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Ergot and ergotamine tartrate in puerperal prophylaxis
ERGOT AND ERGOTAMINE TARTRATE IN PUERPERAL PROPHYLAXIS M. G. DERBRUCKE, M.D., BROOKLYN, N. Y. (From the Department of Obstetrics, Coney Island
Ho/J.pita~)
ROPHYLACTIC measures that tend to lessen maternal morbidity Pshould be welcomed. We offer the results of this study for whatever purpose they may serve in the improvement of the situation. This report is based on 169 consecutive obstetric patients at the Coney Island Hospital, representing 171 deliveries. Our prophylactic, postpartum measures, aside from the regular routine, consisted in the administration of fluid extract of ergot, or its alkaloid, ergotamine tartrate, and a control group. This study was spread over a period of forty-five days. During the first fifteen days all patients delivered received ergotamine tartrate; the second fifteen days, ergot; and those delivered during the third period of fifteen days were used as controls. Each patient received 30 minims of ergotamine tartrate daily for three days, divided in 5 doses of 6 minims each, so that all medication was administered during the patient's waking hours. Fluid extract of ergot was given in 15 minim doses, 4 times per day, over a period of three days. As a result of this arrangement, 67 patients received ergotamine tartrate, 49 received fluid extract of ergot, and 53 were used as controls. Siihs, in a similar study, using ergotamine tartrate in 53 selected cases, found that 57 per cent of these had what he called an ''undisturbed puerperium.'' Of 53 con· trol patients only 6 per cent had an "undisturbed puerperium." By a "disturbed puerperium,'' Siihs refers to an abnormal change in the lochia or a delay in the involution of the uterus.
The following factors were considered in this study: Length of time in labor, number of vaginal examinations, method of delivery, weight of child, and complicating, nonobstetrical conditions. 'J.1he length of time in labor varied from twenty-five minutes to fifty-nine and two-thirds hours. The distribution in the various groups is best shown in Table I. TABLE
I.
DURATION OF LABOR IN HOURS AND MINUTES
MULTIPARAS SHOR'l'
Control Ergot
LONG
--1.15 47.20 2.0 59.40 0.25 58.55
PRIMIPARAS SHORT
LONG
MULTIPARAS SHORT
LONG
~
6.0 4.0
24.0 57.35
272
3.15 1.20
29.05 27.35
PRIMIPARAS SHORT
LONG
7.lil 35.05 30.55 6.15
45.0 57.15
DER BRUCKE :
ERGOT IN PUERPERAL PROPHYLAXIS
273
Routine vaginal examinations are not sanctioned on our service. However, when indicated, under proper aseptic precautions, they may be done. Rectal examinations are employed to follow the progress of labor. There were 149 spontaneous deliveries, 9 forceps and 13 breech. There were two sets of twins. There were two stillbirths, one due to an unrecognized, prolapsed cord, the other followed a forceps delivery. Manual removal of the placenta was resorted to in one case. The smallest baby weighed 1,800 gm., and the largest 4,840 gm.; 44 per cent of all our babies weighed over 3,600 gm.
lll4S,7691011
I'IIElPERIUM
DAYS
FIG. I
Among the complicating conditions, there was one case of old tuberculosis, with a bronchopneumonia, one case of aeute tonsilitis which set in on the tenth day, one of typhoid fever, and one patient with lobar pneumonia was admitted in labor. There were two acute mastitis cases and two of acute pharyngitis. Although the weight of the baby, the length of time in active labor, the amount of manipulation, the mode of delivery all play an important role in the morbidity of the lying-in period, still the gauge for such morbidity is the temperature. The choice in this study, of an arbitrary line of demarcation between a normal temperature and a morbid temperature presented a problem. It seemed unjust to call only such patients with a tempera-
274
AMERICAN JOURNAl, OF OBSTETHICS AND GYNECOLOGY
ture of 100.4° P. on two successive days other than the first, as being morbid, when 16, or almost one-third of all the fluid extract of ergot series had a temperature range of 99 ° P. to 99.8 ° F. from two to five days during· the lying-in period. A like situation existed in the control series. In striking contrast, only 13.4 per cent of all those receiving erg·otamine tartrate had a temperature on any two or more days of 99° P. or 99.8° P. Hampton and Wharton in 1920, reviewing a series of embolic deaths, found one positive factor, which was a persistent temperature of from 99• F. to 100• F. They concluded that such temperature indicated a low grade infection somewhere. They quoted similar statements by Michaelis, G. Petren, and Mahler.
