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Appropriate sedation minimizes endoscopy risks during pregnancy
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PHILADELPHIA – Minimal use of sedatives such as opiates minimizes risks during endoscopy in patients who are pregnant, making it relatively safe, according to a presenter at the American College of Gastroenterology Annual Scientific Meeting.
In his review, Joseph C. Anderson, MD, MHCDS, FACG, from the Dartmouth College Geisel School of Medicine in New Hampshire, provided an outline of safe vs. unsafe sedative options and recent data on increased risk from overexposure.
“The physiologic changes in pregnancy are well-known,” Anderson said during his presentation in the postgraduate course, referring to lab abnormalities such as low platelets, decreased gastric emptying due to progesterone, cholestasis due to estrogen, increased gallstone production, and change in abdominal anatomy due to fetal growth. “And all of those things can be manifested in common GI-related issues that we’ll see in our patients who are pregnant.”
Anderson first advised attendees to promote lifestyle changes and attempt non-endoscopic management of gastroesophageal reflux disease in patients who are pregnant. He said over-the-counter alkaline, calcium and magnesium formulas are relatively safe. Proton-pump inhibitors Prevacid (lansoprazole, GlaxoSmithKline) and Protonix (pantoprazole sodium, Pfizer) are also relatively safe, whereas Prilosec (omeprazole, Proctor & Gamble) has demonstrated embryonic toxicity.
The potential risks from endoscopy include over-sedation which can lead to hypotension and hypoxia in the mother. In turn, hypoxia in the mother can lead to hypoxia in the fetus. The fetus can also be exposed to potentially dangerous medications or radiation, he said. Finally, maternal positioning can cause inferior vena caval compression by pregnant uterus, decreased uterine blood flow, and fetal hypoxia.
Results from a recent study showed that exposure to any endoscopy during pregnancy correlated with an increased risk for preterm birth (adjusted relative risk = 1.54; 95% CI, 1.36-1.75) and small for gestational age (ARR = 1.3; 95% CI, 1.07-1.57). However, endoscopy during pregnancy was not associated with congenital malformation or stillbirth.
Commonly used sedatives with safe or low-risk status include propofol and the opiates Demerol (meperidine, Pfizer) and fentanyl. Benzodiazepines, however, have been associated with poor outcomes, including an association of cleft palate and neurobehavioral issues with diazepam.
Anderson highlighted a recent FDA report that warned that repeated or lengthy use of general anesthetic and sedation drugs during surgeries and procedures in children aged younger than 3 years or in pregnant women in their third trimester may affect the child’s brain development.
Based on the FDA warning, the American College of Obstetricians and Gynecologists recommends use of non-implicated agents such as opioids, minimized duration of exposure, and minimized induction.
“If you’re going to be doing procedures [in pregnant patients], try to make them as short and quick as possible and give as little sedation as you can,” Anderson explained. “The important thing I want you to walk away with is that there are general principles that you should follow.”
Anderson noted a recommendation from ACOG and the American Society of Anesthesiologists, which stated that it is important for a physician to obtain an obstetric consultation before performing non-obstetric surgery or invasive procedures.
In the conclusion of his review, Anderson explained that a pregnant woman should never be denied endoscopy regardless of trimester. However, elective surgery should be postponed until after delivery and non-urgent surgery should be performed in the second trimester if possible. – by Talitha Bennett
Reference:
Anderson J. Endoscopy and Sedation in Pregnancy. Presented at: American College of Gastroenterology Annual Scientific Meeting; Oct. 5-10, 2018; Philadelphia.
Disclosure: Anderson reports no relevant financial disclosures.