Background: Oxytocin is a xenobiotic that increases intracellular calcium concentrations, and is often administered to postpartum women to augment uterine
contraction. There is one published case report of an accidental intramuscular administration of oxytocin to a newborn infant resulting in transient apnea, bradycardia, and hyponatremia. We present 2 cases of neonates accidentally injected intramuscularly with adult doses of oxytocin, neither of which had a negative clinical outcome.
Case Report: In our first case a newborn infant female was given 10U intramuscular oxytocin in the first hour of life. The oxytocin was mistaken for vitamin K. The child did well, and throughout the hospital stay the electrolytes and vital signs remained within normal limits. In the second case a newborn infant female was given 5U intramuscular oxytocin, again in the first hour of life. This time the oxytocin was mistaken for the hepatitis B vaccine. This child also did
well, with stable normal vital signs, and 3 normal serum sodium levels all between 137 and 139 mEq/L.
Case discussion: To our knowledge there is one other published case of oxytocin, as a single agent, being accidentally administered to a neonate. The oxytocin was given in the place of the intended drug, vitamin K. In that case the patient developed decreased urine output, hyponatremia, along with mild episodes of apnea and bradycardia. Our cases represent the second and third examples of accidental oxytocin administration to neonates, and both had benign outcomes. There are 4 published cases of accidental administration of Syntometrine, a combination of oxytocin and ergonovine, to newborns. In these cases the children did develop adverse effects and one child expired. In each of these 4 cases the oxytocin was mistaken for vitamin K. There are also published cases of neonates developing adverse effects after pre-delivery administration of oxytocin to the mother.
Conclusion: The published reports of accidental administration of oxytocin, as a single or combination agent, to neonates lead us to believe that adverse side effects are to be expected. Our cases, however, suggest that some neonates may tolerate an accidental injection very well.