21 weeks prego needs a colonoscopy

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turnupthevapor said:
tommorow am, what do you think the plan should be? RSI GA vs midaz and fent maintaining airway reflexes?????? Let me know what you all think🙂
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titrate a little propofol just like you do for every other colonoscopy with gerd. Oh, did I just fail my oral boards? 🙂
 
turnupthevapor said:
tommorow am, what do you think the plan should be? RSI GA vs midaz and fent maintaining airway reflexes?????? Let me know what you all think🙂
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Pent. Sux. Tube.:laugh:

Kidding...OK, since as an "attending" you posted, I guess you deserve a real response: I personally have done these with propofol only and have not had any problems (obviously if the patient is a 500lb 21 weeker with symptomatic GERD, then you'll have to go with GA). That said, you should always be ready for a GA in any pregnancy setting.... Risk of aspiration is real and you would have no grounds to stand on, should anything go wrong....
 
proman said:
No midaz. If the kid has a cleft palate they'll blame you (without good reason). Propofol only. But why does a pregnant woman need a colonoscopy?
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my thoughts exactly why would a pregnant lady need a scope.. wait til she delivers... or if you must. secure the airway. tell her she may go into pre term labor . .and there may be teratogenic effects to the fetus.. she must understand those risks prior to going in. but do not sedate her. its either asleep with a tube or awake.
 
I am curious why she needs a colonoscopy so bad that we can't wait until she delivers?

If the indication does not involve a life or death situation (I don't think it does) then I would not be part of it.
 
Planktonmd said:
I am curious why she needs a colonoscopy so bad that we can't wait until she delivers?

If the indication does not involve a life or death situation (I don't think it does) then I would not be part of it.
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I think that is a pretty extreme view considering procedures of all kinds are done on pregnant women all the time with no (or VERY few) complications.
 
Planktonmd said:
What kind of procedures are being done routinely on pregnant women other than emergency surgery?
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Colonoscopies?:laugh:
I didn't say that they were not urgent or emergent procedures. Just that they were having procedures done all the time and the babies seem to do just fine. I would be fine doing this procedure if there was some reason to do it now, like non life threatening bleeding, worsening abdominal pain in the face of a history of intestinal disease, etc. I know the snake charmers will scope anything anytime for any reason, but I doubt that this procedure is in any way elective. I would insist on a doppler or US before and after though to show normal fetal HR. To suggest that it must involve a life or death scenario is extreme. But that's just my opinion.
 
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hoyden said:
SPINAL? for colonoscopy?
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lidocaine enema if the spinal fails 🙂

Agree with the fhr monitoring, at leats before and after...also will get the butt docs to consider just how important the procedure is.
 
Here is my justification for the option of spinal. First, I would not want to put an LMA, or ET tube in a pregnant female if I had to. I would like to avoid airway instrumentation, IE ET tube or LMA. Second, given that we are somewhat limited in the type of sedation, propofol only, I would avoid versed given the risk of cleft palate, I would avoid nitrous given risk of NT defects (any evidence of giving folate to mothers whom you would use nitrous). Third my thinking is to minimize patient movement. Given that we cannot use Versed in my limited experiance in order to aptly sedate a pregnant female with propofol to minimize movement we would raise her apneic threshold and in a spontaneous breathing female, we could be impairing oxygen delivery to the fetus as we know pregnant patients O2 consumption is high combined with a smaller dead space. So why not keep her spontaneously breathing, use a lidocaine spinal with minimal propofol sedation.
 
