1
|
Safety of Percutaneous Endoscopic Gastrostomy Placement in Pregnancy: A Case Report and Literature Review. Case Rep Gastrointest Med 2022; 2022:2599274. [PMID: 35039786 PMCID: PMC8761062 DOI: 10.1155/2022/2599274] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 12/30/2021] [Indexed: 11/18/2022] Open
Abstract
Gastrostomy tube placement in pregnancy is historically contraindicated due to risk of injury to the developing fetus and exposure to anesthetic agents. However, in cases where oral nutritional access is severely jeopardized, percutaneous endoscopic gastrostomy (PEG) tube placement can be a life-saving measure. In this case report and literature review, we present a case of successful PEG placement in a pregnant woman, followed by a discussion of the existing literature regarding PEG placement during pregnancy.
Collapse
|
2
|
Wei M, Ho E, Hegde P. An overview of percutaneous endoscopic gastrostomy tube placement in the intensive care unit. J Thorac Dis 2021; 13:5277-5296. [PMID: 34527366 PMCID: PMC8411178 DOI: 10.21037/jtd-19-3728] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Accepted: 05/06/2020] [Indexed: 01/03/2023]
Abstract
Critically ill patients are at increased risk for malnutrition as they often have underlying acute and chronic illness, stress related catabolism, decreased appetite, trauma and ongoing inflammation. Malnutrition is recognized as a leading cause of adverse outcomes, higher mortality, and increased hospital costs. Percutaneous endoscopic gastrostomy (PEG) tubes provide a safe and effective route to provide supplemental enteral nutrition to these patients. PEG placement has essentially replaced surgical gastrostomy as the modality of choice for longer term feeding in patients. This is a highly prevalent procedure with 160,000 to 200,000 PEG procedures performed each year in the United States. The purpose of this review is to provide an overview of current knowledge and practice standards with regards to placement of PEG tube in the Intensive Care Unit (ICU). When a patient is considered for a PEG tube, it is important to evaluate the treatment alternatives and identify the best option for each patient. In this review, we provide the advantages and disadvantages of various feeding modalities and devices. We review the indications and contraindications for PEG tube placement as well as the risks of this procedure. We then describe in detail the per-oral pull, per-oral push, and direct percutaneous techniques for PEG tube placement. Additionally, we review the feasibility of having interventional pulmonologists place PEG tubes in the ICU.
Collapse
Affiliation(s)
- Margaret Wei
- Department of Internal Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Elliot Ho
- Division of Advanced Interventional Thoracic Endoscopy/Interventional Pulmonology, University of California San Francisco - Fresno, Fresno, CA, USA
| | - Pravachan Hegde
- Division of Advanced Interventional Thoracic Endoscopy/Interventional Pulmonology, University of California San Francisco - Fresno, Fresno, CA, USA
| |
Collapse
|
3
|
Wagner BA, Worthington P, Russo-Stieglitz KE, Levine AB, Armenti VT. Invited Review: Nutritional Management of Hyperemesis Gravidarum. Nutr Clin Pract 2016. [DOI: 10.1177/088453360001500203] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
|
4
|
Savas N. Gastrointestinal endoscopy in pregnancy. World J Gastroenterol 2014; 20:15241-15252. [PMID: 25386072 PMCID: PMC4223257 DOI: 10.3748/wjg.v20.i41.15241] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2014] [Revised: 05/25/2014] [Accepted: 07/30/2014] [Indexed: 02/07/2023] Open
Abstract
Gastrointestinal endoscopy has a major diagnostic and therapeutic role in most gastrointestinal disorders; however, limited information is available about clinical efficacy and safety in pregnant patients. The major risks of endoscopy during pregnancy include potential harm to the fetus because of hypoxia, premature labor, trauma and teratogenesis. In some cases, endoscopic procedures may be postponed until after delivery. When emergency or urgent indications are present, endoscopic procedures may be considered with some precautions. United States Food and Drug Administration category B drugs may be used in low doses. Endoscopic procedures during pregnancy may include upper gastrointestinal endoscopy, percutaneous endoscopic gastrostomy, sigmoidoscopy, colonoscopy, enteroscopy of the small bowel or video capsule endoscopy, endoscopic retrograde cholangiopancreatography and endoscopic ultrasonography. All gastrointestinal endoscopic procedures in pregnant patients should be performed in hospitals by expert endoscopists and an obstetrician should be informed about all endoscopic procedures. The endoscopy and flexible sigmoidoscopy may be safe for the fetus and pregnant patient, and may be performed during pregnancy when strong indications are present. Colonoscopy for pregnant patients may be considered for strong indications during the second trimester. Although therapeutic endoscopic retrograde cholangiopancreatography may be considered during pregnancy, this procedure should be performed only for strong indications and attempts should be made to minimize radiation exposure.
