REFERAT

Serotonin Syndrome in Obstetrics: A Case

Report and Review
of Management
Capt Heisy B. Asusta, MC, USAF*; MAJ Erin Keyser, MC, USA*; CPT Patricia
Dominguez, MC, USA†;
Marvin Miller, DO‡; CPT Tolulope Odedokun§

MUHAMMAD ROSAMANILLAH
20174011135
 “ Serotonin syndrome (SS) is a life-
threatening condition, usually
precipitated by a combination of
serotonergic agents. Data
regarding the incidence and
management of SS in obstetrics
are limited.

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 This study presents a case of SS
provoked by an atypical antipsychotic
in :
▪ a second trimester
▪ singleton gestation
▪ reviews the management of SS in an
obstetric patient

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 CASE REPORT
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 Patient ID:
▪ The patient is a 21-year-old

▪ gravida 1 at 24 wk gestation

▪ schizophreniform disorder
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 intravenous
she had taken
labetalol
two additional
And
tablets of
Monitoring in
lurasidone
ICU

hospitalized for Come to ED After 24 h, she

the treatment of with agitation was transferred
new-onset and palpitation to the inpatient
development psychiatric unit
of psychotic
features

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 EXAMINATION
Vital Sign:
Laboratory: all unremarkable
Heart Rate : 180x
▪ Complete Blood Count
Blood Pleasure : 18/89 mmHg
▪ Comprehesive metabolic panel
▪ Creatinine kinase
Physical Exam:
▪ Troponins
Neuromuscular excitability
▪ Urinalysis
Hyperreflexia in the L2–L4
▪ Urine drug screen
Inducible clonus
FHR : 130x
Electrocardiogram: sinus tachycardia
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 MANAGEMENT IN
EMERGENCY DEPARTMENT
▪ intravenous labetalol

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 MANAGEMENT IN
INTENSIVE CARE UNIT
▪ Telemetry

▪ Pulse oxymetri

▪ Supplemental O2

▪ Neurology checks hourly

▪ Fetal heart tones daily

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 What is Serotonin
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Syndrome ?
 DEFINITION
“Serotonin syndrome is the
constellation of clinical findings
resulting from excessive serotonergic
stimulation.”

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 ETIOLOGY
Serotonin syndrome is most oft en triggered by the initiation
of:

▪ two or more medications that affect the serotonin level

▪ a dose increase, resulting in either elevated serotonin
▪ synthesis or release, inhibited serotonin metabolism or
reuptake, or by increased serotonin receptor agonists.
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13
 PATHOPHYSIOLOGY
▪ Serotonin or 5-hydroxytryptamine (5-HT), is a
neurotransmitter that is produced both centrally
and peripherally.
Centrally
Serotonin
Peripherally
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 ▪ There are seven classes of 5-HT receptors to
which serotonin binds, which are designated as
5-HT1 -5-HT7.
▪ The four major mechanisms resulting in
excessive serotonergic stimulation are as
follows:
▪ (1) increased serotonin release,
▪ (2) increased serotonin formation
▪ (3) decreased serotonin reuptake, and
▪ (4) direct serotonin receptor agonism.
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 ▪ Lurasidone is a second generation atypical
antipsychotic which acts as a partial agonist at
the 5-HT1A receptor to decrease some of the
negative extrapyramidal symptoms.

▪ Thus, it is physiologically possible for lurasidone

to result in serotonin syndrome by excessive
serotonergic stimulation of the 5-HT receptor.
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 CLINICAL PRESENTATION
AND DIAGNOSIS
A trio of symptoms point to serotonin syndrome:

▪ Mental status changes

▪ Autonomic stimulation

▪ Neuromuscular hyperactivity

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 ▪ The onset of symptoms usually occurs within 24 h
of an increase in dosage, overdose or withdrawal of
a serotonergic agent.

▪ medical history and completing a medication

reconciliation is essential to recognizing serotonin
syndrome.

▪ The diagnosis is made clinically by using the Hunter

Serotonin Toxicity Criteria (HSTC).
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 MANAGEMENT
Serotonin syndrome is self-limiting, and typically resolves
within 24–72 h after discontinuation of the offending
agent(s).
Supportive measures may include:
▪ oxygen administration,
▪ intravenous fluids,
▪ continuous cardiac monitoring, and
▪ airway support/intubation.
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 Moderate to severe serotonin syndrome may
necessitate:
• neuromuscular sedation with benzodiazepines,
• serotonin antagonist as an antidote, such as
cyproheptadine (pregnancy category B) as follows:
▪ 12 milligram initial dose (oral, or crushed via
nasogastric tube)
▪ 2 milligram every 2 hours thereaft er if symptoms
persist, and
▪ after stabilization, 8 mg every 6 hours
(Ables & Nagubilli, 2010; Cooper & Sejnowski, 2013; Karch, 2013; Wilson et al., 2012).
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 CONCLUSION
This case illustrates some of the unique challenges to making the
diagnosis of serotonin syndrome in obstetrics. Heuristically, a
pregnant patient presenting with hypertension, clonus and
hyperreflexia may be incorrectly diagnosed with preeclampsia.
Failure to recognize serotonin syndrome in a timely manner results
in increased maternal-fetal morbidity and mortality. Awareness of
serotonin syndrome is fundamental to increasing diagnostic
accuracy and appropriate management of the condition.

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 RECOMMENDATION
▪ having a high clinical suspicion of serotonin syndrome in
any obstetric patient who is taking psychiatric
medications and presents with altered mental status and
signs of autonomic dysfunction.
▪ seeking early engagement of a multidisciplinary team.

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 THANKS!
Any questions?

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