order to break the continuous cycle of status migrainosus. We tried a short term 7 days prophylaxis of oral methylergonovine after discharge in order to prevent status migrainosus relapse and extend the therapeutic benefit from IV DHE. Methods: Patients were diagnosed with status migrainosus in clinic setting based on the ICHD-III criteria. They received 1 mg IV DHE every 8 h along with metoclopramide for 3–5 days followed by methylergonovine maleate oral tablets as prophylaxis for 7 days post discharge. They were asked to maintain their headache diaries which included data on headache frequency and intensity. A post discharge follow up at 1 and 68 weeks was planned. Clinical improvement was defined as >50% decrease in frequency and intensity of headaches. Intensity was graded on verbal numerical rating scale (VNRS) with 10 being the worst possible pain. The institutes IRB and ethics committee exempted this study from review given that it had only 3 patients. Results: A total of 3 patients 25–45 years of age who benefited from IV DHE, consented to trial of Methylergonovine Maleate 0.4 mg oral tablets three times a day prophylaxis on the day of discharge for a period of 7 days. At 1 week post discharge, all of the 3 patients had reported sustained improvement with severity dropping from an average of 8/10 intensity to 3/10 on VNRS. The headaches frequency had dropped from daily to episodic in 2 of the 3 patients. At an average of 7 weeks post discharge, 2 out of the 3 patients had reported sustained benefit. The third patient relapsed to the pre-admission status migrainosus severity. One patient reported mild diarrhea and nausea but was still able to continue the drug for a week. Conclusion: Methylergonovine maleate after 3–5 days of IV DHE infusions may be a feasible treatment strategy for status migrainosus. This approach has the potential to prolonged the benefit of IV DHE and prevent relapse in to status migrainosus.

This chapter discusses the various oxytocic drugs utilized during obstetric anesthesia. It discusses the indications and contraindications for each medication, as well as their side effects.

We aimed to show to patients the benefit of post-partum haemorrhage prophylaxis treatment and the effectiveness as a uterotonic agent of the combined use of methylergonovine and oxytocin infusion in the prevention of haemorrhage during and after Caesarean section, by comparison with a control group which received oxytocin infusion only. Two groups of patients undergoing Caesarean section at the same clinic were included in the study. A combination of methylergonovine and oxytocin was administered to the first group during the intra-operative and post-operative periods. The second group did not receive methylergonovine and was administered only with oxytocin infusion in the intra-operative and post-operative periods. Pre-operative and post-operative haemogram readings were taken for all patients in each of the groups for comparison. No difference was found between the two groups with regard to mean ages and pre-operative haemogram values. The decrease in post-operative haemoglobin values for the group administered with methylergonovine maleate and oxytocin was found to be significantly greater than for the group administered with oxytocin only. Results indicated that prophylactic methylergonovine treatment was clearly successful for the patients and no adverse side effects were found. The routine use of methylergonovine and oxytocin infusion in combination during the intra-operative period of Caesarean section reduced the level of post-partum haemorrhage considerably. We believe that this procedure will also reduce the risk of uterine atony, but clearly, prospective studies will be necessary in future to confirm this assumption.

Raynaud's disease is a medical condition in which arterial spasm causes episodes of reduced blood flow, in the setting of certain triggers such as cold weather. Patients with this condition are at risk of adverse reactions if they receive medications with vasoactive properties. Methylergonovine maleate is one drug used during cesarean delivery to treat postpartum hemorrhage due to uterine atony. By acting directly on uterine and vascular smooth muscle, it produces cardiovascular responses such as coronary vasospasm, myocardial infarction, and even cardiac arrest. However, pulmonary events have rarely been reported. We report our anesthetic management of a 36-year-old patient, with undiagnosed Raynaud's disease and undergoing cesarean delivery, who experienced new onset acute pulmonary edema after methylergonovine administration to manage postpartum hemorrhage.

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.

Left ventricular noncompaction is a rare congenital cardiomyopathy that is an arrest in the normal process of cardiac compaction, resulting in the development of multiple prominent trabeculations in the left ventricle. We report a case of a parturient with left ventricular noncompaction causing decompensated heart failure who underwent cesarean delivery that was complicated by an acute pulmonary hypertensive crisis.