narcusprince said:
...Second, given that we are somewhat limited in the type of sedation, propofol only, I would avoid versed given the risk of cleft palate, I would avoid nitrous given risk of NT defects (any evidence of giving folate to mothers whom you would use nitrous) ... Given that we cannot use Versed in my limited experiance in order to aptly sedate a pregnant female with propofol to minimize movement we would raise her apneic threshold and in a spontaneous breathing female, we could be impairing oxygen delivery to the fetus as we know pregnant patients O2 consumption is high combined with a smaller dead space. So why not keep her spontaneously breathing, use a lidocaine spinal with minimal propofol sedation.
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You need not limit yourself to propofol. Versed/valium, etc may be relatively contraindicated during the first trimester, but this patient is half way through the 2nd trimester. I would have no problems giving her a large single dose of morphine and valuim. The baby's not going to retroactively develop a cleft palate, and if the kid is born with one, any expert in embryology could testify that it is impossible for the valium to have caused a cleft palate that would have already developed by this time (21 weeks). Variability in fetal development may be +/- a few days, but not many weeks.
I do this all the time for fetal procedures, they will be awake but really stoned. Add a NC or FM O2 and CO2 monitoring and you can titrate more morphine as needed. Prop-remi might be a reasonable choice, but it would probably be harder to titrate.
 
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IlDestriero said:
You need not limit yourself to propofol. Versed/valium, etc may be relatively contraindicated during the first trimester, but this patient is half way through the 2nd trimester. I would have no problems giving her a large single dose of morphine and valuim. The baby's not going to retroactively develop a cleft palate, and if the kid is born with one, any expert in embryology could testify that it is impossible for the valium to have caused a cleft palate that would have already developed by this time (21 weeks). Variability in fetal development may be +/- a few days, but not many weeks.
I do this all the time for fetal procedures, they will be awake but really stoned. Add a NC or FM O2 and CO2 monitoring and you can titrate more morphine as needed. Prop-remi might be a reasonable choice, but it would probably be harder to titrate.
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the right answer for the boards is to secure the airway.
why would you give a long acting opiate for a brief procedure that can cause nausea and vomiting?
spinal is a very interesting option. you wouldn't even need any sedation, as she wouldn't feel a thing. time to discharge may be prolonged, however, even with lidocaine. chlorprocaine may be a good choice.
 
Jeff05 said:
the right answer for the boards is to secure the airway.
why would you give a long acting opiate for a brief procedure that can cause nausea and vomiting?
spinal is a very interesting option. you wouldn't even need any sedation, as she wouldn't feel a thing. time to discharge may be prolonged, however, even with lidocaine. chlorprocaine may be a good choice.
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Remi and fentanyl would work fine, but would probably be harder (for me) to titrate in this scenario and you would greatly increase the risk of apnea, which I really wouldn't want to deal with in a pregnant woman in the lateral position. Also, I'm not confident that the scope would be the usual 15-20 min job, so longer acting meds are fine with me and nausea is a risk with any opiate. If a resident or fellow was not doing the scope, I might be tempted to use fentanyl. I use fentanyl and propofol for my routine colonoscopies, but I would want her to be more awake. No unsecured airway general anesthetics on pregnant women.
I have a lot of experience using M/V for fetal procedures of various length, so I would probably just use them for this scope. She could be discharged in a couple of hours, just like after a spinal +/- propofol.
 
Planktonmd said:
I am curious why she needs a colonoscopy so bad that we can't wait until she delivers?

If the indication does not involve a life or death situation (I don't think it does) then I would not be part of it.
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Let's say she has a problem and that it needs to be addressed while she is still pregnant. The GI doc, OB doc and pt. are all in agreeance that the procedure can't wait.

Are you still going to refuse to do the case?
 
narcusprince said:
I would avoid versed given the risk of cleft palate, I would avoid nitrous given risk of NT defects (any evidence of giving folate to mothers whom you would use nitrous). Third my thinking is to minimize patient movement. Given that we cannot use Versed ...
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Ignoring for a second the fact that the whole benzos in pregnancy issue has been debunked in multiple prospective trials, think about the timing of what you just said... When do cleft lips/ palates develop? When do neural tubes close? Even a plaintiff lawyer would just :laugh: if the patient tried to sue for that.

