Joining forces: a complex cardio-obstetrics case report of severe ergometrine-induced vasospasm

Ergometrine is part of the current guideline-directed management of post-partum haemorrhage (PPH). However, it is also a potent vasoconstrictor capable of causing significant coronary artery vasospasm in susceptible individuals.

A 31-year-old primigravida suffered from post-partum haemorrhagic shock and disseminated intravascular coagulation following vaginal delivery. She was urgently resuscitated with intravenous fluids and blood products. Intramuscular ergometrine was administered, and surgery was required due to retained placenta. Two days later upon extubation, she demonstrated symptoms of speech apraxia. Brain magnetic resonance imaging (MRI) revealed extensive cerebral and cerebellar infarction with subcortical sparring. Her electrocardiogram showed diffuse T-wave inversions, and a high-sensitivity troponin-I peaked at 37 000 ng/L. Echocardiography showed severe left ventricular (LV) failure, apical akinesia, and thrombi formation. One week later, she suffered a middle cerebral artery stroke causing aphasia and right-sided hemiparesis, necessitating emergency thrombectomy. Cardiovascular MRI showed moderate LV systolic impairment and focal apical infarction. Coronary angiography was unremarkable. The most likely unifying diagnosis was severe ergotamine-induced coronary vasospasm causing acute myocardial infarction in the setting of life-threatening PPH. Following three weeks of multi-disciplinary care, her speech and motor abilities improved. She was discharged on long-acting nitrates, oral anticoagulation, and heart failure therapy with close outpatient monitoring. Subsequent echocardiograms showed marked improvement in LV ejection fraction (45%-50%).

This case highlights the potential life-threatening complications of ergometrine and the importance of recognizing pregnancy-associated myocardial infarction as a significant cause of maternal morbidity and mortality. The cardio-obstetrics team plays a pivotal role in improving patient outcomes.