A Supplement to MARCH 2018 The Frost Series #336 Continuing Medical Education Uterotonic Agents for Cesarean Delivery: All rights reserved. Reproduction in whole or in part without permission is prohibited. Anesthetic Copyright Implications © 2018 McMahon and Publishing Side EffectsGroup unless otherwise noted. PHYSICIAN CONTINUING MEDICAL EDUCATION: Accreditation Statement: This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of Postgraduate Institute for Medicine and Penn State College of Medicine. The Postgraduate Institute for Medicine is accredited by the ACCME to provide continuing medical education for physicians. Credit Designation: The Postgraduate Institute for Medicine designates this enduring material for a maximum of 1.0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. NURSING CONTINUING EDUCATION: Accreditation Statement: Postgraduate Institute for Medicine is accredited with distinc- tion as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. Credit Designation: This educational activity for 1.0 contact hours is provided by Postgraduate Institute for Medicine. Designated for 0.7 contact hours of pharmacotherapy credit for Advance Practice Registered Nurses. DISCLOSURE OF CONFLICTS OF INTEREST Postgraduate Institute for Medicine (PIM) requires instructors, planners, managers, and other individuals who are in a position to control the content of this activity to disclose any real or apparent conflict of interest (COI) they may have as related to the content of RELEASE DATE: March 1, 2018 EXPIRATION DATE: April 30, 2019 this activity. All identified COIs are thoroughly vetted and resolved according to PIM policy. The existence or absence of COIs for everyone in a position to control content will be dis- WRITTEN BY closed to participants prior to the start of each activity. Stacey Duryea, DO Assistant Professor of Anesthesiology FACULTY DISCLOSURES Department of Anesthesiology and Perioperative Medicine Stacey Duryea, DO, and Sonia J. Vaida, MD, have no relationships with commercial inter- Penn State Health Milton S. Hershey Medical Center ests related to the content of this CME activity. Hershey, Pennsylvania The planners and managers reported the following financial relationships or relationships to products or devices they or their spouse/life partner have with commercial interests REVIEWED AND EDITED BY related to the content of this CME activity: Sonia Vaida, MD The following PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, Professor of Anesthesiology & Perioperative Medicine and Obstetrics and Gynecology PharmD, CHCP, Judi Smelker-Mitchek, RN, BSN, and Jan Schultz, MSN, RN, CHCP, hereby Vice Chair, Research state that they or their spouse/life partner do not have any financial relationships or rela- Director, Obstetric Anesthesia tionships to products or devices with any commercial interest related to the content of this Department of Anesthesiology and Perioperative Medicine activity of any amount during the past 12 months. Penn State Health Milton S. Hershey Medical Center The planners and managers from Penn State College of Medicine hereby state that they or Hershey, Pennsylvania their spouse/life partner do not have any financial relationships or relationships to prod- ucts or devices with any commercial interest related to the content of this activity of any TIME TO COMPLETE ACTIVITY: 1 hour amount during the past 12 months. TARGET AUDIENCE SPONSORSHIP This activity is intended for anesthesiologists and certified registered nurse anesthetists. This activity is jointly provided by Postgraduate Institute for Medicine and Penn State LEARNING OBJECTIVES College of Medicine. After completion of this activity, the reader should be able to: INSTRUCTIONS FOR PARTICIPATION 1. Describe the mechanism of action of oxytocin Participants can download and print the course material in an easy to read printer-friendly 2. Indicate the recommended dose of oxytocin format, available through the boxed link at the top of the page. Participants must reflect 3. Recognize the side effects of oxytocin on the information presented, and then register to complete the exam and course evalua- 4. Indicate contraindications of methylergonovine and carboprost tion online before the expiration date at CMEZone.com/TheFrostSeries. 