This is a 40-year-old woman with an 18-yearhistory of migraine without aura that has beenchronic for 6 years. She has failed or been intolerantto numerous preventive medications, including topi-ramate and onabotulinum toxin even though she doesnot have medication overuse. She did become head-ache free after a 5-day intravenous regimen of dihy-droergotamine,but then the headaches returned overseveral months to their prior frequency.Questions:Might she respond to preventive treat-ment with methylergonovine?What is the mechanismof action, pharmacokinetics, and dosing? Whatadverse events are associated with use? Is methyler-gonovine effective for cluster headache prevention?

To evaluate maternal and breastfed infant's outcome following post-partum maternal use of methylergonovine.A prospective, controlled observational study design was used. Mothers who contacted Beilinson Teratology Information Service (BELTIS) were followed by phone interview. Data on lactation, neonatal symptoms and outcomes at the age of 1-3 years were obtained. Mothers' breastfeeding while treated with methylergonovine and their infants were compared to a matched control group of breastfeeding mothers using a drug known to be safe during lactation (amoxicillin).Follow-up was obtained for 38 of 42 women (90.5%). Of whom, six stopped breastfeeding because of concerns regarding drug treatment and three refused to participate. The remaining 29 women and infant pairs were compared to a control group of 58 women and their infants. Comparison showed no effect of methylergonovine on lactation and similarly showed no difference in rate of neonatal complications (p = 1). At time of follow-up there were no differences in growth or in adverse neurodevelopment outcomes (p = 0.26).No increase in adverse long-term outcomes was found in infants exposed to methylergonovine through breastfeeding. Our data in conjunction with previous estimates of very low drug exposure support continuation of breastfeeding in women requiring treatment with methylergonovine.

These medication errors have occurred in health care facilities at least once. They will happen again—perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them at your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the Institute for Safe Medication Practices (ISMP) Medication Errors Reporting Program. Any reports published by ISMP will be anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below. Errors, close calls, or hazardous conditions may be reported directly to ISMP through the ISMP Web site ( www.ismp.org ), by calling 800-FAIL-SAFE, or via e-mail at ismpinfo@ismp.org . ISMP guarantees the confidentiality and security of the information received and respects reporters' wishes as to the level of detail included in publications.

In order to prevent postpartum hemorrhage in caesarean section under spinal anesthesia, patients routinely receive oxytocin. In this study we compared the efficacy of Methylergonovine and Oxytocin on hemodynamic stability and bleeding amount in caesarean section.In this randomised controlled trial study, 80 patients candidate for elective caesarean section under spinal anesthesia divided to two groups: 40 patients in control group received oxytocin and 40 ones in case group received methylergonovine.There was no differences between groups in Mean age, baseline hemodynamic values, after spinal anesthesia and recovery (except diastolic blood pressure min 20), time of uterine atony, dizziness; nausea and vomiting. After drug administration (oxytocin and methylergonovine), systolic blood pressure in minutes 1, 10, 15 and diastolic blood pressure in minutes 1, 3, 20 increased in case group statistically more than control group. In control group, heart rate in minutes 1, 5 increased significantly more than the other group. Mean arterial blood pressure in minutes 1, 3, 5, 10, 15 reduced significantly more than in control group. Need to vasoconstrictor drug statistically was less in case group (p 0.0001).Methylergonovine induced significantly more hemodynamic stability. Adverse effects were similar between two groups. We recommend the use of methylergonovine in patients with caesarean section under spinal anesthesia because of its hemodynamic stability and low need to vasoconstrictor drugs.

Neurological deficits associated with methylergometrine have been reported primarily as a result of reversible cerebral vasoconstriction syndromes (RCVS). RCVS are characterized by reversible multifocal vasoconstrictions of the cerebral arteries heralded by acute severe headache with or without neurological deficits. Here, we present the first case of suspected RCVS with transient limb myoclonus following the intravenous administration of methylergometrine during cesarean section. A 31-year-old woman who received slowly infused intravenous methylergometrine during a cesarean section suddenly reported severe occipital headache after 40 min, followed by apnea and unconsciousness for 8 min. A second administration of methylergometrine to treat the weakness of her uterine contractions resulted in a repeated loss of consciousness within minutes and the development of limb myoclonus. No abnormalities were detected by brain computerized tomography, magnetic resonance imaging, and electroencephalogram. She fully recovered spontaneously within 12 h. We consider that the transient limb myoclonus in our patient appeared as a result of RCVS caused by the intravenous administration of methylergometrine.

