PEDIATRICS Vol. 98 No. 3 September 1996, pp. 457-458
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Accidental Administration of an Ergot Alkaloid to a Neonate

Carl R. Baum MD1, Pamela L. Hilpert MD, PhD2, and Vinod K. Bhutani MD3

1 Children's Hospital, Boston, MA 02115
2 Del Amo Diagnostic Center, Torrance, CA 90503
3 Pennsylvania Hospital, Philadelphia, PA 19107

We describe a neonate with altered splanchnic arterial blood flow after accidental substitution of an ergot alkaloid, methylergonovine maleate (MEM), for vitamin K1.

CASE REPORT

A 2977-g female product of a full-term pregnancy was born in a hospital birthing suite via spontaneous vaginal delivery to a 26-year-old gravida 6, para 5 mother. Apgar scores were 9 at 1 minute (–1 for color) and 9 at 5 minutes (–1 for color). At approximately 90 minutes of age, the neonate was inadvertently administered 0.5 mL (0.1 mg) of MEM instead of phytonadione (vitamin K1) via intramuscular injection. The error was recognized during administration of a 1-mL premeasured adult dose of the ergot derivative, intended for control of postpartum uterine hemorrhage.

Submitted on September 1, 1995
Accepted on November 3, 1995