a 25-year - old , 68 kg , bmi 27.64 kg / m , asa ii primigravida , was taken up for emergency caesarean section for meconium - stained liquor and fetal distress .
she was a known case of preeclampsia and her blood pressure was controlled on methyl dopa 250 mg po thrice daily .
her preoperative hematologic investigations were all within normal limits ( hb , 10.8 g% ; tlc , 5700/mm ; platelets , 2.2 million / mm ; s. bilirubin , 0.85 mg% ; blood urea , 42 mg% ; inr , 1.13 ; pt ( test ) , 13 s ; pt ( control ) , 14 s ; pttk ( test ) , 36 s ; and pttk ( control ) , 35 s. her urine was positive for albumin .
an informed consent was taken after explaining all anesthetic concerns to the patient and her relatives . before induction
she was conscious , oriented with blood pressure 143/88 mmhg , pulse rate 101/ min , and oxygen saturation 98% on room air . in view of acute fetal distress ( urgency grade i ) , it was decided to administer general anesthesia for the caesarean section .
she was preoxygenated with 100% o2 for 3 min and rapid sequence intravenous induction performed with 250 mg thiopentone , 100 mg succinylcholine , using sellick 's maneuver , and the surgery was started .
oxytocin infusion was started at the rate of approximately 0.04 iu / min after a bolus of 5 iu .
however , the patient went into postpartum hemorrhage ( pph ) due to uterine atony , which did not even respond to an increase in the rate of oxytocin infusion .
the surgeons decided to administer prostaglandin f2-alpha  carboprost trometamol 0.25 mg ( prostodin , astrazeneca , india ) intramyometrial . within 12 min of its administration airway pressures shot up to 55 cm and the oxygen saturation fell to 88% , although her pph was now controlled .
her blood pressure fell to 92/54 mmhg with a pulse rate of 110/ min but was successfully restored with the administration of a total volume of 3 l of crystalloids .
she was immediately administered hydrocortisone ( 200 mg ) and deriphyllin ( 110 mg ) and nebulised with salbutamol 2.5 mg diluted in 4 ml saline .
auscultation of the chest now revealed minimal rhonchi but the appearance of fine crepitations , especially at the bases .
a diagnosis of acute pulmonary edema was made and the patient was given frusemide 40 mg along with morphine 6 mg intravenous stat .
after completion of surgery , neuromuscular blockade was not reversed and the patient was shifted to icu for further management . in the icu
she was nursed in the head up position , frusemide 40 mg was repeated and she was electively ventilated . over the next 4 h , the pulmonary edema steadily resolved , chest became clear on auscultation and her arterial blood gas analysis revealed normal gas exchange .
pph is defined as excessive bleeding from the genital tract following the delivery of the baby .
it is called primary if it occurs within 24 h of the delivery or secondary if after that .
the who defines pph as bleeding in excess of 500 ml within the first 24 h after delivery .
pph is a major cause of maternal death worldwide and is a major contributor to maternal mortality and morbidity in third world countries .
a number of medical and surgical interventions are used to control the bleeding in case of pph .
parenteral prostaglandins have shown promise , but their use has been limited by side effects . in dire situations ,
intramyometrial injection of prostaglandin f2-alpha has been used with apparently dramatic effects . intrauterine irrigation with pg f2-alpha has also been used .
prostodin ( 15-methyl pg f2-alpha ) acts as a smooth muscle stimulant and is a recognized second - line agent for use in the management of postpartum uterine atony unresponsive to oxytocin / ergometrine .
it is an analog of pg f2-alpha ( dinoprost ) with a longer duration of action than its parent compound , attributed to its resistance to inactivation by oxidation at the 15-position .
available in single - dose vials of 0.25 mg , it may be administered by deep intramuscular injection or , alternatively , by direct intramyometrial injection .
the latter route of administration is achieved either under direct vision at caesarean section or trans - abdomen or trans - vaginal following vaginal delivery and has the advantage of a significantly quicker onset of action .
peripheral intramuscular injection yields peak plasma concentrations at 15 min in contrast to less than 5 min for the intramyometrial route .
hayashi et al . reported infrequent and mild side effects , including nausea , vomiting , and diarrhea .
sudden collapse and death have been reported by cares and jordan following the use of pg f2-alpha intra - amniotic for abortion .
found a 40% increase in cardiac output in pregnant anesthetized women during infusion of 300 g of pg f2-alpha with an increase in pulmonary arterial pressure , doubling of pulmonary vascular resistance and increase in airway resistance .
reported the development of marked arterial desaturation within 510 min of the administration of 15 methyl pg f2-alpha , secondary to intrapulmonary shunt .
five patients required ventilator support for variable durations . cardiovascular collapse along with left heart failure has been reported with overdose of intramyometrial prostodin , the possible etiology being a combination of acute pulmonary hypertension with decreased left ventricular end - diastolic pressure and decreased cardiac output . in our case , the cause of pulmonary edema could be either fluid overload or the administration of prostodin .
three liters of crystalloids were transfused for a loss of approximately 11.5 l of blood .
development of pulmonary edema immediately after the injection of prostodin points toward it being responsible for the edema .
although pulmonary edema after the administration of prostaglandins is common in patients with pre - existing cardiac disease , it has also been reported in patients with normal heart .
it may be prudent to use first - line uterotonics to control pph as far as possible .
prostaglandin analogs , whenever used , should be used carefully , along with good monitoring and preferably under the cover of diuretics .
 a 25 year old , 68 kg , primigravida , was taken up for emergency caesarean section for meconium stained liquor and fetal distress . 
 she was a known case of pre eclampsia and her blood pressure was controlled on tab methyl dopa . 
 she was administered general anaesthesia . 
 after delivery of baby she went into postpartum hemorrhage which was controlled with intramyometrial prostodin . but immediately after its administration she went into acute pulmonary edema . 
Case Report
Discussion