Correspondence
183 Sugammadex and pregnancy, is it safe? To the Editor:
Figure Intrauterine FHR (yellow, upper line) and MHR (white, second line) corresponding to uterine contractions (lower strip). Maternal heart rate baseline 120, decreasing to below 90.
Bezhold-Jarisch reflex. Stimulation of these cardiac receptors by stretch resulted in increased parasympathetic activity and maternal bradycardia. Administration of 500 mL colloid resulted in resolution of both maternal bradycardia and fetal decelerations. Labor continued uneventfully with a normal abdominal delivery. Potential confusion of maternal and FHRs has been reported [1,2], and maternal decelerations may predict nonreassuring fetal status [3]. We present an image of significant contraction-related maternal bradycardia, which caused consternation to nursing and obstetric colleagues and suggest a possible physiologic explanation.
Kaitlin J. Herald, DO (Resident) Evan G. Pivalizza, MD (Distinguished Teaching Professor)⁎ Department of Anesthesiology University of Texas Health Science Center–Houston MSB 5.020, 6431 Fannin St, Houston, TX, 77030 ⁎Corresponding author. Tel.: +1 713 500 6251 fax: +1 713 500 6270 E-mail address: [email protected]
http://dx.doi.org/10.1016/j.jclinane.2014.11.014
References [1] Emereuwaonu I. Fetal heart rate misrepresented by maternal heart rate: a case of signal ambiguity. Am J Clin Med 2012;9–1:52-7. [2] Murray ML. Maternal or fetal heart rate? Avoiding intrapartum misidentification. J Obstet Gynecol Neonatal Nurs 2004;33:93-104.
We write to you to report a case that happened in our institution, and that made us raise questions about the possibility of using sugammadex in pregnant women and to have an answer from the scientific community. The case involves a 19-year-old and 27-week gestation pregnant admitted to emergency surgery for ovarian torsion. The induction was standard with fentanyl, propofol, and rocuronium; and surgery was performed laparoscopically without incident. The total dose of rocuronium was 50 mg (0.9 mg/kg). The surgery lasted 120 minutes, and at that time, train of four was 1/4. We made a search in PubMed with the terms “sugammadex” and “pregnancy” and found nothing published about safety of use for sugammadex in pregnant women. All articles found referred to the use of sugammadex for blockade reversal after cesarean sections. We contacted the pharmaceutical representative of sugammadex (Bridion; Merck Sharp & Dohme Inc., Madrid, Spain) who told us she had never heard of any similar case. She then contacted the national expert reference for sugammadex (whose name we do not know). The latter told her that no safety studies had been conducted in humans, and therefore, unless it was a case of vital necessity, he discouraged its use because of potential harm, not only for patient but particularly for the fetus. By the time we got this answer, the train of four was 4/4 (21%) and proceeded to the reversal of Neuromuscular Blockade (NMB) with neostigmine (2 mg) and atropine (0.5 mg). The patient was extubated without incident and later discharged from the postanesthesia care unit within 120 minutes with a strictly normal postoperative course. The patient is still in the last months of pregnancy without having had any complications. This case has made us raise a doubt about the safety of sugammadex use in pregnancy, and we therefore write to you. We have no casuistry in our hospital about the use of sugammadex in pregnant women and could not find any reported case, but it is more than likely that it may have been used in situations, where the benefit from its use may exceed the potential risk (eg, “cannot ventilate, cannot intubate” situations in pregnant patients in whom rocuronium may have been used, residual NMB situations, etc). We understand that it may never have been used routinely without proper safety studies, but it is likely that, in these extreme cases of life-threatening emergency situations, it may have. We hope that this letter may stimulate readers to report cases if there are any. Nevertheless, we expect to encourage the scientific community to perform safety studies regarding the use of sugammadex in pregnant women [1-3].
184 Nicolas Varela, MD* Félix Lobato, MD Departamento de Anestesiología y Reanimación, Hospital San Pedro, Logroño, (La Rioja, Spain) *Corresponding author. Hospital San Pedro, Logroño (La Rioja, Spain), Servicio de Anestesiología y Reanimación–Hospital San Pedro, Piqueras, 98, 26006 Logroño–La Rioja, Spain Tel.: + 34 941298000; fax: + 34 941298660 E-mail address: [email protected] http://dx.doi.org/10.1016/j.jclinane.2014.11.015
Correspondence
References [1] Williamson RM, Mallaiah S, Barclay P. Rocuronium and sugammadex for rapid sequence induction of obstetric general anaesthesia. Acta Anaesthesiol Scand 2011;55(6):694-9 [PubMed PMID: 21480829]. [2] McGuigan PJ, Shields MO, McCourt KC. Role of rocuronium and sugammadex in rapid sequence induction in pregnancy. Br J Anaesth 2011;106(3):418-9 [author reply 419–20, PubMed PMID: 21317233]. [3] Pühringer FK, Kristen P, Rex C. Sugammadex reversal of rocuronium-induced neuromuscular block in caesarean section patients: a series of seven cases. Br J Anaesth 2010;105(5):657-60 [PubMed PMID: 20736231].
