Background: Epicardial coronary artery spasm (CAS) is a frequent and important cause of myocardial ischemia. We aimed to develop and validate a noninvasive, artificial intelligence (AI)-driven risk score using routine clinical data to predict CAS in patients without obstructive coronary artery disease (CAD). Methods: This retrospective study analyzed a derivation cohort of 1050 patients and an external validation cohort of 600 patients who underwent intracoronary methylergonovine provocation testing between September 2008 and March 2025. A random forest (RF) model was developed using 15 clinical variables and simplified to a nine-variable model. Additionally, a convolutional neural network-long short-term memory (CNN-LSTM) deep learning model was implemented to predict CAS from raw digital electrocardiogram data (2611 electrocardiogram records). Results: The final nine-variable RF model, including predictors such as diastolic/systolic blood pressure, age, BSA, hemoglobin, smoking, heart rate, sex, and estimated glomerular filtration rate, demonstrated strong discriminatory power. The area under the curve was 85.8% (95% confidence interval [CI]: 85.8-89.9%) in the derivation cohort and 84.1% in the validation cohort (95% CI: 80.6-87.7%). A dose-response relationship was confirmed, with CAS prevalence increasing from 42.1% (0-1 risk factors) to 82.4% (≥5 risk factors). The electrocardiogram-based CNN-LSTM deep learning model achieved high sensitivity (91.4%) but limited specificity (11.9%); therefore, it should be considered a proof of concept rather than a clinical screening tool until further refinement is achieved. Conclusions: The nine-variable RF model provides a practical and accurate tool for early identification and risk stratification of CAS. The electrocardiogram deep learning model complements the RF model to improve clinical decisions and resource allocation in diagnosing CAS.

Major postpartum hemorrhage (PPH) continues to be a significant contributor to maternal health complications, and rapid control of bleeding is essential to prevent hemodynamic instability and the need for surgical intervention. The JADA[®] uterine vacuum system has been increasingly adopted as a primary tool to manage PPH caused by uterine atony. Although reported success rates are high, particularly when used early, device failure can still occur and requires timely escalation of care. We present the case of a 30-year-old woman, gravida 3 para 2, who developed major PPH following a spontaneous vaginal delivery at term. Her bleeding was attributed to uterine atony and persisted despite the administration of multiple uterotonic agents, including Pitocin, methylergonovine, Hemabate, rectal misoprostol, and tranexamic acid. A JADA[®] device was placed but did not achieve adequate hemorrhage control. A second JADA[®] device was subsequently inserted, yet bleeding continued. The patient required transfusion of packed red blood cells and was taken emergently to the operating room for a supracervical hysterectomy, after which her condition stabilized. This case demonstrates sequential JADA[®] device failure in the setting of major PPH and emphasizes the need for clinicians to promptly recognize insufficient response, understand the limitations of uterine vacuum systems, and be prepared to escalate to surgical management when bleeding persists. As the JADA[®] device becomes further integrated into PPH algorithms, documenting real-world experiences with device failure is essential for refining clinical expectations, improving patient care, and reducing mortality.

A woman in her early 30s with a twin pregnancy conceived through ovulation induction underwent elective caesarean delivery at term. Soon after administration of intramuscular methylergometrine (0.2 mg) for mild postpartum bleeding, she developed sudden, severe chest pain with breathlessness. Her ECG showed diffuse ST-segment depression with reciprocal elevation in aVR, and cardiac enzymes were raised. Echocardiography revealed mild left ventricular hypokinesia, while coronary angiography demonstrated normal arteries. She responded promptly to nitrate therapy and supportive care. The temporal relationship between methylergometrine administration and symptom onset, together with angiographically normal coronaries, confirmed coronary vasospasm secondary to methylergometrine. This case underscores the need for careful cardiovascular monitoring when vasoconstrictive uterotonics are used in the postpartum period, particularly in women with predisposing factors such as multiple gestation.