If we followed the accepted standard, our total morbidity in this series would have been 3.5 per cent. We believe that this is a fair ll
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result, when we consider the overcrowding in our wards and the size and weight of our babies. Lochia.-All cases in the control series had some lochia at the time of their discharge on the eighth to the tenth day of the puerperium. Lochia rubra was present in over 79 per cent of the cases. In no case was there an absence of the lochia. In 4 cases it was termed scant. Forty per cent of the fluid extract of ergot cases showed an absence or change in the character of the lochia at the time of discharge as compared with 30 per cent of the ergotamine series. How-
l-It
DER BRUCKE:
ERGOT IX f'rERPERAL PROPIJYLAXI~
·>7:">
ever the latter group showed a scanty lochia in 61 per cent of the patients in contrast to 46 per cent of the fluid extract of ergot ease:s. The importance of this is readily seen in a reYit-w of the temperatnr1• charts. The ergotamine tartrate group had a eorreeted morbidity, according- to the stricter classification, of 14.9 JWr cent as compar·ed with a 40 per cent and 53 per cent, respeetiYely. in the fluid t>xtrHet of erg·ot and control series. \Vith regard to inyolution under such stimulatic·n, the general aver~ age for all seems to show a better involutionary rt>Hponse to ergotamint:• tartrate. 'I' his is more evident in the multipara ( B'igs. 1 and 2). In~ volution in the primipara. howevet', Sf'f•ms to progre:.;s better wht>n left alonP. (Fig. 3.) SUM:VIARY
]n a :.;eries of 169 consecutive parturients delivered under the same conditions we find that many patients had a mild temperature, 11ot high enough to be put in the accepted morbidity group, yet of sufficient per~-;istence to make one realize that all was not quite well. In the group with the greatest number of temperature cases ( 53.15 per cent, the control group), lochia rubra persisted beyond normal ex~ peetancy; there was some form of lochia present at the timf' of dis~ charge, and involution had not progrefised as W<'ll in the multiparas as in the primiparas. The administration of ergot and more particularly its alkaloid. ergotamine tartrate, prophylactically, hastened involution, lessened lochia rubra, and clweked lo<:hial diRcharge by thP tenth day. CONCLUSIONS
From this study it would seem justifiablP to rlraw the following conclusions: 1. The administration of ergot or its alkaloid. ergotamine tartrate, during the first three days of the puerperium hastens involution and lessens the lochial discharge during the parturient's stay in the hos~ pita!. Ergotamine tartrate, as shown by this study, accomplishes this better than the usual preparations of ergot. 2. Our series, of course, is too small to warrant definite conclusions. We believe, however, that enough positive data haYe been presented to warrant further investigation of tlw use of oxytocics during the puerperium. I wish to thank Dr. Harvey B. Matthews, Director of
th•~
ObFtetric Departnwnt.
for his interest and suggestions in the preparation of this paper. 901 WASHINGTON AVENUE
REFERENCES
l. Siih.~, .J.: Med. J. & Rec. 86: 468, 1932. .Johns Hopkins Hosp. 31: 9i}, 1920.
(2) Hampton and Wha·rfvn: BulL
Ho/J.pita~)
ROPHYLACTIC measures that tend to lessen maternal morbidity Pshould be welcomed. We offer the results of this study for whatever purpose they may serve in the improvement of the situation. This report is based on 169 consecutive obstetric patients at the Coney Island Hospital, representing 171 deliveries. Our prophylactic, postpartum measures, aside from the regular routine, consisted in the administration of fluid extract of ergot, or its alkaloid, ergotamine tartrate, and a control group. This study was spread over a period of forty-five days. During the first fifteen days all patients delivered received ergotamine tartrate; the second fifteen days, ergot; and those delivered during the third period of fifteen days were used as controls. Each patient received 30 minims of ergotamine tartrate daily for three days, divided in 5 doses of 6 minims each, so that all medication was administered during the patient's waking hours. Fluid extract of ergot was given in 15 minim doses, 4 times per day, over a period of three days. As a result of this arrangement, 67 patients received ergotamine tartrate, 49 received fluid extract of ergot, and 53 were used as controls. Siihs, in a similar study, using ergotamine tartrate in 53 selected cases, found that 57 per cent of these had what he called an ''undisturbed puerperium.'' Of 53 con· trol patients only 6 per cent had an "undisturbed puerperium." By a "disturbed puerperium,'' Siihs refers to an abnormal change in the lochia or a delay in the involution of the uterus.
The following factors were considered in this study: Length of time in labor, number of vaginal examinations, method of delivery, weight of child, and complicating, nonobstetrical conditions. 'J.1he length of time in labor varied from twenty-five minutes to fifty-nine and two-thirds hours. The distribution in the various groups is best shown in Table I. TABLE
I.
DURATION OF LABOR IN HOURS AND MINUTES
MULTIPARAS SHOR'l'
Control Ergot
LONG
--1.15 47.20 2.0 59.40 0.25 58.55
PRIMIPARAS SHORT
LONG
MULTIPARAS SHORT
LONG
~
6.0 4.0
24.0 57.35
272
3.15 1.20
29.05 27.35
PRIMIPARAS SHORT
LONG
7.lil 35.05 30.55 6.15
45.0 57.15
DER BRUCKE :
ERGOT IN PUERPERAL PROPHYLAXIS
273
Routine vaginal examinations are not sanctioned on our service. However, when indicated, under proper aseptic precautions, they may be done. Rectal examinations are employed to follow the progress of labor. There were 149 spontaneous deliveries, 9 forceps and 13 breech. There were two sets of twins. There were two stillbirths, one due to an unrecognized, prolapsed cord, the other followed a forceps delivery. Manual removal of the placenta was resorted to in one case. The smallest baby weighed 1,800 gm., and the largest 4,840 gm.; 44 per cent of all our babies weighed over 3,600 gm.