Collapse
|
5
|
Schwoerer JAS, Obernolte L, Van Calcar S, Heighway S, Bankowski H, Williams P, Rice G. Use of Gastrostomy Tube to Prevent Maternal PKU Syndrome. JIMD Rep 2013; 6:15-20. [PMID: 23430933 DOI: 10.1007/8904_2011_95] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2011] [Revised: 09/13/2011] [Accepted: 09/19/2011] [Indexed: 02/16/2023] Open
Abstract
Maternal Phenylketonuria Syndrome (MPKU) can occur in infants born to mothers with PKU with poor metabolic control during pregnancy. Elevated phenylalanine (phe) acts as a teratogen to the developing fetus with consequences including intellectual disability, microcephaly, facial dysmorphism, growth retardation, and congenital heart disease. MPKU can be prevented if metabolic control is achieved by 8-10 weeks gestation. If control is not achieved, there is a significant risk for MPKU. Therefore, in women with poor metabolic control at time of pregnancy, establishing metabolic control quickly is important.Clinically, establishing metabolic control in women with PKU can present challenges. Social issues, psychological issues, and insufficient education about PKU play an important role in a patient's inability to reinstitute this challenging diet. Maintaining phe levels within a range to allow for infant growth, while preventing toxicity, is challenging, particularly for those women who no longer follow the PKU diet. Gastrostomy tube placement is an option to deliver medical formula to women who are unable to restart diet due to severe nausea or palatability issues.Here we discuss two pregnancies in which a gastrostomy tube was placed to achieve metabolic control after other measures failed to reduce phe concentrations into the recommended range. For these two pregnancies, placement of the gastrostomy tube led to improvement in phe levels with normal infant outcomes including normal growth, head circumference, and heart structure.
Collapse
|
6
|
Abstract
Although gastrointestinal endoscopy is generally safe, its safety must be separately analyzed during pregnancy with regard to fetal safety. Fetal risks from endoscopic medications are minimized by avoiding FDA category D drugs, minimizing endoscopic medications, and anesthesiologist attendance at endoscopy. Esophagogastroduodenoscopy seems to be relatively safe for the fetus and may be performed when strongly indicated during pregnancy. Despite limited clinical data, endoscopic banding of esophageal varices and endoscopic hemostasis of nonvariceal upper gastrointestinal bleeding seems justifiable during pregnancy. Flexible sigmoidoscopy during pregnancy also appears to be relatively safe for the fetus and may be performed when strongly indicated. Colonoscopy may be considered in pregnant patients during the second trimester if there is a strong indication. Data on colonoscopy during the other trimesters are limited. Therapeutic endoscopic retrograde cholangiopancreatography seems to be relatively safe during pregnancy and should be performed for strong indications (for example, complicated choledocholithiasis). Endoscopic safety precautions during pregnancy include the performance of endoscopy in hospital by an expert endoscopist and only when strongly indicated, deferral of endoscopy to the second trimester whenever possible, and obstetric consultation.
Collapse
|
7
|
Chanana C, Kumar S, Malhotra N, Sharma JB, Roy KK. Pregnancy followed by caesarean delivery in a patient with tracheostomy and gastrostomy after corrosive acid ingestion. Arch Gynecol Obstet 2006; 275:295-6. [PMID: 16957909 DOI: 10.1007/s00404-006-0243-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2006] [Accepted: 08/16/2006] [Indexed: 10/24/2022]
Abstract
Corrosive acid ingestion in pregnancy is rare. We present a rare case of corrosive acid ingestion during pregnancy. The patient subsequently had tracheal stenosis and had to undergo a tracheostomy. Feeding gastrostomy was created for nutritional support of both mother and fetus. The patient delivered at term by an elective caesarean section.