The management of immediate and delayed postpartum hemorrhage with cesarean delivery presents specific challenges in diagnosis and treatment. Real-time monitoring and quantitation of intraoperative and postoperative blood loss facilitate rapid recognition of immediate or delayed abnormal bleeding, enabling timely intervention. Effective response to ongoing postpartum hemorrhage depends on clear communication and collaboration among the nursing, obstetric, and anesthesiology teams. Medical management involves multiple courses of uterotonics and associated resuscitative measures, which should be applied concurrently with surgical interventions if needed (targeted sutures, vessel ligation, uterine compression sutures, and, in the most severe cases, peripartum hysterectomy). Surgical injuries, such as unintended extension of the hysterotomy leading to uterine vascular pedicle injury, are among the most frequent causes of postpartum hemorrhage during or after cesarean delivery. In these cases, bleeding may occur in the intra-abdominal or retroperitoneal spaces and may not present as vaginal bleeding or be detectable with bedside ultrasound. Therefore, delayed postpartum hemorrhage should be considered a likely cause of any alteration in maternal clinical condition in the hours after cesarean delivery, even without vaginal bleeding or intra-abdominal fluid on ultrasonography. Relaparotomy remains the gold standard for diagnosing and treating suspected intra-abdominal or retroperitoneal bleeding and should be performed without unnecessary delays. Intrauterine devices, such as tamponade balloons or vacuum-induced control systems, have not been sufficiently evaluated during cesarean delivery, and uterine-sparing surgical procedures should be considered for managing refractory postpartum hemorrhage after cesarean. However, these devices may be useful to temporize bleeding until surgical control of bleeding is attained. Similarly, arterial embolization requires time and is feasible only for hemodynamically stable patients with slow persistent bleeding. We propose management algorithms for 2 types of postpartum hemorrhage associated with cesarean delivery: perioperative immediate hemorrhage and postoperative delayed hemorrhage.

Background: The lack of an accurate coronary artery spasm (CAS) risk prediction model highlights the failure to consider dynamic coronary health and reveals a gap in understanding CAS. Methods: A total of 913 Taiwanese patients (460 women and 453 men) with suspected ischemic heart disease but without angiographic obstructive coronary artery disease were subjected to intracoronary methylergonovine testing during the period 2008-2025. Results: The study included 645 CAS cases (70.6%) and 268 non-CAS controls (29.4%). The multivariable logistic regression model identified 10 variables significantly associated with CAS (p < 0.05): male sex, smoking, low systolic and diastolic blood pressure, reduced B-type natriuretic peptide levels, elevated low-density lipoprotein levels, increased relative wall thickness at end-systole, high left ventricular mass index, low e'(l) values, and high Tei index. Discrimination performance was moderate, with an AUC value of 73.8% that dropped to 72.4% after bootstrapped internal validation, suggesting the potential generalizability of the derived model. The total score ranged from 36 to 98, representing a predicted probability between 12% and 98%, respectively. Conclusions: While a total score of ≥58 with the probability of CAS exceeding 50% indicates a significant chance of undiagnosed CAS, for patients with a total score ≥ 69 and a high probability of CAS ≥ 75%, coronary catheterization with CAS provocation testing is strongly recommended for a definite diagnosis. The simple 10-variable scoring model allows ranking of at-risk populations and is designed to be used as a screening tool rather than a diagnostic adjunct, enabling more efficient diagnostic resource allocation.

Limited information indicates that maternal doses of methylergonovine up to 0.75 mg daily produce low levels in milk. Product labeling in the U.S. currently recommends avoiding breastfeeding for 12 hours following the last dose of methylergonovine. This warning appears to be based on unpublished adverse reactions in breastfed infants after several days of maternal methylergonovine therapy. The use of shorter courses of the drug after delivery during the colostral phase of lactation are not expected to transfer appreciable amounts of drug to the breastfed infant or risk adverse effects in the infant. The lack of infant side effects was documented in one case-control study. Long courses of methylergonovine, especially after the milk comes in, are best avoided in mothers who wish to nurse. When they are required, withholding breast feeding for 12 hours following the last dose of methylergonovine is prudent. If adverse reactions in the breastfed infant are seen, such as tachycardia, vomiting, diarrhea or agitation, the drug should be discontinued. Some sources recommend avoiding methylergonovine altogether during breastfeeding.[1] Although results of several imperfect studies are somewhat mixed, it appears that methylergonovine can decrease serum prolactin and possibly the amount of milk production and duration of lactation, especially when used in the immediate postpartum period. The effect seems to be related to the dosage and route of administration, with injected doses having a greater impact than oral. A short course immediately postpartum does not appear to have a detrimental effect on lactation.

Coronary artery spasm (CAS) is a reversible vasoconstriction of normal or atherosclerotic epicardial coronary arteries with a subsequent reduction in myocardial blood flow, leading to myocardial ischemia, myocardial infarction, severe arrhythmias, or even sudden death. It is an entity that should be recognized based on a particular clinical presentation. Numerous differences exist between CAS and obstructive coronary disease in terms of mechanisms, risk factors, and therapeutic solutions. The gold standard for CAS diagnosis is represented by transitory and reversible occlusion of the coronary arteries at spasm provocation test, which consists of an intracoronary administration of Ach, ergonovine, or methylergonovine during angiography. The pathophysiology of CAS is not fully understood. However, the core of CAS is represented by vascular smooth muscle cell contraction, with a circadian pattern. The initiating event of this contraction may be represented by endothelial dysfunction, inflammation, or autonomic nervous system unbalance. Our study explores the intricate balance of these factors and their clinical relevance in the management of CAS.