Background Uterine arteriovenous malformations are a rare and potentially life-threatening condition. Medical therapy has not been popular because of the propensity for excessive bleeding in the patient. As a result, the effect of gonadotropin-releasing hormone (Gn-RH) agonists on uterine arteriovenous malformations has not been established. Case A 30-year-old patient presented with persistent vaginal bleeding. Based on the color Doppler ultrasound and magnetic resonance imaging findings, a uterine arteriovenous malformation was diagnosed. Because initial treatment with methylergonovine maleate was unsuccessful, the patient was treated with Gn-RH agonists. The lesion completely disappeared after 6 months of Gn-RH agonist treatment. Five months after the completion of Gn-RH agonist therapy, the patient conceived spontaneously and successfully completed a normal pregnancy. The patient has remained free from recurrence of the lesion. Conclusion Gonadotropin-releasing hormone agonist therapy has the potential to be a conservative treatment modality for uterine arteriovenous malformations in hemodynamically stable patients.

Methylergonovine (MEV) is a semi-synthetic ergot alkaloid used in the prevention and control of postpartum hemorrhage. This report describes 12 newborns born on the same day in a local country hospital in Turkey and developed sepsis-like symptoms and encephalopathy within the first 6 h of life due to accidental administration of MEV instead of vitamin K in the delivery room. The major features of MEV poisoning were lethargy (41.7%), seizure (75.0%), feeding intolerance (66.6%), hypoventilation (58.3%), irritability (25%), and peripheral circulatory abnormalities (58.3%). As a conclusion, clinical findings of ergot toxicity in newborns cannot be distinguished from infectious disease or neonatal encephalopathy.

Background Meta-analyses of postpartum blood loss and the effect of uterotonics are biased by visually estimated blood loss. Objectives To conduct a systematic review of measured postpartum blood loss with and without prophylactic uterotonics for prevention of postpartum haemorrhage (PPH). Search strategy We searched Medline and PubMed terms (labour stage, third) AND (ergonovine, ergonovine tartrate, methylergonovine, oxytocin, oxytocics or misoprostol) AND (postpartum haemorrhage or haemorrhage) and Cochrane reviews without any language restriction. Selection criteria Refereed publications in the period 1988–2007 reporting mean postpartum blood loss, PPH (‡500 ml) or severe PPH (‡1000 ml) following vaginal births. Data collection and analysis Raw data were abstracted into Excel by one author and then reviewed by a co-author. Data were transferred to SPSS 17.0, and copied into RevMan 5.0 to perform random effects meta-analysis. Main results The distribution of average blood loss (29 studies) is similar with any prophylactic uterotonic, and is lower than without prophylaxis. Compared with no uterotonic, oxytocin and misoprostol have lower PPH (OR 0.43, 95% CI 0.23–0.81; OR 0.73, 95% CI 0.50–1.08, respectively) and severe PPH rates (OR 0.61, 95% CI 0.29–1.29; OR 0.74, 95% CI 0.52–1.04, respectively). Oxytocin has lower PPH (OR 0.65, 95% CI 0.60–0.70) and severe PPH (OR 0.71, 95% CI 0.56–0.91) rates than misoprostol, but not in developing countries. Conclusion Oxytocin is superior to misoprostol in hospitals. Misoprostol substantially lowers PPH and severe PPH. A sound assessment of the relative merits of the two drugs is needed in rural areas of developing countries, where most PPH deaths occur.

Management of infection with human immunodeficiency virus (HIV) dramatically improved during the 1990s. The advent of high-performance quantitative HIV assays and highly active anti-retroviral therapy (HAART) were the two most important developments in HIV medicine. As a result, HIV mortality and morbidity have significantly reduced. This improvement in life quality and expectancy through the use of HAART has led to an increase in the number of HIV-infected patients wishing to have children. The mother-to-child transmission which was of major concern previously can now be significantly reduced by newer management strategies. This review stresses on the management of pregnancy in HIV.

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 case is reported of a 30-year-old multigravida, with insignificant history and stable vital signs, admitted to the labour room for normal vaginal delivery of twins. She received combined spinal epidural analgesia (bupivacaine plus fentanyl) for 3 h. Following uneventful delivery she received 0.2 mg methylergonovine maleate, intramuscularly. Nausea and vomiting occurred 70 min after placenta delivery, heart rate decreased, arterial blood pressure increased and there was chest pain. After excluding cardiac ischaemia, 0.5 mg atropine sulphate was administered intravenously. Chest pain improved but heart rate and blood pressure increased more than expected. The patient had mild headache and nausea, and antiemetic 4 mg ondansetron was given intravenously. Continuous monitoring for 4 h showed spontaneous chest pain relief and blood pressure improvement. In conclusion, serious delayed side-effects arising from methylergonovine maleate can occur in young, normal patients and close monitoring is required. Intravenous atropine sulphate following methylergonovine maleate administration may lead to severe hypertension and tachycardia.