5. Choose the appropriate uterotonic for the individual patient Because there is no commercial support subsidizing this activity, the certification fee for 2 I Anesthesiology News MARCH 2018 The Frost Series #336 CME/CE credit is $25. During the period March 1, 2018 through April 30, 2019, participants The content of this activity was developed by the faculty indicated herein under the super- must read the learning objectives and faculty disclosures and study the educational activity. vision of Postgraduate Institute for Medicine and assistance from Penn State University. Upon registering and successfully completing the post-test with a score of 75% or better Applied Clinical Education (ACE) is responsible for graphic design and distribution of the and the activity evaluation, your certificate will be made available immediately. activity via Anesthesiology News and CMEZone.com. All information included in this activ- ity is believed to be true and accurate at the date of publication. ACE makes no warranty, DISCLOSURE OF UNLABELED USE expressed or implied, with respect to the material contained herein. This educationalAll rights activity might reserved. contain discussion Reproduction of published and/or investigationalin whole uses or in part without permission is prohibited. of agents that are not indicated by the FDA. The planners of this activity do not recom- CONTACT INFORMATION mend the use of any agent outside Copyright of the labeled ©indications. 2018 The McMahon opinions expressed Publishing in Questions Group regarding unlesscourse content otherwise may be directed tonoted. Dr. Sonia Vaida at svaida@ the educational activity are those of the faculty and do not necessarily represent the views pennstatehealth.psu.edu. Questions regarding continuing education may be directed to of the planners. Please refer to the official prescribing information for each product for [email protected]. discussion of approved indications, contraindications, and warnings. CALL FOR WRITERS DISCLAIMER If you would like to author a future installment of The Frost Series in Anesthesiology News, Participants have an implied responsibility to use the newly acquired information to enhance please send an email to Sonia Vaida, MD, at [email protected]. patient outcomes and their own professional development. The information presented in this activity is not meant to serve as a guideline for patient management. Any procedures, med- STATEMENT OF NEED ications, or other courses of diagnosis or treatment discussed or suggested in this activity Administration of uterotonic agents can be associated with serious adverse effects. It is should not be used by clinicians without evaluation of their patients’ conditions and possi- important to strike a balance between achieving the desired uterotonic effect while mini- ble contraindications and/or dangers in use, review of any applicable manufacturer’s product mizing the risk for complications. This manuscript reviews side effects and complications information, and comparison with recommendations of other authorities. caused by commonly administrated uterotonics during cesarean delivery. Case 1: Oxytocin A 23-year-old primigravida at 35 weeks’ gestation, weighing bicuspid aortic valve at 4 years of age and has been followed 88 kg and measuring 165 cm in height, who has severe aortic by the cardiology service since childhood. She was scheduled stenosis was admitted to the labor and delivery unit in active to have her aortic valve replaced and had been advised against labor. The patient had been diagnosed with a congenital pregnancy. Due to severe aortic stenosis and fetal breech presentation, elec- The newborn was delivered 2 minutes after skin incision with tive cesarean delivery (CD) was planned at 37 weeks of pregnancy. Apgar scores of 3 and 6 at 1 and 5 minutes, respectively. An Physical examination showed a score of Mallampati class I, with 6 cm infusion of 10 IU of oxytocin in 500 mL of lactated Ringer’s solution thyromental distance and a grade 3/4 systolic murmur at the left ster- was started with an immediate decrease in blood pressure to nal border. The patient reported exertional orthopnea, and echogenic 85/45 mm Hg and heart rate increase to 124 beats per minute. findings were consistent with severe aortic stenosis: ejection fraction Hypotension was refractive to repeated doses of phenylephrine of 100 of 48%, pressure gradient of 50 mm Hg across the valve, and an aortic mcg, totaling 500 mcg. Norepinephrine at 8 mcg was administered as valve area of 0.9 cm2. an IV bolus, and the oxytocin infusion was stopped. Compared with previous studies, her condition was progress- The blood pressure and heart rate returned to baseline values, and ing. Electrocardiogram (ECG) showed sinus tachycardia (heart rate, no further uterotonic agents were administered. Before extubation, 112 beats/min) with left ventricular hypertrophy. Her blood pres- 100