From the Editor

Farewell to indigo carmine

OBG Manag. 2014 September;26(9):8, 9

References

1. Indigo carmine injection. American Society of Health-System Pharmacists (ASHP) Web site. http://www.ashp.org/menu/DrugShortages/CurrentShortages/Bulletin.aspx?id=861. Updated July 29, 2014. Accessed August 21, 2014.

2. Lin BL, Iwata Y. Modified cystoscopy to evaluate unilateral traumatic injury of the ureter during pelvic surgery. Am J Obstet Gynecol. 1990;162(5):1343–1344.

3. Lee M, Sharifi R. Methylene blue versus indigo carmine. Urology. 1996;47(5):783–784.

4. Thompson JD. Operative injuries to the ureter: prevention, recognition and management. In Rock JA, Thompson JD, eds. TeLinde’s Operative Gynecology. Philadelphia, PA: Lippincott Williams & Wilkins; 1997:1155.

5. Wang AC. The techniques of trocar insertion and intraoperative urethroscopy in tension-free vaginal taping: an experience of 600 cases. Acta Obstet Gynecol Scand. 2004;83(3):293–298.

6. Boyer EW, Shannon M. The serotonin syndrome. N Engl J Med. 2005;352(11):1112–1120.

7. Shah-Khan MG, Lovely J, Degnim AC. Safety of methylene blue dye for lymphatic mapping in patients taking selective serotonin reuptake inhibitors. Am J Surg. 2012;204(5):798–799.

8. Ng BK, Cameron AJ. The role of methylene blue in serotonin syndrome: a systematic review. Psychosomatics. 2010;51(3):194–200.

9. Hui JY, Harvey MA, Johnston SL. Confirmation of ureteric patency during cystoscopy using phenazopyridine HCl: a low-cost approach. J Obstet Gynaecol Can. 2009;31(9):845–849.

10. Moore CR, Shirodkar SP, Avallone MA, et al. Intravesical methylene blue facilitates precise identification of the diverticular neck during robot-assisted laparoscopic bladder diverticulectomy. J Laparoendosc Adv Surg Tech A. 2012;22(5):492–495.

11. Mhaskar R, Mhaskar AM. Methemoglobinemia following chromopertubation in treated pelvic tuberculosis. Int J Gynaecol Obstet. 2002;77(1):41–42.

12. Rzymski P, Wozniak J, Opala T, Wilczak M, Sajdak S. Anaphylactic reaction to methylene blue dye after laparoscopic chromopertubation. Int J Gynaecol Obstet. 2003;81(1):71–72.

13. Dewachter P, Mouton-Faivre C, Trechot P, Lieu JC, Mertes PM. Severe anaphylactic shock with methylene blue instillation. Anesth Analg. 2005;101(1):149–150.

14. McFadyen I. The dangers of intra-amniotic methylene blue. Br J Obstet Gynaecol. 1992;99(2):89–90.

15. Van der Pol JG, Wolf H, Boer K, et al. Jejunal atresia related to the use of methylene blue in genetic amniocentesis in twins. Br J Obstet Gynaecol. 1992;99(2):141–143.

16. Kidd SA, Lancaster PA, Anderson JC, et al. Fetal death after exposure to methylene blue dye during mid-trimester amniocentesis in twin pregnancy. Prenat Diagn. 1996;16(1):39–47.

17. Hobbins JC, Winsberg F, Blanchett M, et al. Section 5: fetal imaging. Prenat Diagn. 1981;1(5):35–38.

Option to test patency of the fallopian tubes (chromopertubation)
Methylene blue. If methylene blue is used via a cannula in the uterine cavity to test the patency of the fallopian tubes, I recommend diluting 10 mg methylene blue in 150 mL normal saline and using the dilute solution to test tubal patency.

It is unlikely that this process will lead to sufficient methylene blue absorption to cause a serotonin syndrome. Therefore, this technique can be used in patients taking SSRIs, SNRIs and MAOIs. However, if intrauterine injection of the dilute dye solution results in extravasation of the dye into the pelvic veins, a significant amount of dye can enter the circulation.¹¹ There are case reports of anaphylaxis following intrauterine injection of methylene blue to test tubal patency.^12,13

Options to diagnose PROM and to use for twin amniocentesis
None. Most experts recommend against the intra-amniotic injection of methylene blue to diagnose PROM or in twin amniocentesis procedures. Methylene blue injected into the intra-amniotic fluid during amniocentesis in multiple gestations has been reported to cause fetal bowel obstruction or atresia.^14,15 Fetal death also has been reported.¹⁶ Decades ago, indocyanine green, which is FDA approved to determine cardiac output, liver blood flow, and hepatic function, was reported to be useful to mark one sac of a twin gestation during amniocentesis.¹⁷ With modern ultrasonography technology, the need to rely on a dye to mark a sac of a twin has decreased significantly.

Our only option is to cope—effectively as possible Over decades, the medical community develops patterns of patient care that are critically dependent on the availability of key pharmaceuticals and devices. When a pharmaceutical or device suddenly becomes unavailable, it can disrupt important patterns of patient care. Imagine the impact on obstetrics practice if oxytocin became unavailable due to manufacturing shortages. Likely, both market forces and government regulation are the root cause of the shortfalls. Preventing the adverse consequences of the sudden loss of key pharmaceuticals and devices is an important priority to ensure optimal care of our patients.

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