Severe fetal bradycardia in a pregnant surgical patient despite normal oxygénation and blood pressure

Abstract

P Pu ur rp po os se e: : To report and discuss a case of fetal bradycardia in a parturient under anesthesia for cholecystectomy despite normal maternal oxygenation and arterial blood pressure.C Cl li in ni ic ca al l f fe ea at tu ur re es s: : A 27-yr-old woman (gravida 2 para 1), with a fetus of 34 weeks gestation, received general anesthesia for cholecystectomy. After anesthesia induction and tracheal intubation, anesthesia was maintained with oxygen, sevoflurane and iv remifentanil infusion. While preparing for surgery, the fetal heart rate decreased within about half a minute to 70 beats·min -1 and remained at that level. The maternal blood pressure, heart rate and oxygen saturation were normal. An emergency Cesarean delivery was performed. The infant had Apgar scores of 1 at one minute, 5 at five minutes, 7 at ten minutes and required resuscitation after birth.C Co on nc cl lu us si io on n: : Ideally, women having non-obstetric surgery during the third trimester of pregnancy will have intraoperative fetal heart rate monitoring. S many as 2% of pregnant women undergo non-obstetric surgery during pregnancy 1 and cholecystectomy is one of the common surgical procedures performed. Pancreatitis and cholecystitis can complicate cholelithiasis and lead to significant maternal and fetal morbidities. Some surgeons, therefore, advocate cholecystectomy during pregnancy rather than delaying surgery until delivery has occurred. 2 One of the controversies in anesthesia for a pregnant patient having non-obstetric surgery is intraoperative fetal heart rate monitoring. A recent review on anesthesia for pregnant patients having non-obstetric surgery and obstetric anesthesia textbooks recommended fetal heart rate monitoring during anesthesia and surgery whenever possible. [3][4][5] Some obstetricians believe that the fetus would not be compromised as long as maternal oxygenation and circulation remain normal. Horrigan et al. 6 suggested that fetal monitoring by obstetric personnel was unnecessary during surgery in pregnant patients. We report a case of fetal bradycardia in a parturient under anesthesia for cholecystectomy despite normal maternal oxygenation and arterial blood pressure. Objectif : Présenter un cas de bradycardie foetale chez une parturiente sous anesthésie pour cholécystectomie malgré l'oxygénation et la tension artérielle maternelles normales.

General anesthesia using remifentanil for Cesarean delivery in a parturient with Marfan’s syndrome

“…12,13 Others have described the need for naloxone at birth, 14 neonatal chest wall rigidity, 15 and severe fetal bradycardia. 16 A recent study showed that a bolus dose of 1 µg·kg -1 of remifentanil, during induction of general anesthesia for Cesarean delivery, blunts maternal cardiovascular effects of intubation, but may cause neonatal depression. 17 We ensured that a neonatal team was present to resuscitate the baby, if required.…”

Delayed awakening following inadvertent high-dose remifentanil infusion in a 13 year old patient

“…There are limited data about remifentanil hazards; they are reported mostly in pediatric patients [13,15,16]. In our case, the patient was hemodynamically stable without signs of muscle rigidity.…”

Intraoperative fetal heart rate monitoring during emergency neurosurgery in a parturient

“…The combination of increased vascular resistance from the tightly coiled state and further external compression may cause marked reduction of the umbilical circulation. Impaired umbilical blood flow may lead to fetal hypoxia even if the maternal oxygenation and circulation are normal [12]. Liu et al [13] reported on five patients who demonstrated loss of variability following induction of anesthesia, with two of the five demonstrating a reduction in the baseline FHR with no detectable maternal changes.…”