The only contraindication to versed in this patient is if you are worried that you won't be able manage her airway if you give too much and can't get the flumazenil in fast enough.

Personally, I would just have her fast, toss back some bicitra and give whatever propofol sedation is necessary to get her through just like any other sedation. Maybe even a touch of fentanyl to blunt the response to distention.

If you are really shy about it you could give her a little ketamine and talk her through it.

- pod
 
If elective, recommend postpone

If "emergent"

ASA standard monitors plus fetal HR monitor
NPO >8hrs
Sodium citrate 30ml PO
Famotidine 20mg IVP
Midazolam 2mg IVP
Ketafol infusion (Propofol + Ketamine 1mg/ml) for sedation - cuts the amount of propofol, maintains respiration, provides some analgesia
Spont resp w/ NC plus ETCO2 monitor

http://www.anesthesia-analgesia.org/cgi/content/abstract/92/6/1465
 
Fetal heart rate monitoring at 21 weeks? Really?

What information are you looking for? How would you use that information to guide your anesthetic? Do you have much experience interpreting fetal heart rates at 21 weeks?

Any evidence that fetal heart rate monitoring has any bearing on outcomes in non-obstetric surgery?

Apparently, new mom's aren't the only ones who get a little crazy with pregnancy.

- pod
 
Jay K said:
If elective, recommend postpone

If "emergent"

ASA standard monitors plus fetal HR monitor
NPO >8hrs
Sodium citrate 30ml PO
Famotidine 20mg IVP
Midazolam 2mg IVP
Ketafol infusion (Propofol + Ketamine 1mg/ml) for sedation - cuts the amount of propofol, maintains respiration, provides some analgesia
Spont resp w/ NC plus ETCO2 monitor

http://www.anesthesia-analgesia.org/cgi/content/abstract/92/6/1465
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fetus is non-viable at 21 weeks. so not sure why you need fetal monitors.

i do have to stress, that any expert witness will destroy anyone who puts this lady down without an unsecured airway (full stomach). anything other than conscious sedation - (patient is AWAKE, responding to voice commands) without a tube would technically be malpractice.
 
What does the ASA have to say about FHR monitoring?

STATEMENT ON NONOBSTETRIC SURGERY DURING PREGNANCY Committee of Origin: Obstetrical Anesthesia (Approved by the ASA House of Delegates on October 21, 2009)

This is a joint statement from the American Society of Anesthesiologists (ASA) and the American College of Obstetricians and Gynecologists (ACOG). It has been designed to address issues of concern to both specialties.

1. NONOBSTETRIC SURGERY DURING PREGNANCY
The American College of Obstetricians and Gynecologists Committee on Obstetric Practice and the American Society of Anesthesiologists Committee on Obstetric Anesthesia acknowledge that the issue of nonobstetric surgery during pregnancy is an important concern for physicians who care for women. Due to the difficulty of conducting large-scale randomized clinical trials in this population, there are no data to allow for specific recommendations. It is important for physicians to obtain obstetric consultation before performing nonobstetric surgery and some invasive procedures (e.g., cardiac catheterization, colonoscopy) because obstetricians are uniquely qualified to discuss aspects of maternal physiology and anatomy that may affect intraoperative maternal-fetal well-being.

The following generalizations may be helpful to guide decision-making:
  • 1.1 No currently used anesthetic agents have been shown to have any teratogenic effects in humans when using standard concentrations at any gestational age.
  • 1.2 Fetal heart rate monitoring may assist in maternal positioning and cardiorespiratory management, and may influence a decision to deliver the fetus.

2. CONSENSUS
The following recommendations represent the consensus of the two Committees:
  • 2.2 A pregnant woman should never be denied indicated surgery, regardless of trimester.
  • 2.3 Elective surgery should be postponed until after delivery.
  • 2.4 If possible, non-urgent surgery should be performed in the second trimester when preterm contractions and spontaneous abortion are least likely.