183 Sugammadex and pregnancy, is it safe? To the Editor:
Figure Intrauterine FHR (yellow, upper line) and MHR (white, second line) corresponding to uterine contractions (lower strip). Maternal heart rate baseline 120, decreasing to below 90.
Bezhold-Jarisch reflex. Stimulation of these cardiac receptors by stretch resulted in increased parasympathetic activity and maternal bradycardia. Administration of 500 mL colloid resulted in resolution of both maternal bradycardia and fetal decelerations. Labor continued uneventfully with a normal abdominal delivery. Potential confusion of maternal and FHRs has been reported [1,2], and maternal decelerations may predict nonreassuring fetal status [3]. We present an image of significant contraction-related maternal bradycardia, which caused consternation to nursing and obstetric colleagues and suggest a possible physiologic explanation.
Kaitlin J. Herald, DO (Resident) Evan G. Pivalizza, MD (Distinguished Teaching Professor)⁎ Department of Anesthesiology University of Texas Health Science Center–Houston MSB 5.020, 6431 Fannin St, Houston, TX, 77030 ⁎Corresponding author. Tel.: +1 713 500 6251 fax: +1 713 500 6270 E-mail address: [email protected]
http://dx.doi.org/10.1016/j.jclinane.2014.11.014
References [1] Emereuwaonu I. Fetal heart rate misrepresented by maternal heart rate: a case of signal ambiguity. Am J Clin Med 2012;9–1:52-7. [2] Murray ML. Maternal or fetal heart rate? Avoiding intrapartum misidentification. J Obstet Gynecol Neonatal Nurs 2004;33:93-104.
We write to you to report a case that happened in our institution, and that made us raise questions about the possibility of using sugammadex in pregnant women and to have an answer from the scientific community. The case involves a 19-year-old and 27-week gestation pregnant admitted to emergency surgery for ovarian torsion. The induction was standard with fentanyl, propofol, and rocuronium; and surgery was performed laparoscopically without incident. The total dose of rocuronium was 50 mg (0.9 mg/kg). The surgery lasted 120 minutes, and at that time, train of four was 1/4. We made a search in PubMed with the terms “sugammadex” and “pregnancy” and found nothing published about safety of use for sugammadex in pregnant women. All articles found referred to the use of sugammadex for blockade reversal after cesarean sections. We contacted the pharmaceutical representative of sugammadex (Bridion; Merck Sharp & Dohme Inc., Madrid, Spain) who told us she had never heard of any similar case. She then contacted the national expert reference for sugammadex (whose name we do not know). The latter told her that no safety studies had been conducted in humans, and therefore, unless it was a case of vital necessity, he discouraged its use because of potential harm, not only for patient but particularly for the fetus. By the time we got this answer, the train of four was 4/4 (21%) and proceeded to the reversal of Neuromuscular Blockade (NMB) with neostigmine (2 mg) and atropine (0.5 mg). The patient was extubated without incident and later discharged from the postanesthesia care unit within 120 minutes with a strictly normal postoperative course. The patient is still in the last months of pregnancy without having had any complications. This case has made us raise a doubt about the safety of sugammadex use in pregnancy, and we therefore write to you. We have no casuistry in our hospital about the use of sugammadex in pregnant women and could not find any reported case, but it is more than likely that it may have been used in situations, where the benefit from its use may exceed the potential risk (eg, “cannot ventilate, cannot intubate” situations in pregnant patients in whom rocuronium may have been used, residual NMB situations, etc). We understand that it may never have been used routinely without proper safety studies, but it is likely that, in these extreme cases of life-threatening emergency situations, it may have. We hope that this letter may stimulate readers to report cases if there are any. Nevertheless, we expect to encourage the scientific community to perform safety studies regarding the use of sugammadex in pregnant women [1-3].
184 Nicolas Varela, MD* Félix Lobato, MD Departamento de Anestesiología y Reanimación, Hospital San Pedro, Logroño, (La Rioja, Spain) *Corresponding author. Hospital San Pedro, Logroño (La Rioja, Spain), Servicio de Anestesiología y Reanimación–Hospital San Pedro, Piqueras, 98, 26006 Logroño–La Rioja, Spain Tel.: + 34 941298000; fax: + 34 941298660 E-mail address: [email protected] http://dx.doi.org/10.1016/j.jclinane.2014.11.015
Correspondence
References [1] Williamson RM, Mallaiah S, Barclay P. Rocuronium and sugammadex for rapid sequence induction of obstetric general anaesthesia. Acta Anaesthesiol Scand 2011;55(6):694-9 [PubMed PMID: 21480829]. [2] McGuigan PJ, Shields MO, McCourt KC. Role of rocuronium and sugammadex in rapid sequence induction in pregnancy. Br J Anaesth 2011;106(3):418-9 [author reply 419–20, PubMed PMID: 21317233]. [3] Pühringer FK, Kristen P, Rex C. Sugammadex reversal of rocuronium-induced neuromuscular block in caesarean section patients: a series of seven cases. Br J Anaesth 2010;105(5):657-60 [PubMed PMID: 20736231].