lll4S,7691011
I'IIElPERIUM
DAYS
FIG. I
Among the complicating conditions, there was one case of old tuberculosis, with a bronchopneumonia, one case of aeute tonsilitis which set in on the tenth day, one of typhoid fever, and one patient with lobar pneumonia was admitted in labor. There were two acute mastitis cases and two of acute pharyngitis. Although the weight of the baby, the length of time in active labor, the amount of manipulation, the mode of delivery all play an important role in the morbidity of the lying-in period, still the gauge for such morbidity is the temperature. The choice in this study, of an arbitrary line of demarcation between a normal temperature and a morbid temperature presented a problem. It seemed unjust to call only such patients with a tempera-
274
AMERICAN JOURNAl, OF OBSTETHICS AND GYNECOLOGY
ture of 100.4° P. on two successive days other than the first, as being morbid, when 16, or almost one-third of all the fluid extract of ergot series had a temperature range of 99 ° P. to 99.8 ° F. from two to five days during· the lying-in period. A like situation existed in the control series. In striking contrast, only 13.4 per cent of all those receiving erg·otamine tartrate had a temperature on any two or more days of 99° P. or 99.8° P. Hampton and Wharton in 1920, reviewing a series of embolic deaths, found one positive factor, which was a persistent temperature of from 99• F. to 100• F. They concluded that such temperature indicated a low grade infection somewhere. They quoted similar statements by Michaelis, G. Petren, and Mahler.
If we followed the accepted standard, our total morbidity in this series would have been 3.5 per cent. We believe that this is a fair ll
I
- I tt
14 IS
~'""~ G:~:~N~~~
+
PI.IMIPAI.AE AVEI.'-GE
OF UTIRUS
ft
~
,..:._
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~IG . 3
result, when we consider the overcrowding in our wards and the size and weight of our babies. Lochia.-All cases in the control series had some lochia at the time of their discharge on the eighth to the tenth day of the puerperium. Lochia rubra was present in over 79 per cent of the cases. In no case was there an absence of the lochia. In 4 cases it was termed scant. Forty per cent of the fluid extract of ergot cases showed an absence or change in the character of the lochia at the time of discharge as compared with 30 per cent of the ergotamine series. How-
l-It
DER BRUCKE:
ERGOT IX f'rERPERAL PROPIJYLAXI~
·>7:">
ever the latter group showed a scanty lochia in 61 per cent of the patients in contrast to 46 per cent of the fluid extract of ergot ease:s. The importance of this is readily seen in a reYit-w of the temperatnr1• charts. The ergotamine tartrate group had a eorreeted morbidity, according- to the stricter classification, of 14.9 JWr cent as compar·ed with a 40 per cent and 53 per cent, respeetiYely. in the fluid t>xtrHet of erg·ot and control series. \Vith regard to inyolution under such stimulatic·n, the general aver~ age for all seems to show a better involutionary rt>Hponse to ergotamint:• tartrate. 'I' his is more evident in the multipara ( B'igs. 1 and 2). In~ volution in the primipara. howevet', Sf'f•ms to progre:.;s better wht>n left alonP. (Fig. 3.) SUM:VIARY
]n a :.;eries of 169 consecutive parturients delivered under the same conditions we find that many patients had a mild temperature, 11ot high enough to be put in the accepted morbidity group, yet of sufficient per~-;istence to make one realize that all was not quite well. In the group with the greatest number of temperature cases ( 53.15 per cent, the control group), lochia rubra persisted beyond normal ex~ peetancy; there was some form of lochia present at the timf' of dis~ charge, and involution had not progrefised as W<'ll in the multiparas as in the primiparas. The administration of ergot and more particularly its alkaloid. ergotamine tartrate, prophylactically, hastened involution, lessened lochia rubra, and clweked lo<:hial diRcharge by thP tenth day. CONCLUSIONS
From this study it would seem justifiablP to rlraw the following conclusions: 1. The administration of ergot or its alkaloid. ergotamine tartrate, during the first three days of the puerperium hastens involution and lessens the lochial discharge during the parturient's stay in the hos~ pita!. Ergotamine tartrate, as shown by this study, accomplishes this better than the usual preparations of ergot. 2. Our series, of course, is too small to warrant definite conclusions. We believe, however, that enough positive data haYe been presented to warrant further investigation of tlw use of oxytocics during the puerperium. I wish to thank Dr. Harvey B. Matthews, Director of
th•~
ObFtetric Departnwnt.
for his interest and suggestions in the preparation of this paper. 901 WASHINGTON AVENUE
REFERENCES
l. Siih.~, .J.: Med. J. & Rec. 86: 468, 1932. .Johns Hopkins Hosp. 31: 9i}, 1920.
(2) Hampton and Wha·rfvn: BulL