Coronary spasm (CS) or Prinzmetal's angina is an important cause of pectoral angina but remains difficult to diagnose. Historical descriptions presented the syndrome as a benign affection, but recent reports showed that CS could trigger ventricular arrhythmias and sudden cardiac arrest. We present the case of a 77-year-old patient referred to our hospital after several syncope. Continuous ECG monitoring during his hospital stay demonstrated recurrent episodes of sustained polymorphic ventricular tachycardia (PVT), systematically proceeded by a transient but marked ST-segment elevation without chest pain. A coronary angiography was performed and showed only a non-significant atherosclerotic plaque in the left anterior descending coronary artery (LAD). However, infusion of methylergonovine induced a dramatic CS resulting in the complete occlusion of both left coronary arteries (see Supplementary material online, Video). Simultaneously, a marked ST-segment elevation occurred, immediately followed by a sustained PVT degenerating into VF and necessitating a cardiac resuscitation. Despite an intensive therapy combining high dose of calcium channel blocker and nitroglycerin, the patient remained symptomatic. Accordingly, an implantable cardiac defibrillator (ICD) was implanted before hospital discharge. During the early follow-up, several new episodes of VF appropriately treated by ICD shocks occurred. Finally, a selective angioplasty of the proximal segment of the LAD allowed for controlling most of the episodes, the patient being finally defibrillated only once again over a 2-year follow-up period. [...]

Aim To assess the effectiveness of oral misoprostol compared with methylergometrine in the prevention of primary post-partum hemorrhage during the third stage of labor. Methods This was a randomized controlled trial of 864 singleton low-risk pregnant women. The outcomes were total blood loss, duration of the third stage of labor and peripartal change in hematocrit. Comparisons were by the chi2-test and Student t-test. Relative risks were calculated for side-effects profile. A P-value of less than 0.05 was statistically significant. Results The biodata of all the participants were similar. The mean blood loss for the misoprostol and methylergometrine groups was 191.6 +/- 134.5 mL and 246.0 +/- 175.5 mL, respectively (95% CI: -79.3 to -39.5 mL). The mean duration of the third stage of labor was 19.6 +/- 2.4 min and 9.4 +/- 3.3 min in the misoprostol and methylergometrine groups, respectively (95% CI: 9.82-10.58 min). More subjects had blood loss >500 mL, 42 (9.7%) versus 6 (1.4%), and peripartal hematocrit change greater than 10%, 38 (8.8%) versus 5 (1.2%), in the methylergometrine group than in the misoprostol group, respectively. Also, more subjects received additional oxytocic in the methylergometrine group, compared to the misoprostol group (80 [18.5%] versus 33 [7.6%] patients, respectively). Conclusions Orally administered misoprostol was more effective in reducing blood loss during the third stage of labor than intramuscular methylergometrine. However, there were more subjects in the misoprostol group in whom duration of the third stage of labor was greater than 15 min and who also had manual placental removal than in the methylergometrine group.

C l i n M e d International Library Citation: Restrepo JA, Salamanca J, Diego G, Rivero F, Alfonso F, et al. (2015) MethylErgonovine Stress Echocardiography in the Study of Kounis Syndrome due to Anisakis Simplex: A Case Report. Int J Clin Cardiol 2:056 Received: September 09, 2015: Accepted: October 07, 2015: Published: October 10, 2015 Copyright: © 2015 Restrepo JA. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Restrepo et al. Int J Clin Cardiol 2015, 2:7 ISSN: 2378-2951