Collapse
Affiliation(s)
- Charu Chanana
- Department of Gynecology & Obstetrics, All India Institute of Medical Sciences, New Delhi, India.
| | | | | | | | | |
Collapse
|
8
|
Chiossi G, Novic K, Celebrezze JU, Thomas RL. Successful neonatal outcome in 2 cases of maternal persistent vegetative state treated in a labor and delivery suite. Am J Obstet Gynecol 2006; 195:316-22. [PMID: 16631100 DOI: 10.1016/j.ajog.2006.01.077] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2005] [Revised: 01/14/2006] [Accepted: 01/20/2006] [Indexed: 10/24/2022]
Abstract
Two cases of maternal vegetative state after motor vehicle accidents are presented. Aggressive support allowed the prolongation of both pregnancies into the third trimester without neonatal compromise. After initial medical stabilization in intensive care unit environments, both patients were treated in a labor and delivery setting with consultative supports from various subspecialists.
Collapse
Affiliation(s)
- Giuseppe Chiossi
- Department of Obstetrics and Gynecology, Allegheny General Hospital, Pittsburgh, PA 15212, USA.
| | | | | | | |
Collapse
|
9
|
Abstract
Endoscopy during pregnancy raises the unique issue of fetal safety. Endoscopic medications comprise a significant component of fetal risks from endoscopy. Before endoscopy, the gastroenterologist or anesthesiologist should evaluate the potential fetal risks of sedation and analgesia, identify any contraindications to endoscopy, stabilize the maternal medical status as necessary, and correct maternal hypoxia or hypotension. The mother should be informed about the potential teratogenic risks of endoscopic medications during pregnancy. Patients who receive sedation and analgesia should be monitored during endoscopy by continuous electrocardiography, continuous pulse oximetry, and intermittent sphygmomanometry, as well as by the pulse and respiratory rate. General principles of sedation and analgesia during pregnancy include use of the minimal effective dose, avoidance of unnecessary medications, and preferable use of Food and Drug Administration category B medications.
Collapse
Affiliation(s)
- Mitchell S Cappell
- Division of Gastroenterology, Department of Medicine, Albert Einstein Medical Center, Klein Professional Building, Philadelphia, PA 19141, USA.
| |
Collapse
|
10
|
Bush MC, Nagy S, Berkowitz RL, Gaddipati S. Pregnancy in a persistent vegetative state: case report, comparison to brain death, and review of the literature. Obstet Gynecol Surv 2004; 58:738-48. [PMID: 14581825 DOI: 10.1097/01.ogx.0000093268.20608.53] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
UNLABELLED Severe maternal neurologic injury during pregnancy has the potential for fetal demise without advanced critical care support to the mother. Brain death is the unequivocal and irreversible loss of total brain function, whereas patients in a vegetative state, by contrast, have preserved brain stem function but lack cerebral function. They can appear to be awake, have sleep-wake cycles, be capable of swallowing, and have normal respiratory control, but there are no purposeful interactions. These conditions have different maternal prognoses, but both have resulted in near-normal neonatal outcomes with long latencies from maternal injury to delivery in previously published cases. This article compares and contrasts the 11 cases of brain death with 15 cases of persistent vegetative state in pregnancy. We found that the mean latency between maternal brain injury and delivery was significantly shorter in the brain-dead patients as compared with those in a vegetative state (46 days vs. 124 days, P </=.001). Correspondingly, the gestational ages at delivery (29.7 weeks vs. 33.2 weeks, P </=.01) and the birth weights (1380 g vs. 2145 g, P </=.01) were shorter in duration and smaller in size in the brain-dead group. We also present a case of persistent vegetative state in pregnancy at our institution with both maternal and neonatal death in the context of previously published literature with a focus on obstetric and ethical management. We hope this information will help elucidate the issues for providers confronted with these unique and challenging cases. TARGET AUDIENCE Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES After completion of this article, the reader should be able to state the difference between coma, persistent vegetative state and brain death, to describe the neurologic aspects of a patient in a persistent vegetative state, and to list the fetal effects of maternal brain injury.
