Cardiovascular Collapse Following an Overdose of Prostaglandin F2 Alpha: A Case Report

A 31-year-old previously healthy gravida was admitted at 35 weeksʼ gestation because of pregnancy-induced hypertension and vaginal bleeding. Labor was induced with IV oxytocin. After 3 hr of first stage, the woman had a one minute second stage, with delivery of a healthy baby. The placenta delivered spontaneously 6 minutes later. Brisk bleeding ensued; blood loss was estimated at 3,000 ml. Hypotension and tachycardia developed. Additional IV lines were inserted, IV oxytocin was administered and bimanual uterine compression was performed. Two units of packed red cells and 2 liters of saline were infused, and BP and HR stabilized. However, bleeding continued. Coagulogram was normal. Therefore, manual exploration and curettage of the uterus were performed under endo-tracheal N2O-O2-fentanyl anesthesia; no retained products were obtained. Bleeding was then considered to be due to a poorly contractile lower uterine segment, and the entire content of a vial of prostaglandin F2 alpha (PGF2) (40 mg), diluted in 30 ml of saline, was injected into the lower uterine segment. Aproximately 4 min later, bleeding had stopped but no BP or pulse could be obtained; ECG still showed sinus tachycardia of 130. Ventilation with 100% O2, IV increments of ephedrine, epinephrine, and phenylephrine failed to improve the situation. Corticosteroid was administered and, following development of premature ventricular beats, a bolus of lidocaine was given. Minutes later, fulminant pulmonary edema developed. A dopamine infusion was started through a central venous line, and the patient developed a palpable femoral pulse and a systolic pressure of 80 mmHg. In the ICU, a Swan-Ganz catheter was inserted; initial PCWP was 25 cm H2O. The patient was conscious and responded to furosemide. She was extubated 17 h postpartum and went home 4 days later.