Background Estrogens produce several beneficial effects upon the cardiovascular system. Amongst these, an endothelium-independent effect has been convincingly demonstrated only in vitro, while there is no evidence for such an effect in vivo. The aim of the present study was to evaluate the effect of acute administration of estradiol 17β upon coronary artery reactivity to methylergometrine in 16 menopausal patients with coronary artery disease. Methods Sixteen menopausal patients underwent coronary angiography at rest and after incremental doses of methylergometrine (intracoronary 2, 10, 30 μg) before and 20 min after either intracoronary estradiol 17β (20 ng/mL at 1 mL/min for 20 min; 8 patients) or placebo (Dextrose 5%, 1 mL/min; 8 patients). Results and conclusions No significant differences were observed in baseline coronary artery diameter or area between the 2 groups. No significant differences in the degree of coronary artery constriction were observed after either estradiol 17β or placebo at submaximal doses of methylergometrine. However, the degree of coronary artery constriction after maximal doses of methylergometrine was significantly attenuated by estradiol 17β compared to placebo (change in diameter: −0.9±4.5% vs. −19±6%, p p Condensed Abstract The effect of acute administration of estradiol 17β upon coronary artery reactivity to methylergometrine was evaluated by coronary angiography in 16menopausal women with CAD. The investigation was performed at rest and after incremental dose of methylergometrine before and 20 min after either intracoronary estradiol 17β or placebo. Significant differences were not observed either in the baseline coronary artery diameter or the area between the 2groups, or in the degree of coronary artery constriction after either estradiol 17β or placebo at submaximal doses of methylergometrine. Coronary artery constriction after maximal doses of methylergometrine resulted attenuated by estradiol 17β for its calcium-antagonist properties.

Background Exercise-induced ST-segment elevation is a relatively uncommon problem and occurs more frequently in patients who have had a myocardial infarction. Data is limited on the characteristics of Taiwanese patients without prior myocardial infarction who develop exercise-induced ST-segment elevation. Methods and Results Exercise-induced ST-segment elevation developed in 9 of 6,147 consecutive patients without myocardial infarction who underwent treadmill exercise testing at out institution over a 4-year period. The clinical and angiographic characteristics of these patients were studied. Angiographically normal coronary arteries with coronary vasospasm were found in 5 patients, hemodynamically significant coronary stenosis was found in 3 patients, and coexisting spasm in angiographically normal coronary arteries combined with hemodynamically significant coronary stenosis in the different vessel was found in 1 patient. During a median follow-up of 71 months, 2 patients with coronary vasospasm developed recurrent angina after self-discontinuation of calcium antagonists and 2 patients (1 with coronary vasospasm and 1 with hemodynamically significant coronary stenosis) died of cardiac causes before arrival at the emergency department. Conclusion Coronary vasospasm was a more common underlying pathology of exercise-induced ST-segment elevation in this Taiwanese cohort. Coronary angiography ± intracoronary ergonovine provocation testing is necessary in these patients to identify the underlying pathology and appropriate treatment. (Circ J 2006; 70: 254 - 261)

To determine the efficacy of intravenous oxytocin administration compared with intravenous methylergometrine administration for the prevention of postpartum hemorrhage (PPH), and the significance of administration at the end of the second stage of labor compared with that after the third stage.A prospective study was undertaken: two major groups (oxytocin group and methylergometrine group) of 438 women with singleton pregnancy and vaginal delivery were studied during a 15-month period. These two groups were subdivided into three subgroups: 1. intravenous injection (two minutes) group immediately after the delivery of the fetal anterior shoulder, 2. intravenous injection (two minutes) group immediately after the delivery of the placenta, and 3. drip infusion (20 min) group immediately after the delivery of the fetal head. In each group, quantitative postpartum blood loss, frequencies of blood loss500 ml, and need of additional uterotonic treatment were evaluated.As compared with methylergometrine, oxytocin administration was associated with a significant reduction in postpartum blood loss and in frequency of blood loss500 ml. The risk of PPH was significantly reduced with intravenous injection of oxytocin after delivery of the fetal anterior shoulder, compared with intravenous injection of oxytocin after expulsion of the placenta (OR 0.33, 95%CI 0.11-0.98) and intravenous injection of methylergometrine after delivery of the fetal anterior shoulder (OR 0.31, 95%CI 0.11-0.85).Intravenous injection of 5 IU oxytocin immediately after delivery of fetal anterior shoulder is the treatment of choice for prevention of PPH in patients with natural course of labor.