Collapse
Affiliation(s)
- Melissa C Bush
- Department of Obstetrics, Gynecology and Reproductive Science, Mount Sinai School of Medicine, New York, New York 10029, USA.
| | | | | | | |
Collapse
|
11
|
Cappell MS. The fetal safety and clinical efficacy of gastrointestinal endoscopy during pregnancy. Gastroenterol Clin North Am 2003; 32:123-79. [PMID: 12635415 DOI: 10.1016/s0889-8553(02)00137-1] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
More than 12,000 pregnant patients in the United States per annum have conditions that are normally evaluated by EGD. More than 6000 pregnant patients in the United States per annum have conditions that are normally evaluated by sigmoidoscopy or colonoscopy. About one thousand more have symptomatic choledocholithiasis during pregnancy, which is a strong indication for endoscopic sphincterotomy in nonpregnant patients. Endoscopy during pregnancy raises the unique issue of fetal safety. Endoscopic medications comprise a significant component of fetal endoscopic risks. Safety of EGD during pregnancy has been examined in a case-controlled study of 83 patients, a mailed survey of 73 patients, and 28 case reports. Safety of sigmoidoscopy during pregnancy has been examined in a case-controlled study of 46 patients, a mailed survey of 13 patients, and 10 case reports. Safety of therapeutic ERCP during pregnancy has been analyzed in studies of 23, 10, 6, and 5 patients, and in 32 case reports. These studies suggested that EGD, sigmoidoscopy, and ERCP should be performed when strongly indicated: EGD for significant upper gastrointestinal bleeding, sigmoidoscopy for nonhemorrhoidal rectal bleeding, and ERCP for symptomatic choledocholithiasis when sphincterotomy is contemplated. PEG and colonoscopy are currently considered experimental during pregnancy because of insufficient data on fetal safety. Several cases of PEG and colonoscopy were successfully performed during pregnancy. Performance of endoscopy during pregnancy should increase with further technical refinements, and greater awareness of procedure safety.
Collapse
Affiliation(s)
- Mitchell S Cappell
- Division of Gastroenterology, Department of Medicine, Woodhull Medical Center, 760 Broadway Avenue, Brooklyn, NY 11206, USA
| |
Collapse
|
12
|
Godil A, Chen YK. Percutaneous endoscopic gastrostomy for nutrition support in pregnancy associated with hyperemesis gravidarum and anorexia nervosa. JPEN J Parenter Enteral Nutr 1998; 22:238-41. [PMID: 9661126 DOI: 10.1177/0148607198022004238] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Pregnant women with hyperemesis gravidarum (HEG) or anorexia nervosa are at high risk of developing malnutrition and adverse fetal outcome. Providing adequate nutrition support is the mainstay of therapy in these patients. Because of potential complications associated with total parenteral nutrition (TPN), enteral nutrition support is the preferred route. METHODS We describe the first two reported cases of percutaneous endoscopic gastrostomy (PEG) placement in two conscious pregnant women who could not tolerate oral feedings because of severe anorexia nervosa and HEG, respectively. RESULTS PEG was placed safely and provided adequate enteral nutrition in both patients, resulting in favorable maternal and fetal outcomes. CONCLUSIONS Our observation is the first demonstration that PEG may be a safe and effective alternative to TPN in selected pregnant women with HEG or anorexia nervosa who have failed conventional treatment.
Collapse
Affiliation(s)
- A Godil
- Department of Medicine, Loma Linda University School of Medicine, California, USA
| | | |
Collapse
|
13
|
Serrano P, Velloso A, García-Luna PP, Pereira JL, Fernádez Z, Ductor MJ, Castro D, Tejero J, Fraile J, Romero H. Enteral nutrition by percutaneous endoscopic gastrojejunostomy in severe hyperemesis gravidarum: a report of two cases. Clin Nutr 1998; 17:135-9. [PMID: 10205331 DOI: 10.1016/s0261-5614(98)80008-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
We describe the first two cases in which percutaneous endoscopic gastrojejunostomy was used as a means to provide enteral nutrition in severe hypermesis gravidarum. The use of this method of enteral access provided an alternative to parenteral nutrition, was well tolerated, cost-effective and had no major complications. In both cases the nutritional goal for mothers as well as appropriate fetal growth and development were achieved.
