Intramyometrial terlipressin in atonic postpartum hemorrhage: A uterine salvage decision

Abstract

Citation: Samanta S, Samanta S, Jain K and Chatterjee D. Intramyometrial terlipressin in atonic postpartum hemorrhage: A uterine salvage decision. Anaesth Pain & Intensive Care 2014;18(3):313-14

Terlipressin is a long acting analog of vasopressin mainly used in the treatment of upper gastrointestinal bleeding with minimal cardiovascular effects.¹_. We report a case where intra myometrial terlipressin effectively controlled postpartum hemorrhage (PPH) refractory to conventional uterotonic drugs.

A 27 year old primigravida parturient was posted for emergency cesarean section (CS) in view of fetal bradycardia under general anesthesia. Rapid sequence induction with cricoid pressure application was performed with thiopental sodium and paralysis achieved with succinylcholine. Anesthesia was maintained with oxygen-nitrous oxide-isoflurane with atracurium keeping minimum alveolar concentration at 0.7-1. She developed PPH after CS and went into hemorrhagic shock with invasive arterial blood pressure (ABP) of 66/40 mmHg and heart rate of 130 /min. Traumatic PPH and gross coagulopathy were excluded from detailed local exploration and previous routine coagulogram (normal platelets count and prothrombin time). No history of any comorbidity or coagulation disorder was noted in her antenatal record. Oxytocin 25 units in 500 ml saline was started after delivery of the baby in titrated fashion. The surgeon reported a non-contractile uterus which did not respond to 25 U oxytocin by intravenous infusion. Intramuscular ergometrine 0.2 mg was injected after placental removal. Manual uterine massage was performed and clots from the uterus were removed by obstetrician. Hypotension was managed with crystalloid and hydroxy ethyl starch. Three units of packed red blood cells and 1gm of tranexamic acid were given. A total of 4 litres of fluids including blood products was transfused. After resuscitation, ABP improved to 90/50 mmHg and heart rate to 115/min. Forced air warming was used to prevent hypothermia. Injection 15 methyl PGF₂α (Carboprost™) 250 µg was given intramuscularly with a repeat dose injected into myometrium. Even after two repeat doses of Carboprost™ (both intramuscular and intramyometrial) uterus remained atonic. Rectal 1000 µg misoprostal also failed to improve the uterine tone. Uterine tamponade was also unsucessful. Uterine artery ligation was performed but due to continued bleeding, a consent for hysterectomy was taken. In the mean time we decided to give a trial of intramyometrial 1 mg terlipressin (Remestyp™, Ferring Pharmaceuticals Pvt. Ltd. Mumbai, India) injection after taking consent from relatives. Surprisingly the uterine tone improved after 5 min of terlipressin injection. We repeated second dose after 20 min and with this second dose uterus became more firm and PPH was controlled. So hysterectomy was deferred and patient was shifted to high dependency unit. Her vital signs improved further with fluids and blood products. She was discharged home 7 days after CS.

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