Intravenous nitroglycerin: a potent uterine relaxant for internal podalic version: case.

Dear Editor, The uterine-muscle relaxation required for complicated obstetric situations traditionally has been achieved by use of a potent inhalation anesthetic. However, this procedure exposes the obstetric patient with full stomach to unnecessary general anesthesia, with the attendant risk and potentially lethal complications. Emergent uterine relaxation may be required for conditions such as retained placenta, uterine inversion, internal podalic version (IPV), and breech extraction. EVective on smooth muscle tissue and a venodilator, nitroglycerin is a short-acting and a potent uterine relaxant [1, 2]. Safety, predictability, and ease of intravenous (IV) administration of this drug have been established, and it has attracted the attention of obstetricians. Nitroglycerin is primarily indicated for the treatment or prevention of angina pectoris. Nitroglycerin has been used during manual extraction of retained placenta without clinically signiWcant hemodynamic eVects [1] and during replacement of a contracted, completely prolapsed uterus [1, 2]. Its use as a tocolytic has been reported in cesarean delivery of twins performed under spinal anesthesia: two cases of intrapartum external cephalic version, internal intrapartum podalic version of the second twin, and for the fetal head entrapment during vaginal breech delivery [1]. We report a case of IPV of intrauterine fetal demise (IUFD) in which relaxation of the uterus was accomplished quickly and safely with the use of IV nitroglycerin. A 30-year-old gravida 4 para 3 at 38 weeks gestation presented in active labor with antepartum hemorrhage since 2 h. Ultrasound conWrmed transverse lie, abruption placentae and IUFD; and examination revealed 4 cm dilated cervix. Her vitals were stable, hematocrit was 28% and coagulation proWle was normal. She made good progress, reaching 8 cm cervical dilatation over the next 4 h after which she started having hematuria so the decision was taken immediately to deliver the fetus by IPV. Uterine relaxation was achieved by direct IV nitroglycerin bolus 50 mcg along with ketamine hydrochloride 30 mg IV for sedation. Infusion of nitroglycerin at the rate of 50 mcg/min was started after 1 min of loading dose. When the uterus was relaxed (conWrmed with manual palpation), approximately 45 s after bolus, the obstetrician performed IPV and breech extraction. The procedure was completed in 4 min and 30 s. The total dose of nitroglycerin was 250 mcg. The placenta delivered spontaneously with no unusual cord traction. Transabdominal massage of the uterus and oxytocin infusion improved uterine tone. The hematocrit had decreased from 28 to 22%. One unit blood transfusion was given and she remained stable in the postpartum period. Hematuria was cleared in 2 h postpartum. Monitoring consisted of electrocardiogram, SpO2 and non-invasive blood pressure measurement. Hypotension occurred 1 min after nitroglycerin injection, which was normalized within 50 s with rapid infusion of crystalloids. The heart rate increased at the same time to 130 bpm. Side M. N. Gandhi · H. R. Iyer Department of Anaesthesiology, B. Y. L. Nair Charitable Hospital, T. N. Medical College, Dr. A. L. Nair road, Bombay 400008, Maharashtra, India