CASE REPORT |
https://doi.org/10.5005/jp-journals-10049-2051 |
Anesthesia Management in Pregnant Patient Posted for Endoscopic Retrograde Cholangiopancreatography
1,2Department of Anesthesia, Seth Gordhandas Sunderdas Medical College (GSMC) and the King Edward Memorial (KEM) Hospital, Mumbai, Maharashtra, India
Corresponding Author: Mahalakshmi Ethiraj, Department of Anesthesia, Seth Gordhandas Sunderdas Medical College (GSMC) and the King Edward Memorial (KEM) Hospital, Mumbai, Maharashtra, India, Phone: +91 9710059400, e-mail: mahalakshmiethiraj94@gmail.com
Received: 29 February 2024; Accepted: 12 July 2024; Published on: 18 December 2024
ABSTRACT
Pregnancy and its resultant physiologic changes cause the gallbladder volume to double, the emptying rate to slow, and motility impairment, resulting in saturation of cholesterol, which contributes to the ideal environment for gallstone formation. Gallstones can lodge in the common bile duct (CBD) and hence can cause choledocholithiasis.
A case of cholelithiasis in the second trimester of pregnancy was complicated by choledocholithiasis and abdominal pain. Treatment was safely achieved using endoscopic retrograde cholangiopancreatography (ERCP), which was done under total intravenous anesthesia (TIVA).
Keywords: Case report, Choledocholithiasis, Fluoroscopy, Pregnancy, Total intravenous anesthesia
How to cite this article: Ethiraj M, Chaskar VP. Anesthesia Management in Pregnant Patient Posted for Endoscopic Retrograde Cholangiopancreatography. Res and Innov Anesth 2024;9(2):58–60.
Source of support: Nil
Conflict of interest: None
Patient consent statement: The author(s) have obtained written informed consent from the patient for publication of the case report details and related images.
INTRODUCTION
Symptomatic gallstones disease during pregnancy is the second most common abdominal surgery.1,2 The incidence of gallstone formation during pregnancy is 3–12%.3,4 This risk is higher with each pregnancy, and multiparous women are ten times more likely to develop biliary complications.5 This is a life-threatening situation for both mother and fetus, which requires immediate intervention such as endoscopic retrograde cholangiopancreatography (ERCP). We report a case of anesthetic management of symptomatic choledocholithiasis in a pregnant patient who underwent therapeutic ERCP.
CASE DESCRIPTION
A 32-year-old female patient, who was 23 weeks of gestation (G3P2L2), presented with complaints of pain in the right side of the abdomen, radiating to the back for the past 5 days, and associated with vomiting, fever, and chills. Her ultrasound suggested multiple gallbladder calculi, around 8 mm in size, with a thickened wall, and the common bile duct (CBD) dilated to 15 mm at the portal with mild central intrahepatic biliary radical dilation and a terminal calculus measuring 13 × 7 mm. The pancreas appeared normal, and a single live fetus in the uterus had a normal heart rate. The mother was scheduled for therapeutic ERCP. A preanesthetic evaluation was conducted, and she was thoroughly assessed by the anesthesiology team. Laboratory investigations were within normal limits, except for deranged liver enzymes: serum aspartate transaminase 73 IU/L, serum alanine transaminase 43 IU/L, and alkaline phosphatase 250 U/L. The patient was classified as grade II according to the American Society of Anesthesiologists (ASA) grading.
On the day of the procedure, a preprocedure fetal Doppler was performed, and the heart rate was recorded at 152 bpm, which was within normal limits according to the obstetrician. The anesthesia technique decided was total intravenous anesthesia (TIVA) for this procedure. After obtaining written informed high-risk consent and confirming adequate fasting, the patient was taken to the endoscopic room. Standard ASA monitors, including a pulse oximeter, noninvasive blood pressure (NIBP), end-tidal carbon dioxide (EtCO2), and electrocardiogram (ECG), were attached. The patient was placed in the left lateral position. Oxygen at 6 L/minute via nasal prongs was administered throughout the procedure to maintain SpO2 above 95%. End-tidal CO2 was also monitored by attaching the capnometer sample line near the nostril. A 20 G peripheral intravenous cannula was secured, and Ringer’s lactate solution was started at 2 mL/kg/hour. The patient was medicated with intravenous ondansetron 4 mg to prevent vomiting, fentanyl 50 µg, and propofol 100 mg in titrated dosages to achieve deep sedation with spontaneous ventilation. The procedure lasted 40 minutes, during which selective CBD cannulation and biliary sphincterotomy were performed by a senior gastroenterologist. Fluoroscopy was used only once during the procedure to confirm the guidewire’s position in the CBD. Periprocedure, the patient was vitally stable, and the course of anesthesia was uneventful. The obstetrician performed a postoperative fetal Doppler, and the heartbeats were recorded as normal. The patient was discharged the next day after 24 hours of observation. A healthy baby girl was delivered at 38 weeks of gestation by normal vaginal delivery.