Collapse
Affiliation(s)
- P Serrano
- Department of Clinical Nutrition, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | | | | | | | | | | | | | | | | | | |
Collapse
|
14
|
Uchide K, Suzuki N, Oota T, Terada S, Inoue M. Pregnant women with transient gastric obstruction managed by Naso-Jejunal nutrition. Nutrition 1998; 14:458-61. [PMID: 9614312 DOI: 10.1016/s0899-9007(98)00018-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
A pregnant woman with transient gastric obstruction was fed by enteral nutrition alone for 11 wk and 6 d. Her body mass index of 23.2 kg/m2 before pregnancy declined to 21.8 kg/m2 after delivery. Although she did not gain weight during enteral nutrition, fetal growth, estimated by ultrasonography, was normal, and she delivered a 3030-g female infant at 38 wk gestation. The blood laboratory data during pregnancy and the breast milk after pregnancy were also normal. The results suggest that factors other than maternal weight gain alone should be considered in the evaluation of nutritional status for the pregnant woman.
Collapse
Affiliation(s)
- K Uchide
- Department of Obstetrics and Gynecology, School of Medicine, Kanazawa University, Ishikawa, Japan
| | | | | | | | | |
Collapse
|
15
|
Abstract
More than 12,000 pregnant patients in the United States per year have conditions normally evaluated by esophagogastroduodenoscopy (EGD). More than 6000 pregnant patient in the United States per year have conditions normally evaluated by sigmoidoscopy or colonoscopy. Endoscopy during pregnancy raises the unique issue of fetal safety, and endoscopic medications comprise a significant component of fetal risks from endoscopy. This article analyzes the safety of endoscopic medications during pregnancy, reviews the literature on the safety of gastrointestinal endoscopy during pregnancy, proposes guidelines for endoscopic indications during pregnancy, and describes modifications of gastrointestinal endoscopy during pregnancy to increase fetal and maternal safety.
Collapse
Affiliation(s)
- M S Cappell
- Department of Medicine, Maimonides Medical Center, Brooklyn, New York, USA
| |
Collapse
|
16
|
Affiliation(s)
- N J Shaheen
- Division of Digestive Diseases and Nutrition, University of North Carolina, Chapel Hill 27599-7080, USA
| | | | | | | |
Collapse
|
17
|
Wong M, Apodaca CC, Markenson MG, Yancey M. Nutrition management in a pregnant comatose patient. Nutr Clin Pract 1997; 12:63-7. [PMID: 9155403 DOI: 10.1177/011542659701200263] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Major intracranial injury or disease during pregnancy resulting in a comatose state presents unique and complex management challenges. Our patient is a 34-year-old woman who suffered a closed-head injury associated with spousal abuse at 22 weeks' gestation. This injury resulted in a large right frontoparietal hematoma that was subsequently evacuated via a right frontotemporal craniotomy 5 days after the injury. She remained in a vegetative state postoperatively. Aggressive nutrition support was provided with enteral feedings through a nasoduodenal feeding tube. Mild oligohydramnios was detected at 30 weeks' gestation and was subsequently determined to be due to preterm premature rupture of membranes. She was managed until 33 weeks' gestation, when signs of chorioamnionitis were noted. She then underwent a primary cesarean delivery and was delivered of an appropriate-for-gestational-age 2150-g viable male infant. The patient had progressive improvement in her mental status with occupational and physical therapy and was discharged on the 29th postpartum day. This case presents the nutrition and medical challenges of maintaining adequate maternal and fetal health in a pregnant comatose patient.
Collapse
Affiliation(s)
- M Wong
- Nutrition Care Division, Tripler Army Medical Center, Honolulu, Hawaii, USA
| | | | | | | |
Collapse
|
18
|
Clevenger FW, Rodriguez DJ. Decision-making for enteral feeding administration: the why behind where and how. Nutr Clin Pract 1995; 10:104-13. [PMID: 7616930 DOI: 10.1177/0115426595010003104] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Enteral nutrition has become the preferred route of nutrient administration. Because of vigorous attempts to deliver nutrient enterally in expanded patient groups, many different locations for enteral access have been advocated along with a variety of methods related to rate and pattern of delivery. Because all modes of delivery are not compatible with all sites of access and both need to be tailored to specific subsets of patients, confusion can develop regarding where and how enteral nutrients are best delivered and why. In an era when such a high priority has been placed on feeding through the enteral route, a review of the methods and rationale behind the ever-expanding choices of enteral access is timely.
Collapse
|