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Fetal Heart Rate Assessment by Anesthesiologists – Improving Efficiency in Ambulatory Practice?
Abstract Number: S1C-4
Abstract Type: Case Report/Case Series
Most discussions about peri-surgical fetal monitoring are concerned with if and when it should occur. But who should perform it? Depending on fetal age, this responsibility is relegated to radiologic or obstetric teams. But as anesthesiologists are becoming more comfortable with ultrasonography, is it reasonable for us to assess the fetal heart rate (FHR)?
This question occurred during a first-start delay at a busy hybrid surgical center. The patient, 7 wks pregnant by pelvic ultrasound, presented for outpatient repair of mandibular fractures. Pre-op clinic arranged for pre- and post-op fetal heart tone assessment, but the OB team declined, arguing that transabdominal ultrasonography is unreliable in a fetus less than 8 wks. The patient was taken to radiology for transvaginal ultrasound. One hour later the patient returned and surgery proceeded uneventfully. In the PACU we faced the same dilemma. Reluctant to endure another delay and subject the patient to another invasive procedure, we performed an abdominal ultrasound with a curvilinear probe. We visualized a FHR of 150 bpm (25 beats/10 sec). Perhaps the method was crude, but image clarity was convincing and the exam took less than two minutes.
According to 2017 guidelines published jointly by ACOG and the ASA, “If the fetus is considered previable, it is generally sufficient to ascertain the FHR by Doppler before and after the procedure.” Arguably, some anesthesiologists and surgeons would have foregone all FHR monitoring in this case of nonobstetric surgery during pregnancy in early getstaion.
In this patient with a BMI of 37, ultrasound imaging proved technically unchallenging. Anesthesiologists commonly use ultrasound when cannulating vessels and performing nerve blocks and echocardiography. There may be advantages to transferring this technology to FHR monitoring as demonstrated in this case, but safety is an issue. It has been suggested that fetal injury may occur via thermal and mechanical effects, prompting a recommendation that ultrasound imaging (especially Doppler ultrasound) should be restricted to medically indicated diagnostic purposes with the shortest possible exposure duration performed by competent personnel. Are we competent personnel?
Although there is no policy or standard regarding FHR assessment, there seems to be a threshold that anesthesiologists are reluctant to cross, regardless of fetal age and viability. We are not suggesting dabbling in the territory of other specialties, but that we should consider the unspoken boundaries of ultrasonography. We might do well to recall that intraoperative transesophageal echocardiography was once performed by cardiologists.
Nonobstetric Surgery During Pregnancy, Interim Update. Committee on Obstetric Practice, American Society of Anesthesiologists. April 2017. http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Nonobstetric-Surgery-During-Pregnancy. Accessed 4/13/2017.