DISCUSSION
The risk of aspiration is 0.08% due to reduced gastric barrier pressure and lower esophageal sphincter tone (a progesterone effect).6,7 Prophylaxis against aspiration pneumonitis should be administered from 16 weeks of gestation with H2-receptor antagonists and nonparticulate antacids.
Tham et al.’s study has proven the safety and efficacy of therapeutic ERCP in pregnant patients, though the potential risks of ERCP should not be underestimated.5,8 Risks of any procedure in the second trimester include fetal complications such as low birth weight, intrauterine growth retardation, and preterm delivery. Maternal complications may include severe pancreatitis, perforation, bleeding, and cholecystitis.
Only emergency situations in the second trimester are considered for intervention. Common indications for performing therapeutic ERCP during pregnancy are symptomatic choledocholithiasis, obstructive jaundice, biliary pancreatitis, and cholangitis.1,9 The patient was having gallstones with symptoms, which constituted an emergency situation, so she was scheduled for therapeutic ERCP as it could not be managed conservatively. ERCP during the second trimester is relatively safer than during the first trimester.
According to the risk–benefit ratio, TIVA was administered. The worldwide accepted method is deep sedation in the presence of an anesthetist without intubation. Intubation is recommended only in exceptional cases. Sedation is the most commonly practiced anesthetic technique.10,11 General anesthesia and endotracheal intubation with controlled ventilation increase the risk associated with a physiologically difficult airway due to pregnancy. Deranged liver function can delay recovery and increase morbidity as well. Most anesthetic drugs, such as barbiturates, propofol, opioids, muscle relaxants, and local anesthetics, have been widely used during pregnancy with a good safety record.12 Fentanyl and propofol are Category B drugs, which have a rapid onset and short duration of action. Both were administered in titrated dosages to avoid respiratory depression and hypotension. Low doses of these drugs do not have any recorded fetal growth abnormalities. Continuous monitoring included electrocardiography, pulse oximetry, intermittent sphygmomanometry, and EtCO2.
In patient positioning, care must be taken to avoid uterine compression on the inferior vena cava.1 However, a left pelvic tilt is also acceptable. Prone positions are avoided in advanced pregnancy, as they are poorly tolerated by the patient.13 None of the studies clearly state that the prone position should be avoided in the second trimester. The prone position is recommended based on patient tolerance.
According to the American College of Obstetricians and Gynecologists, exposure of <5 rad or 50 mGy does not appear to be associated with an appreciable increase in the rate of fetal anomalies, pregnancy loss, or childhood leukemia.14,15 Thus, the use of fluoroscopy was restricted to avoid fetal radiation exposure.
In the Kahaleh et al.’s study, conceptus dosing was estimated at 0.40 mGy using thermoluminescent dosimetry readings.16 The senior gastroenterologist performed the procedure to complete it within a short span of time.
Complicated gallstone disease in pregnancy can lead to preterm delivery and fetal loss. Therefore, interventional procedures like ERCP, as seen in this case, are essential for the timely management of both maternal and fetal well-being.
CONCLUSION
Anesthesia for a pregnant patient undergoing an ERCP procedure is a challenging process that must ensure safety for both mother and fetus. Multidisciplinary management, such as in a tertiary setup, contributes to the successful and safe induction and maintenance of anesthesia during the procedure.
ORCID
Vaishali P Chaskar https://orcid.org/0000-0002-3479-7359
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