Objective: To compare the efficacy and side effects of sublingual misoprostol and intravenous methylergometrine for active management of third stage of labor. Method: One hundred twenty low risk pregnant women at term with spontaneous onset of labor were included in the study. The women were randomized to receive either two tablets of misoprostol (200 μg/tablet) sublingually or 1 ml of methylergometrine (200 μg) intravenous injection, after the delivery of the anterior shoulder of the baby. The main outcome measures were: need for additional oxytocic drugs, blood loss ≥500 ml, change in hemoglobin levels and side effects. Results: Postpartum hemorrhage as defined by hemorrhage ≥500 ml occurred in 3.1% of the women in the sublingual misoprostol group but none of the women in the methylergometrine group (P>0.05). There was a need for additional oxytocic drugs in 5.0% and 8.3% after methylergometrine and misoprostol, respectively (P>0.05). The change in hemoglobin levels at 24 h postpartum were 0.8 and 0.7 gm% in methylergometrine and misoprostol group, respectively(P>0.05). In the misoprostol group, 6.6% women developed fever ≥38 °C and 21.6% had shivering while in methylergometrine group none experienced these side effects. However, the incidence of other side effects like nausea, vomiting, headache and giddiness were similar in both groups. Conclusion: Sublingual misoprostol appears to be as effective as intravenous methylergometrine in the prevention of postpartum hemorrhage. However, larger randomized studies are needed to advocate its routine use.

Objective To compare oral misoprostol with conventional oxytocics in the management of the third stage of labor. Methods In a controlled trial, 1574 women were randomized into four groups, as follows: Group 1 received intravenous infusion of oxytocin 10 IU plus oral misoprostol 400 μg, followed by two doses of oral misoprostol 100 μg 4 hours apart; group 2 received oral misoprostol 400 μg, followed by two doses of oral misoprostol 100 μg 4 hours apart; group 3 received intravenous infusion of oxytocin 10 IU; and group 4 received intravenous infusion of oxytocin 10 IU plus intramuscular administration of methylergonovine maleate (Methergine) 0.2 mg. The incidence of postpartum hemorrhage and decrease in hemoglobin concentration from before delivery to 24 hours postpartum were the main outcome measures. Results The primary outcome measures were similar in groups 2 and 3. The incidence of postpartum hemorrhage was 9% in group 2, compared with 3.2% in group 1 and 3.5% in group 4 ( P P = .01, respectively). There were no significant differences among the four groups regarding hemoglobin concentrations. Significantly more women needed additional oxytocin in group 2, when compared with group 4 (5.9% versus 2.2%; P = .01). The proportion of women requiring additional methylergonovine maleate was 4.8% in group 2, compared with 0.7% in group 1 and 1% in group 4 ( P P = .01, respectively). Conclusion Oral misoprostol alone is as effective as oxytocin alone for the prevention of postpartum hemorrhage; it is less effective than oxytocin plus methylergonovine maleate and oral misoprostol plus oxytocin.

A 63-year-old man presented with an out-of-hospital cardiac arrest. The coronary angiogram with intravascular imaging was performed and showed a mid-left anterior descending artery atherosclerotic cap rupture with thrombus burden treated with drug-eluting stent (DES) implantation. During the hospitalisation in the intensive care unit, the patient experienced recurrent ventricular fibrillations and asystole with transient ST-segment elevation in the inferior leads with normal coronary angiography. A methylergonovine provocative test was therefore performed and showed an occlusive right coronary artery (RCA) spasm. Due to recurrent RCA spasm, the patient was treated with DES implantation with favourable results at 3-month follow-up.

Introduction. We report a case of a female neonate who developed respiratory depression following the unintentional administration of methylergonovine. The respiratory depression appeared to improve after the administration of bag mask ventilation, stimulation, and naloxone; and the baby was able to be managed without endotracheal intubation and prolonged positive-pressure ventilation. Case. A full-term female neonate was delivered vaginally without issue. Approximately 10 min after delivery, the infant was inadvertently administered 0.1 mg of methylergonovine intramuscularly instead of vitamin K. Thirty minutes later the child developed cyanotic extremities and respiratory depression with an oxygen saturation of 75%. Naloxone, 0.4 mg IM, was recommended to mitigate respiratory depression. Within 5 min the patient ’ s respirations improved to 40 breaths per minute, cyanosis improved, and she began resisting ventilations and crying loudly. The child continued to improve and was back to baseline that evening. Discussion. Methylergonovine toxicity in neonates has been commonly associated with respiratory depression necessitating ventilatory support. In consideration of chemical structural similarity between methylergonovine and morphine, as well as signs/symptoms consistent with opioid-induced respiratory depression, naloxone was suggested. Conclusion . It appears that naloxone may reverse methylergonovine toxicity in neonates. The identifi cation of a safe and potentially useful antidote to mitigate respiratory depression, potentially avoiding the need for intubation and more invasive interventions in this patient population is important.

