British Journal of Obstetrics and Gynaecology March 1977. Vol84. pp 229-230
ADVERSE REACTION TO EXTRA-AMNIOTIC PROSTAGLANDIN Ez BY
EVELYN MCNICOL,Senior Registrar * AND
HELENGRAY,Registrar Department of Obstetrics and Gynaecology, Southern General Hospital Glasgow G514TF
Summary An immediate and severe reaction to prostaglandin E, (PGEJ, given by the extra-amniotic route to induce the abortion of a hydatidiform mole, is reported.
CASEREPORT The patient was 18 years old, para 1+0, and, when seen on 9th July, 1975, gave a history of irregular and occasionally heavy vaginal bleeding since her first confinement in April, 1974. She also complained of headaches, dizziness and morning sickness for the previous six weeks. On clinical examination the uterus was found to be soft and enlarged to the size of a 16-week pregnancy. The cervix was closed and no fetal circulation was detectable by sonicaid. Sonar examination showed appearances suggestive of a diagnosis of hydatidiform mole. It was decided to terminate the pregnancy using ‘extra-amniotic’ prostaglandin. Four units of compatible whole blood were cross matched. Taking the usual sterile precautions, a 22 gauge Foley catheter with a 30 ml balloon was introduced through the cervix after which the balloon was inflated. Two ml of a solution containing 100 pg/ml of prostaglandin E, (PGE,) was instilled into the uterus (Embrey et al, 1974). The patient complained immediately of severe abdominal pain, dizziness, difficulty in breathing and produced frothy, blood-stained sputum. She complained of nausea and retched --
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-~
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__
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but did not vomit. Her pulse was imperceptible and the blood pressure was recorded as 90/50 mm Hg. She was cold and clammy and had several rigors. The patient was given 50 mg of pethidine and 50 mg promethazine hydrochloride intravenously and also 50 mg of promethazine hydrochloride intramuscularly. After one hour the blood pressure was 120/70 mm Hg and the pulse rate 100 to 120 beats per minute and after another two hours the patient was given a further 50 mg of promethazine hydrochloride and 100 mg of hydrocortisone intravenously. The uterus remained firmly contracted and tender for four hours while the patient slept deeply. Mild regular contractions were then felt and these were augmented by intravenous oxytocin given by a Palmer pump, the maximum dose of 32 mU/minute being reached after two hours. Obvious molar tissue was expelled ten hours after the extra-amniotic PGE, had been given and the uterus was then evacuated under general anaesthesia. The total blood loss was estimated at 1500 ml and 2000 ml of whole blood was transfused. Evacuation of the uterus was repeated eight days later when only a small amount of tissue was obtained. On histological examination, the molar tissue showed the features of hydatidiform mole with
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*
Present appointment: Consultant, Bellshill Hospital, Lanarkshire.
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mild trophoblastic proliferation and the curettings showed normal decidua. The patient was well when discharged on her second postoperative day and has since failed to attend the hospital for review although she has sent urine specimens for radioimmunoassay of human chorionic gonadotrophin to Dundee (Hydatidiform Mole Registration) and the results have been satisfactory, varying from 14 IU/24 hours to 54 IU/24 hours over the five months following the induction of abortion. COMMENT PGE, has been given by the intravenous (Karim, 1970; Filshie, 1971 ; Naismith and Barr, 1974) and extra-amniotic routes (Embrey et al, 1974) in the management of hydatidiform mole. Some consider that evacuation of a hydatidiform mole by suction is a safer alternative. Because there is no extra-amniotic space in a hydatidiform mole we probably injected the 2 ml bolus of PGE, solution directly into the maternal circulation thus producing a
severe and alarming reaction. Embrey et a1 (1974) injected PGE, into the uterus by mechanical infusion pump while Karim et a1 (1974), using an analogue of PGE,, used a bolus dose with no reported side effects in 20 patients with a hydatidiform mole. We feel that a bolus dose of PGE, is dangerous and that mechanical infusion pumps should be used in patients where the use of extra-amniotic prostaglandins is indicated. REFERENCES Embrey, M. P., Calder, A. A., and Hillier, K. (1974): Journal of Obstetrics and Gynaecology of the British Commonwealth, 81, 47. Filshie, G. M. (1971): Journal of Obstetrics and Gynaecology of the British Commonwealth, 78, 87. Karim, S. M. M. (1970): British MedicalJournal, 3, 196. Karim, S. M. M., Ratnam, S. S., and Choo, S. S . (1974): Journal of Obstetrics and Gynaecology of the British Commonwealth, 81, 650. Naismith, W. C. M. K., and Barr, W. (1974): Journal oj'obstetrics and Gynaecology ofthe British Commonwealth, 81, 146.
