Oxytocin

Oxytocin is a commonly used agent for placental expulsion and the treatment of uterine atony. It
is also used to induce or posterior pituitary gland. Synthetic oxytocin is known as Pitocin or
Syntocinon. Intravenous administration of Pitocin is associated with hypotension. Hypotension is
well tolerated in healthy women because this effect is transient. However, it can be problematic
in women with severe hypovolemia or under regional anesthesia.

The effect of intravenous oxytocin was studied during cesarean section under general anesthesia.
A bolus of 10 units of oxytocin was associated with a decrease in femoral arterial pressure of
40%, systemic resistance of 59%, and pulmonary resistance of 44%, 30 s after injection.
However, the heart rate increased 31% and stroke volume 17%, so that the cardiac output
increased by 54%. The pulmonary arterial pressure and wedge pressure were increased
by 33% and 35%, respectively, 150 s after injection. However, no changes were seen in the
hemodynamic parameters during infusion of 80 mU/min oxytocin for 10 min.

Hence, it is suggested that this drug be administered via infusion rather than by bolus injection. It
is prudent to restrain administering oxytocin as a bolus dose of more than 2 units. Our practice is
to use infusions of oxytocin.
Synthetic oxytocin can cause antidiuretic responses in large doses.

Water intoxication, has been described following the

infusion of larger doses of oxytocin. Use of isotonic saline solution
in place of 5% glucose in water should diminish the risk
of water intoxication.
Ergot Alkaloids
Ergonovine maleate (Ergotrate) and methylergonovine maleate (Methergine) are used for tetanic
uterine contractionand are the drugs of choice when oxytocin fails to produce
adequate uterine contraction. However, in contrast to synthetic oxytocin, these agents will cause
maternal hypertension by causing direct peripheral vasoconstriction. Severe hypertension with
cerebral hemorrhage has been described when intravenous methylergonovine is administered in
combination with other vasoactive drugs such as ephedrine and phenylephrine.
Methylergonovine, 0.2 mg, should be administered. via intramuscular injection whenever

indicated. It should not be administered in parturients with preeclampsia.

In addition to the hemodynamic effects of local anesthetics used for regional anesthesia
discussed earlier, these drugs may have direct effects on uterine blood flow. In vitro studies
on human uterine arteries obtained from pregnant and nonpregnant uteri showed that high doses
of the local anesthetics lidocaine and mepivacaine (400–1,000 µg/mL) caused uterine
artery vasoconstriction only in specimens obtained from pregnant uteri.
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This observation is likely related to the ability of local anesthetics to block endothelium-
dependent relaxation by nitric oxide, which is increased in the pregnant state.
The vasoconstrictive effects observed in these studies were seen with concentrations that could
only be achieved in a clinical situation by injecting local anesthetics intravenously while
performing epidural anesthesia or perhaps during performance of a paracervical block (an
outdated technique which is associated with fetal bradycardia, most likely due to uterine artery
vasoconstriction).

Lower concentrations of lidocaine (blood level, 2–4 µg/mL), similar to those produced during
properly performed epidural anesthesia, do not decrease uterine blood flow even after
prolonged infusion.
Ropivacaine and bupivacaine also do not cause vasoconstriction or reduce uteroplacental blood
flow On the other hand, cocaine is associated with dose-related uterine so constriction and
reduction in uterine blood flow and this effect does occur at clinically encountered
concentrations.
Epinephrine
Epinephrine is frequently added to local anesthetics to intensify the sensory and motor blockade
as well as prolong the duration of anesthesia. Epinephrine possesses both a-andßadrenergic
effects. Fifteen micrograms of epinephrine has been suggested as an intravascular test dose.
Doses of this magnitude produce dose-dependent but short-lived decreases in
uterine blood flow in pregnant sheep.

Systemic absorption of epinephrine from the epidural space produces effects similar
to intravenous injection of very low doses. Beta effects predominate (increased heart rate and
cardiac output, decreased vascular resistance and arterial pressure) and uteroplacental
blood flow may decrease.

Opioids
Fentanyl is commonly added to local anesthetics used in epidural analgesia. In pregnant ewes, it
has no effect on uterine blood flow.Intrathecal opioids, especially meperidine, which has a local
anesthetic-like effect, but also sufentanil, because of pain relief and possibly sympathetic
blockade, can lower maternal blood pressure and thus potentially reduce uterine blood flow.

Vasopressors
Ephedrine, which has mainly a ß-adrenergic effect, has for several decades been considered the
drug of choice for the treatment of hypotension in the parturient. Ephedrine increases
the blood pressure by both ionotropic and chronotropic effect on the heart as well as increasing
venous return (preload). In addition, ephedrine causes release of nitric oxide in the
pregnant uterine circulation, helping to preserve uterine blood flow.

Classic experiments suggested, conversely, that vaso- pressors which have mainly a-adrenergic
effects (mephentermine, metaraminol, methoxamine) increase the blood pressure primarily by
peripheral vasoconstriction, with a significant reduction in uterine blood flow.

In the past two decades, however, numerous comparative trials have failed to confirm
this advantage in the clinical setting. The difference may be due to the very large doses of alpha
agonists used in classic sheep studies, or perhaps to a species difference. The results
from seven RCTs in human clinical use show no difference in efficacy or neonatal outcome
(clinical acidosis, Apgar scores), but a small benefit in neonatal pH (mean 0.03 units) favoring
phenylephrine.
Two cautions should be noted when interpreting this finding, however: (1) widely different
assumptions on relative potency of the drugs have been employed, sometimes leading to very
high doses of ephedrine being administered; and (2) only healthy parturients undergoing elective
cesarean delivery were studied. Indeed, in a compromised fetal sheep model, phenylephrine used
to correct epiduralinduced hypotension caused marked fetal deterioration when
compared to ephedrine.
We therefore recommend eitherdrug for use in elective surgery, but consideration for ephedrine
as a first choice when impaired uteroplacental circulation is suspected on the basis of maternal
history or the fetal heart rate tracing