In the absence of clear-cut indications for provocative test (PT), coronary artery spasm (CAS) may be underdiagnosed whereas the widespread use of early coronary angiography has found that acute ischemic syndromes are not always related to atherosclerotis. The objective of the present study was to

AIMS Abnormal coronary vasomotion plays a role in the clinical expression of coronary artery disease. We hypothesized that the functional C825T polymorphism located in the ubiquitous G-protein beta3 subunit, implicated in the cellular signal transduction of many receptors, could modify artery coronary vasomotion. We assessed the potential association of the pertussis toxin-sensitive G protein beta3 subunit (GNB3) gene C825T polymorphism on coronary vasomotion in humans. METHODS AND RESULTS We examined the response of angiographically normal human coronary arteries (n=131) after intravenous injection of methylergonovine maleate, a vasoconstrictor, followed by injection of isosorbide dinitrate, a vasodilator, according to GNB3 genotypes. Coronary vasomotion was assessed with quantitative coronary angiography. Subjects bearing at least one T allele had greater susceptibility to vasoconstriction in response to methylergonovine maleate than CC subjects, whereas vasodilation in response to isosorbide dinitrate did not differ among the different genotypes. CONCLUSION The C825T polymorphism of the G-protein beta3 subunit may be a genetic determinant of coronary artery vasomotion in humans.

Active management of the third stage of labor (AMTSL) is more effective in reducing postpartum hemorrhage than expectant management. Widespread implementation of AMTSL in remote and rural areas, however, is hampered by the lack of availability of an efficacious, easily administered, safe, and storable oxytocic. Two parenterally administered oxytocics, methyl ergometrine, and oxytocin, have a number of drawbacks in addition to their routes of administration. Methylergometrine is associated with the occurrence of life-threatening complications, and oxytocin requires careful handling and storage due to thermal- and photolability. In previous studies, a synthetic prostaglandin E1 analog, misoprostol has shown promise as an effective oxytocic agent. This agent is affordable, stable at room temperature, has a long-shelf, and can be administered orally or by other routes. This double-blind randomized trial compared the effectiveness of sublingual misoprostol with that of intravenous oxytocin, and intravenous methylergometrine in reducing blood loss during the third and fourth stages of labor. A total of 300 singleton women with healthy pregnancies in spontaneous or induced labor at term were randomized to receive either 400 mcg or 600 mcg of sublingual misoprostol, 5 IU of intravenous oxytocin, or 200 mcg of intravenous methylergometrine. Each group was comprised of 75 women. Patients who received 600 mcg (96.05 ± 21.1 mL) or 400 mcg (126.24 ± 49.3 mL) of misoprostol had significantly less mean blood loss during the third and fourth stages of labor compared to oxytocin (154.7 ± 45.7 mL) and methylergometrine (223.48 ± 73.7 mL) (P < 0.01). The duration of the third stage of labor was significantly shorter with 600 mcg of misoprostol (5.74 minutes) than for methylergometrine (6.83 minutes) (P < 0.05), and was comparable to that of oxytocin (6.17 minutes). At 1 hour after delivery, pyrexia ranging from 100°F to 101°F was observed in 12% and 21.3% of patients in the 400 mcg and 600 mcg groups, respectively, whereas temperatures were in the normal range in both the oxytocin and methylergometrine groups (P < 0.001). At 4 hours after delivery, none of the misoprostol patients was febrile. A significant increase in blood pressure occurred in patients receiving methylergometrine (P < 0.001), but was not observed among patients in the other groups. There was a slight decrease in mean hemoglobin concentration 24 hours postpartum in all groups but the difference between the groups was not significant. These findings suggest that the use of sublingual misoprostol to prevent blood loss in AMTSL has several advantages in comparison to oxytocin or methylergometrine. These include greater effectiveness, stability at room temperature, affordability, and easier administration. Overall, these properties could lead to widespread acceptance of this drug for AMTSL in low-income developing countries.

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.

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.

