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CASE REPORT
Year : 2021 | Volume
: 10
| Issue : 3 | Page : 245-247
Fetal monitoring in neurosurgery: An essential paradigm?
Saurav Singh1, Amiya Kumar Barik2, Sanjay Agarwal3
1 Department of Neuroanaesthesia, Max Super Speciality Hospital, Patparganj, New Delhi, India
2 Department of Anaesthesiology, AIIMS, Bhopal, Madhya Pradesh, India
3 Department of Anaesthesiology, AIIMS, Rishikesh, Uttarakhand, India
Correspondence Address:
Dr. Saurav Singh
Department of Neuroanaesthesia, Max Super Speciality Hospital, Patparganj, New Delhi
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/ijhas.IJHAS_242_20
Neurosurgical procedures during pregnancy are not uncommon, and anesthetic management of these patients are complicated by the physiologic changes of pregnancy, effects of anesthetic agents on fetus, and a need for vigilance to prevent a possibility of fetal demise. The value of intraoperative fetal heart rate (FHR) monitoring though controversial, is immense, and with various modalities available to choose from, necessary interventions could be made before fetal viability is jeopardized. We report the utility of intraoperative FHR monitoring using ultrasonography in case of a 32-year-old, 28 weeks, pregnant female, G4P(1)A2, posted for bifrontal craniotomy and excision of meningioma with subfalcine herniation.
Keywords: Anesthesia, craniotomy, fetal monitoring, heart rate, meningiomas, pregnancy
Neurosurgical procedures during pregnancy are not uncommon, and anesthetic management of such patients is complicated by the physiologic changes of pregnancy. Although maternal well-being remains a primary concern, it is important to recognize interventions which might harm the fetus.[1] Risk of fetal hypoxia, respiratory depression, cardiovascular complications, teratogenicity, and preterm delivery related to anesthesia and surgery should be borne in mind.[2] The value of intraoperative fetal heart rate (FHR) monitoring though controversial, is immense, and with various modalities available to choose from, necessary interventions could be made before fetal viability is jeopardized.[1],[3],[4]
Case ReportA 32-year-old, 28 weeks, pregnant female, G4P(1)A2, presented to the neurosurgery with complains of sensory deficit on right side of face and difficulty in chewing for 2 months. On examination, Glasgow Coma Scale was E4V5M6, with bilateral pupil normal in size, reactive to light and no motor or any other sensory deficit. All other examinations and investigations were within the normal limits. Magnetic resonance imaging scan of the brain showed right-sided frontal meningioma with subfalcine herniation [Figure 1].
Figure 1: Magnetic resonance imaging scan showing meningioma with subfalcine herniation in right frontal regionThe patient was scheduled for bifrontal craniotomy and excision of tumor. Written and informed consent was obtained about the effects of anesthetic drugs on developing fetus and possibility of loss of pregnancy. The patient was kept nil per oral for solids for 8 h and was allowed clear fluids up to 2 h before the surgery. Tablet (tab) metoclopramide 10 mg and tablet ranitidine 150 mg was administered night before and 2 h before surgery with a sip of water.
In the operating room, patient was positioned with 15° left lateral tilt using a wedge below the right hip, standard ASA monitors were attached, 0.9% normal saline intravenous (IV) infusion was started and injection ceftriaxone 2 g IV was given for surgical prophylaxis. Baseline ultrasonography (USG) of the abdomen was performed, which showed a single live fetus with FHR of 120 beats per minute [Figure 2]. Patient was preoxygenated for 3 min with 100% oxygen. Induction of anesthesia was achieved with fentanyl 2 mcg/kg IV, lignocaine 1.5 mg/kg IV, propofol 2 mg/kg IV, and rocuronium 1.2 mg/kg, following which trachea was intubated with 7 mm cuffed endotracheal tube. The maintenance of anesthesia was done with 60% air in oxygen, propofol infusion (100–150 μg/kg/min), sevoflurane (MAC 0.3), and intermittent boluses of vecuronium and fentanyl. The right subclavian vein and left radial artery was cannulated for central venous and arterial pressure monitoring. Three percentage hypertonic saline at 5 ml/kg IV was given as an osmolar therapy to reduce intracranial pressure (ICP). Blood pressure was kept within 20% of the baseline and phenylephrine 50 μg IV bolus, if needed was used to treat hypotension. Levipil 500 mg IV and dexamethasone 8 mg IV were given, respectively, as antiseizures prophylaxis and for the reduction of vasogenic edema associated with tumor growth during pregnancy.[2] Along with intraoperative vitals and urine output monitoring; FHR was monitored intermittently, throughout the surgery using USG [Figure 3]. Uterine activity was assessed by the obstetrician throughout and was not appreciable at any point of time. Blood loss of 700 ml was replaced with two units of packed red blood cell. Injection paracetamol 1 g IV was supplemented for analgesia. Intraoperative period was uneventful following which patient was extubated, both mother and fetus well-being were assessed and shifted with stable vitals, which mirrored in the postoperative period.
Figure 2: Intraoperative ultrasound guided fetal heart rate monitoring before the start of surgery
Figure 3: Intraoperative ultrasound guided fetal heart rate monitoring during surgery Discussion The incidence of pregnant women requiring nonobstetric surgery is 1%–2%.[3] Pregnancy is not a contraindication for surgery.[1] Although uncommon, neurosurgical disorders are important causes of morbidity and mortality in the pregnant population.[5] The incidence of intracranial neoplasms is not influenced by pregnancy, though hormonal changes of pregnancy may influence the growth of brain tumors like meningiomas.[1] Surgical resection in such conditions is considered only when there are signs of progressive neurological deficit or else it is desirable to wait for the delivery of the fetus.[2]
Anesthetic goals in such patients includes prevention of hypoxemia, hypercarbia, painful stimulation, and subsequent increases in ICP; anti-aspiration prophylaxis and rapid sequence induction to prevent gastric regurgitation and aspiration; 15° left lateral tilt to avoid aortocaval compression and hypotension which can cause decreased uteroplacental perfusion.[1] Avoidance of potentially dangerous drugs that crosses placenta and may lead to intrauterine growth restriction or fetal demise and is important for fetus safety.[3] The use of prophylactic tocolytics is debatable, keeping in mind that inhalational agent can cause uterine relaxation. However, it may be considered during third trimester in case of abdominal and pelvic surgery.[3] In 2011, the American College of Obstetricians and Gynecologists stated that intraoperative fetal monitoring should be individualized and may be done when certain conditions are met.[1] Monitoring is further confounded by factors like the anesthetic drugs that can also affect healthy, uncompromised fetus. Despite these factors, close monitoring of FHR for signs of distress is strongly advocated and should be done and interpreted by an experienced operator.[3] Continuous intraoperative fetal monitoring may be performed using an electronic FHR monitor, a Doppler ultrasound, or a transvaginal ultrasound, depending on the availability and personal preference of the obstetrician and any change in FHR beyond the normal physiological parameters should alert the anesthesiologist to take necessary steps to optimize the condition.[4] In this case, USG was preferred over other monitors because of its easy availability, point of care utility, repeatability, and no radiation risk to the fetus.
Therefore, proper understanding of the maternal and fetal physiology, fetal drug pharmacology, fetal monitoring, principles of neuroanesthesiology, and multidisciplinary approach is required and essential for the feto-maternal well-being during neurosurgical procedures.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understand that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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