Introduction
The Ergot analogues ergometrine is recommended by the Royal College of Obstetricians and Gynaecologists as a second‐line pharmaceutical agent for the treatment of uterine atony in cases of postpartum haemorrhage after first‐line oxytocin administration1.
We have described a case of a woman who developed peripheral limb ischemia following administration of the ergot analogue ergometrine for control of postpartum bleeding. Peripheral limb ischemia is a rare acute or chronic complication of the administration of ergometrine and its analogues in obstetric patients in the absence of pre existing vascular disorders. It is important to recognize the rare side effect of ergometrine administration.
Case Presentation
Mrs.21 years old, P2L1 presented with breathlessness, fever, and discolouration of all digits of both lower limbs associated with tingling and numbness and generalised weakness since 8 days. Patient had a normal vaginal delivery 8 days back at a PHC and delivered a live term baby. She had post-partum haemorrhage which was medically managed with ergometrine. On examination patient had pallor, temperature and tachycardia. Dorsalis pedis pulsation was palpable in both lower limbs, blood pressure 90/60 mm of Hg, respiratory rate 28 breaths per minute. Bilateral lower limb toes showed gangrene till metatarsophalangeal joints with no proper line of demarcation (Figure 1, Figure 2). There were no gangrenous changes in upper limbs and nose. There was no past history of cold or heat intolerance, smoking or collagen vascular disease.
The laboratory findings showed severe anaemia (haemoglobin 6.9 gm %) and septicaemia with total count 23,000/cumm and raised C-reactive protein (CRP). Radiological intervention showed normal 2D-echo and arterial doppler of both lower limbs. Gynecologist and Physician examined the case and final diagnosis was made as gangrene of lower limb gangrene due to ergometrine with septicaemia. No other possible aetiology could be derived from clinical and laboratory aids. Therapy was started in the form of injections lower molecular weight heparin, antiplatelet, broad spectrum antibiotics, steroids and anti inflammatory tablets.
Patient was managed conservatively after which she improved symptomatically but there was no improvement in the line of demarcation in both lower limbs. Due to financial constraints, patient decided to shift to government setup for further management.
Discussion
Ergot alkaloids are well-known preparations which act as partial antagonist at alpha receptors and direct vasocontrictive action on dilated arterioles. They induce contraction of uterine musculature and give a central stimulation of dopamine receptors. Ergot alkaloids used in obstetrics and gynaecology are ergometrine (ergonovin), methylergometrine (methergine) and bromocriptine.
Methylergometrine has a pronounced action in small dose with fast action to decrease postpartum haemorrhage by tetanic contraction of myometrium. Ergometrine may be administered IV or IM. The IV route has an immediate onset of uterine contraction and to be readministered every 2‐4 hours as necessary, slowly over a period of 1 minute, while IM administration has onset of uterine contractions within 2‐5 minutes and is less likely to precipitate hypertension.
Ergotamine is contraindicated in eclampsia or pre eclampsia and vascular diseases or heart diseases, impaired renal and hepatic function. They metabolised in liver by cytochrome P450 3A4 enzyme. Other medications like antifungal drugs (azole derivative), protease inhibitors and floxitine like antidepressant prolong the metabolism of ergotamine, causing serious side effects like stroke, gangrene and death etc.1 Adverse reaction after ergometrine administration includes – headache, abdominal pain, palpitations, tingling numbness and muscle cramps.
Most common causes of peripheral gangrene include frostbite, ergotism, vasospasm and certain rheumatological / immunological disorders.2 Usually microvascular thrombose cause symmetrical peripheral gangrene and in most of these cases, arteries are pathologically more involved rather than veins.3 But in this case, the peripheral gangrene is due to vasculitis that is induced by a drug and that too involving venules rather than arteries.
Blood vessel wall changes include thickening, narrowing and scarring which cause near obliteration of the lumen, thus impeding blood supply to the respective tissue. This can result in that particular organ or tissue death.2 Drugs like ergometrine (methergine used for PPH) can cause all these vessel wall changes resulting in significant peripheral ischemia and eventual gangrene.
Mahanta B N4 reported similar case of postpartum gangrene of all four limbs following injection of ergometrine.
Conclusions
Administration of ergometrine is crucial for post-partum haemorrhage management but close monitoring should be done for early diagnosis of adverse effects. This case highlights the continued importance of recognizing the rare occurrence of peripheral limb ischemia induced by ergometrine.