We report a case of general anesthesia in a 25-year-old female patient with moyamoya disease who presented for cesarean section. General anesthesia was induced with propofol 100 mg, succinylcholine 50 mg, and nicardipine 1 mg intravenously (IV), and maintained with 60% nitrous oxide in oxygen. Just after the clamp of the umbilical cord, propofol 10 mg/kg/hr following propofol 50 mg, pentazocine 15 mg, vecuronium 8 mg, and methylergometrine maleate 0.2 mg were given IV. The rate of infusion of propofol was reduced to 8 mg/kg/hr 10 minutes after the clamp and reduced to 6 mg/kg/hr 20 minutes after the clamp. Additional pentazocine 15 mg was given IV. Blood pressure was maintained between 110 and 145 systolic, and 50 and 85 diastolic mmHg, and end-tidal carbon dioxide was between 34 and 36 mmHg. No postoperative deterioration of the patient's neurologic findings occurred. For the anesthetic management of moyamoya disease patients, especially in delivery, it is important to avoid hemodynamic changes and to maintain cerebral blood flow (CBF). We used propofol for hemodynamic stability and avoided hyperventilation so as to maintain CBF. We successfully managed the patient perioperatively.

A 37-year-old woman had postpartum myocardial infarction complicated with cardiogenic shock. The infarction was attributed to diffuse coronary artery spasm caused by methylergonovine, which had been used to treat the postpartum haemorrhage due to placenta increta. The haemodynamics could not be maintained with catecholamine infusion and intraaortic balloon counterpulsation. At last, an extracorporeal membrane oxygenator was used to save her life, and the patient was successfully weaned from the machine 100 h later; she made an uneventful recovery thereafter.

Background Surveillance of drug quality for antibiotics, antiretrovirals, antimalarials and vaccines is better established than surveillance for maternal health drugs in low-income countries, particularly uterotonic drugs for the prevention and treatment of postpartum hemorrhage. The objectives of this study are to: assess private sector accessibility of four drugs used for uterotonic purposes (oxytocin, methylergometrine, misoprostol, valethamate bromide); and to assess potency of oxytocin and methylergometrine ampoules purchased by simulated clients. Methods The study was conducted in Hassan and Bagalkot districts in Karnataka state and Agra and Gorakhpur districts in Uttar Pradesh state. A sample of 877 private pharmacies was selected (using a stratified, systematic sampling with random start), among which 847 were successfully visited. The target sample size for assessment of accessibility was 50 pharmacies per drug, per district. The target sample size for potency assessment was 100 purchases each of oxytocin and methylergometrine across all districts. Successful drug purchases varied by state. Results In Agra and Gorakhpur, 90%-100% of visits for each of the drugs resulted in a purchase. In Bagalkot and Hassan, only 29%-52% of visits for each drug resulted in a purchase. Regarding potency, the percent of active pharmaceutical ingredient was assessed using United States Pharmacopeia monograph #33 for both drugs; 193 and 188 ampoules of oxytocin and methylergometrine, respectively, were assessed. The percent of oxytocin ampoules outside manufacturer specification ranged from 33%-40% in Karnataka and from 22%-50% in Uttar Pradesh. In Bagalkot and Hassan, 96% and 100% of the methylergometrine ampoules were outside manufacturer specification, respectively. In Agra and Gorakhpur, 54% and 44% were outside manufacturer specification, respectively. Conclusion Private sector accessibility of uterotonic drugs in study districts in Karnataka warrants attention. Most importantly, interventions to assure quality oxytocin and particularly methylergometrine are needed in study districts in both states.

Methylergonovine maleate (Methergine®), an ergot derivative with vasoconstrictive properties, has been cited as an effective treatment for vascular headaches. Few studies are available to support its use in headache management. An uncontrolled pilot study of 20 episodic cluster headache patients confirmed its effectiveness and tolerability as an adjunct cluster headache prophylactic. Decreased headache frequency was reported by 19 of 20 patients (95%), and 15 of 20 patients (75%) reported decreased intensity of headaches within 1 week of initiating therapy. A review of methylergonovine's pharmacokinetic, molecular, and tolerability profile clarifies its mechanisms and clinical role in headache management.

A 35-year-old, 39-week pregnant woman underwent an uneventful emergent cesarean delivery for suspected placental abruption or uterine dehiscence. Given the urgency of the situation and the unremarkable airway anatomy, general anesthesia was the chosen technique. Four hours after her surgery, she returned to the operating room for persistent vaginal bleeding. Hematology tests performed before the cesarean delivery revealed severe thrombocytopenia. This was later diagnosed as idiopathic thrombocytopenia, which was treated successfully with steroid therapy.