3. FETAL MONITORING
When non-obstetric surgery is planned, the primary obstetric care provider should be notified. If that provider is not at the institution where surgery is to be performed, another obstetric care provider with privileges at that institution should be involved. If fetal monitoring is to be used:
  • 3.1 Surgery should be done at an institution with neonatal and pediatric services.
  • 3.2 An obstetric provider with cesarean delivery privileges should be readily available.
  • 3.3 A qualified individual should be readily available to interpret the fetal heart rate.
  • 3.4 General guidelines for fetal monitoring include –
    • 3.4.1 If the fetus is considered previable, it is generally sufficient to ascertain the fetal heart rate by Doppler before and after the procedure.
    • 3.4.2 At a minimum, if the fetus is considered to be viable, simultaneous electronic fetal heart rate and contraction monitoring should be performed before and after the procedure to assess fetal well-being and the absence of contractions.
    • 3.4.3 Intraoperative electronic fetal monitoring may be appropriate when all of the following apply:
      • 3.4.3.1 The fetus is viable;
      • 3.4.3.2 It is physically possible to perform intraoperative electronic fetal monitoring;
      • 3.4.3.3 A provider with obstetrical surgery privileges is available and willing to intervene during the surgical procedure for fetal indications.
      • 3.4.3.4 When possible, the woman has given informed consent to emergency cesarean delivery.

In select circumstances, intraoperative fetal monitoring may be considered for previable fetuses to facilitate positioning or oxygenation interventions.
The decision to use fetal monitoring should be individualized, and, if used, should be based on gestational age, type of surgery, and facilities available. Ultimately, each case warrants a team approach (anesthesia, obstetric care providers, surgery, pediatrics, and nursing) for optimal safety of the woman and the fetus.
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Sorry for the additional dots, it is the only way I could get it to line up nicely. I don't know what happened to 2.1 This is a direct quote so ask ASA.

- pod
 
Jeff05 said:
i do have to stress, that any expert witness will destroy anyone who puts this lady down without an unsecured airway (full stomach). anything other than conscious sedation - (patient is AWAKE, responding to voice commands) without a tube would technically be malpractice.
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Could you define what you mean by "down?" "Conscious sedation" is a less imprecise term, but it still can mean very different things to different people. It is used to describe everything from light sedation to deep sedation bordering on general anesthesia. It sounds like you are saying that anything deeper than anxiolysis (without airway control) is malpractice. How do you support that idea?

As with any sedation, the least amount of medication necessary should be utilized. I am not concerned about intubating her if necessary, but neither am I particularly concerned about providing moderate sedation.

-pod
 
Arch Guillotti said:
Let's say she has a problem and that it needs to be addressed while she is still pregnant. The GI doc, OB doc and pt. are all in agreeance that the procedure can't wait.

Are you still going to refuse to do the case?
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I should be convinced that the "problem" if not addressed now will cause harm more significant than the loss of the pregnancy.
Can you think of a situation where a colonoscopy would solve a problem that without a colonoscopy would be more harmful than the real possibility of triggering labor and loosing the baby?
If it does not make sense to me then the answer to your question would be yes, I will not agree to be part of it.
 
Ok just forget it then.

We all understand the risks and nobody wants to touch a pregnant woman unless absolutely necessary.

The OP was looking for some advice on how to do the case, not a discussion of the necessity of the procedure.

Planktonmd said:
I should be convinced that the "problem" if not addressed now will cause harm more significant than the loss of the pregnancy.
Can you think of a situation where a colonoscopy would solve a problem that without a colonoscopy would be more harmful than the real possibility of triggering labor and loosing the baby?
If it does not make sense to me then the answer to your question would be yes, I will not agree to be part of it.
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Acute and worsening anemia with positive FOBT. Volvulus. Hematochezia in a patient with a prior history of colon cancer or significant bowel surgery. Foreign body removal. Chron's or UC flare. Ogilve's. Bored.