This study aimed to evaluate the time to uterotonic administration before and after the implementation of an obstetric hemorrhage (OBH) bundle.This is a retrospective cohort study of deliveries at an urban tertiary care hospital before and after the implementation of an OBH bundle. Two groups were compared on time from delivery to the first dose of postpartum uterotonic intervention. Secondary outcomes included a total number of uterotonics, transfusion rates, and utilization of nonuterotonic hemorrhage interventions including uterine artery embolization and balloon tamponade.Of the 4,275 deliveries of live births included in this study, 1,944 occurred preintervention and 2,331 occurred postintervention. The mean time to oxytocin decreased from 12.2 to 5.9 minutes after implementation of the bundle (p < 0.01). Postintervention deliveries received significantly more second-line uterotonics when compared to preintervention deliveries (p < 0.01).Implementation of an OBH bundle was associated with improved management as reflected in faster and increased delivery of uterotonic interventions for hemorrhage. Future studies should continue to explore the effect of hemorrhage bundle protocols on hemorrhage-related process measures. · Oxytocin was administered more rapidly with OBH bundle use.. · Oxytocin was administered more frequently with OBH bundle use.. · Methylergonovine was administered more frequently with OBH bundle use..

Background and Objectives: We aimed to evaluate the current uterotonic administration practices among anesthesiologists and obstetricians and gynecologists (OBGYNs) during cesarean section (CS), focusing on variations in approaches for low- and high-risk postpartum hemorrhage (PPH) cases. The objective was to identify key differences and provide evidence that could contribute to the development of standardized national protocols for uterotonic usage. Materials and Methods: A snapshot online survey was employed between October 2021 and January 2022 and distributed to anesthesiologists and OBGYNs from university-affiliated, government, and private hospitals across Turkey, consisting of 23 questions addressing demographic data, institutional PPH rates, first-line uterotonic choices, administration methods, and dose adjustments for low- and high-risk PPH cases. Specific questions also targeted uterotonic usage in the presence of comorbidities such as pre-eclampsia and cardiac disease. Results: There were 204 responses (54% anesthesiologists and 46% OBGYNs) out of 220, yielding a response rate of 92.7%. Oxytocin was the most common first-line uterotonic for CS with low-risk PPH (99.1% of the anesthesiologists and 96.8% of the OBGYNs). In total, 60% of the anesthesiologists favored an intravenous (IV) bolus followed by infusion, while 56.4% of the OBGYNs preferred IV infusion alone (p < 0.001). For CS with high-risk PPH, approximately half of the participants reported increases in oxytocin dose, while 26.4% of the anesthesiologists and 20.2% of the OBGYNs opted for combined oxytocin and carbetocin use. During intrapartum CS, 69.1% of anesthesiologists and 77.7% of OBGYNs reported no change in dose. However, 11.8% of the anesthesiologists indicated combining oxytocin and carbetocin (p < 0.05). In managing pre-eclampsia and cardiac disease, the anesthesiologists were likely to reduce uterotonic doses (15.5%) and avoid methylergonovine (35.5%) compared to the OBGYNs, who reduced doses less frequently (4.3%), but 79.8% of the OBGYNs avoided methylergonovine (p < 0.001). Conclusions: There was considerable variability in uterotonic administration practices between the anesthesiologists and OBGYNs.

Methylergometrine has widely been used pharmacologically to treat conditions such as pain, addiction, vasoconstriction, migraines, and Parkinson's disease. Despite its side effects, it is used as a therapeutic agent and research material for various diseases based on its natural potential; however, the regulatory effect of its interaction with the nicotinic acetylcholine receptor (nAChR) has not yet been investigated. The α3β4 nAChR is an ion channel essential for neurotransmission within the sympathetic, parasympathetic, and autonomic nervous systems. Inhibiting the α3β4 nAChR can suppress neural signaling, affecting physiological processes such as heart rate, blood pressure, and digestion. This inhibition also holds analgesic potential by blocking pain pathways. Additionally, because the α3β4 nAChR is linked to addiction, its inhibition may reduce dependence, offering promise for addiction therapies. Inhibiting the α3β4 nAChR may impact cardiovascular and gastrointestinal regulation, presenting therapeutic possibilities for related disorders. This study investigated methylergometrine's regulatory effects on the α3β4 nAChR using oocytes and a two-electrode voltage clamp. Methylergometrine inhibited α3β4 nAChR activity in a reversible, concentration-dependent, and non-competitive manner with the interaction of α3-and β4-subunit E175 and E51 residues. These findings indicate that methylergometrine modulates α3β4 nAChR function by interacting with specific ligand-binding sites, as evidenced by electrophysiological analysis. This study advances the pharmacological understanding of methylergometrine, elucidating its mechanism of action at the cellular level.