ADVERSE REACTION TO EXTRA-AMNIOTIC PROSTAGLANDIN Ez BY
EVELYN MCNICOL,Senior Registrar * AND
HELENGRAY,Registrar Department of Obstetrics and Gynaecology, Southern General Hospital Glasgow G514TF
Summary An immediate and severe reaction to prostaglandin E, (PGEJ, given by the extra-amniotic route to induce the abortion of a hydatidiform mole, is reported.
CASEREPORT The patient was 18 years old, para 1+0, and, when seen on 9th July, 1975, gave a history of irregular and occasionally heavy vaginal bleeding since her first confinement in April, 1974. She also complained of headaches, dizziness and morning sickness for the previous six weeks. On clinical examination the uterus was found to be soft and enlarged to the size of a 16-week pregnancy. The cervix was closed and no fetal circulation was detectable by sonicaid. Sonar examination showed appearances suggestive of a diagnosis of hydatidiform mole. It was decided to terminate the pregnancy using ‘extra-amniotic’ prostaglandin. Four units of compatible whole blood were cross matched. Taking the usual sterile precautions, a 22 gauge Foley catheter with a 30 ml balloon was introduced through the cervix after which the balloon was inflated. Two ml of a solution containing 100 pg/ml of prostaglandin E, (PGE,) was instilled into the uterus (Embrey et al, 1974). The patient complained immediately of severe abdominal pain, dizziness, difficulty in breathing and produced frothy, blood-stained sputum. She complained of nausea and retched --
-
-~
-
__
-
but did not vomit. Her pulse was imperceptible and the blood pressure was recorded as 90/50 mm Hg. She was cold and clammy and had several rigors. The patient was given 50 mg of pethidine and 50 mg promethazine hydrochloride intravenously and also 50 mg of promethazine hydrochloride intramuscularly. After one hour the blood pressure was 120/70 mm Hg and the pulse rate 100 to 120 beats per minute and after another two hours the patient was given a further 50 mg of promethazine hydrochloride and 100 mg of hydrocortisone intravenously. The uterus remained firmly contracted and tender for four hours while the patient slept deeply. Mild regular contractions were then felt and these were augmented by intravenous oxytocin given by a Palmer pump, the maximum dose of 32 mU/minute being reached after two hours. Obvious molar tissue was expelled ten hours after the extra-amniotic PGE, had been given and the uterus was then evacuated under general anaesthesia. The total blood loss was estimated at 1500 ml and 2000 ml of whole blood was transfused. Evacuation of the uterus was repeated eight days later when only a small amount of tissue was obtained. On histological examination, the molar tissue showed the features of hydatidiform mole with
-
*
Present appointment: Consultant, Bellshill Hospital, Lanarkshire.
229
230
MCNICOL AND GRAY
mild trophoblastic proliferation and the curettings showed normal decidua. The patient was well when discharged on her second postoperative day and has since failed to attend the hospital for review although she has sent urine specimens for radioimmunoassay of human chorionic gonadotrophin to Dundee (Hydatidiform Mole Registration) and the results have been satisfactory, varying from 14 IU/24 hours to 54 IU/24 hours over the five months following the induction of abortion. COMMENT PGE, has been given by the intravenous (Karim, 1970; Filshie, 1971 ; Naismith and Barr, 1974) and extra-amniotic routes (Embrey et al, 1974) in the management of hydatidiform mole. Some consider that evacuation of a hydatidiform mole by suction is a safer alternative. Because there is no extra-amniotic space in a hydatidiform mole we probably injected the 2 ml bolus of PGE, solution directly into the maternal circulation thus producing a
severe and alarming reaction. Embrey et a1 (1974) injected PGE, into the uterus by mechanical infusion pump while Karim et a1 (1974), using an analogue of PGE,, used a bolus dose with no reported side effects in 20 patients with a hydatidiform mole. We feel that a bolus dose of PGE, is dangerous and that mechanical infusion pumps should be used in patients where the use of extra-amniotic prostaglandins is indicated. REFERENCES Embrey, M. P., Calder, A. A., and Hillier, K. (1974): Journal of Obstetrics and Gynaecology of the British Commonwealth, 81, 47. Filshie, G. M. (1971): Journal of Obstetrics and Gynaecology of the British Commonwealth, 78, 87. Karim, S. M. M. (1970): British MedicalJournal, 3, 196. Karim, S. M. M., Ratnam, S. S., and Choo, S. S . (1974): Journal of Obstetrics and Gynaecology of the British Commonwealth, 81, 650. Naismith, W. C. M. K., and Barr, W. (1974): Journal oj'obstetrics and Gynaecology ofthe British Commonwealth, 81, 146.