There have been several retrospective studies of colonoscopy in pregnancy and I cannot find a report of pre-term labor as a complication. I think we all agree that there should be a strong indication. If there is a reasonable indication, I think it is reasonably safe and I wouldn't make a fuss about it.

-pod
 
You asked if there was a "problem" and the OB and the GI guys said it's necessary to proceed if I would proceed based on their opinion.
I answered you that it's my opinion as the consultant anesthesiologist that matters here.
I am not sure why you are getting defensive?
If you base your clinical decisions on what the OB and GI people tell you then good for you!
As for advice on how to anesthetize a pregnant woman for a NECESSARY colonoscopy it is very simple: do what you do on every colonoscopy.
You agree with me that this is far less exciting than deciding to proceed or not don't you?

Arch Guillotti said:
Ok just forget it then.

We all understand the risks and nobody wants to touch a pregnant woman unless absolutely necessary.

The OP was looking for some advice on how to do the case, not a discussion of the necessity of the procedure.
Click to expand...
 
periopdoc said:
Acute and worsening anemia with positive FOBT. Volvulus. Hematochezia in a patient with a prior history of colon cancer or significant bowel surgery. Foreign body removal. Chron's or UC flare. Ogilve's. Bored.

There have been several retrospective studies of colonoscopy in pregnancy and I cannot find a report of pre-term labor as a complication. I think we all agree that there should be a strong indication. If there is a reasonable indication, I think it is reasonably safe and I wouldn't make a fuss about it.

-pod
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Foreign body is an emergency.
A Volvulus is an emergency.
Acute anemia with blood in the stool is an emergency

Hematochezia with a previous history of abdominal surgery is debatable.
Chronic anemia with blood positive stools in a pregnant woman is debatable, depends on how bad the anemia is.
Acute episode of known inflammatory bowel disease does not require a colonoscopy it requires treatment.

No one said that Emergency life saving procedures should not be done.
 
Planktonmd said:
As for advice on how to anesthetize a pregnant woman for a NECESSARY colonoscopy it is very simple: do what you do on every colonoscopy.
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Forgive me if I missed sarcasm or facetiousness, but her being pregnant would not change your anesthesia plan at all from what it would be if this lady was not pregnant?
 
Planktonmd said:
No,
If she really needs a colonoscopy she gets Propofol exactly as if she was not pregnant.
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At suggested 21 weeks.

What about 38 weeks?
--------------------------------

On the technical side - with a pregnant uterus displacing all the abdominal contents it would be extremely difficult to complete the procedure... and potentially dangerous as well.
 
hoyden said:
At suggested 21 weeks.

What about 38 weeks?
--------------------------------

On the technical side - with a pregnant uterus displacing all the abdominal contents it would be extremely difficult to complete the procedure... and potentially dangerous as well.
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Answer: C/S followed by C-scope
 
Bertelman said:
Answer: C/S followed by C-scope
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everyone after 24 weeks will get C/S first?
Oh, no, steroids for 24 hours first 😀

On a more serious side - the need for colonoscopy will push the decision for C/S if the fetus is viable. More closer to the end - more ease for the C/S. But at the 30-31 weeks of geastation the balance is right in the middle. Will you still do a colonoscopy under propofol sedation only or would you go straight to GA
 
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hoyden said:
everyone after 24 weeks will get C/S first?
Oh, no, steroids for 24 hours first 😀

On a more serious side - the need for colonoscopy will push the decision for C/S if the fetus is viable. More closer to the end - more ease for the C/S. But at the 30-31 weeks of geastation the balance is right in the middle. Will you still do a colonoscopy under propofol sedation only or would you go straight to GA
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If the indication is good enough to do the colonoscopy I would not hesitate to do it under straight Propofol sedation at any gestational stage.
There is absolutely no difference in my opinion between this pregnant woman and all the 400 pound diabetics with GERD we do colonscopies on every day.
They all make it.
 
Planktonmd said:
If the indication is good enough to do the colonoscopy I would not hesitate to do it under straight Propofol sedation at any gestational stage.
There is absolutely no difference in my opinion between this pregnant woman and all the 400 pound diabetics with GERD we do colonscopies on every day.
They all make it.
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Could not agree more. Having said that, I am always prepared for a GA. Case in point: had this 20 something year old girl who had "major depression" come in for an ECT: you guessed it, she was about 70kg and 34 weeks pregnant. Yeah, she was an easy intubation, but was I going to intubate a 34 weeker, dry lips, no history of any GERD during her pregnancy? No, I wasn't going to do that.... She got the propofol stick, just like everyone else. Fast forward another week later, as she was coming in for further ECT "therapy," one of my senior partners decided to intubate her for the procedure. I view both his technique and mine to have been safe, with GETA being the "standard of care," whatever the hell that means.... Anyhow, fast forward yet another week, when she comes in for yet another ECT "therapy" session--the b*otch is now thinking of hurting the baby, she was an inpatient all along--the first thing she and her mom complained about? "Why's my throat so sore? Can you give me something that's not gonna make it sore?" You get the picture, bro'.... To those who vehimently objected to straight up propofol: there are "standards of care" and then there is clinical experience and always being ready for the worst.... Plank, I value your judgement and experience with deciding on the propofol. Now if my path runs across this patient again and she had not delivered yet, she will get the propofol, sux, tube treatment--no, not 'cause I'm worried about reflux BS, but as my way for reducing her suicide risk:laugh::laugh:.
 
Planktonmd said:
If the indication is good enough to do the colonoscopy I would not hesitate to do it under straight Propofol sedation at any gestational stage.
There is absolutely no difference in my opinion between this pregnant woman and all the 400 pound diabetics with GERD we do colonscopies on every day.
They all make it.
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I just can't imagine anybody pushing hard (as they do) the pregnant enough belly without causing any harm...not in terms of causing aspiration...

That is, however, not an anesthesiologist's thought in me :laugh:
 
Planktonmd said:
Foreign body is an emergency.
A Volvulus is an emergency.
Acute anemia with blood in the stool is an emergency...

No one said that Emergency life saving procedures should not be done.
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I was simply responding to what you asked.

Planktonmd said:
...Can you think of a situation where a colonoscopy would solve a problem that without a colonoscopy would be more harmful than the real possibility of triggering labor and loosing [sic] the baby?
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There is no evidence that a colonoscopy, performed in the second trimester, can trigger labor.

I agree with you. If the scope is indicated, the patient gets the same treatment as a non-pregnant person with high VO2 and physical impairment of normal ventilatory mechanics. For me that is moderate propofol sedation.

-pod
 
This was one of my associates case, this is his response:


The first thing that you need to do is find out about patients emotional status. This patient had metastic cancer . After explanation of case and your anesthetic intent determine if she will tolerate sedation. In this case patient was ok with using seditive vs having to put her to sleep with tube rapid sequence ect. The case was done with a little Demerol and a tad of diprivan. She was awake for the case. The most important part of the anesthetic was my warm comforting calm voice and my holding her hand during the case. If patient was not ok with this technique then rapid sequence tube pre fetal and post monitoring .
 
turnupthevapor said:
This was one of my associates case, this is his response:


The first thing that you need to do is find out about patients emotional status. This patient had metastic cancer . After explanation of case and your anesthetic intent determine if she will tolerate sedation. In this case patient was ok with using seditive vs having to put her to sleep with tube rapid sequence ect. The case was done with a little Demerol and a tad of diprivan. She was awake for the case. The most important part of the anesthetic was my warm comforting calm voice and my holding her hand during the case. If patient was not ok with this technique then rapid sequence tube pre fetal and post monitoring .
Click to expand...
Well if that's what she needed, she would have gotten the tube!:laugh:
 
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