Question about NMB reversal in pregnancy

[Nunchuk]

Hi folks,

Quick physiological question(s) for you guys. If I'm understanding it correctly, is the recommendation to use neostigmine/atropine rather than neostigmine/glycopyrrolate in pregnancy based on the concept that placental transfer of neostigmine is more extensive than that of glycopyrrolate, and thus using atropine (which more readily crosses placenta than glyco) can ameliorate any bradycardia induced by neostigmine?

Also, out in practice, are you guys routinely using neostigmine/atropine to reverse neuromuscular blockade in pregnant patients that may require GA? Do any of you continue to use suggammadex despite the theoretical antagonism with progesterone?

I tried to look up evidence for these, but didn't find anything too convincing one way or the other and wanted to see what you experienced folks are doing out in practice. At my training institution, our attendings had widely varying opinions on the topic.

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[dannyboy1]

No suggamadex?

 

[D P356]

This is definitely a gray area.

When faced with this situation, I’m more inclined to not use non-depolarizers because of the situation you present.

Neostigmine and atropine would be the most feasible to me if I had to give anything.

I prefer to avoid sugammadex in pregnant patients, especially during organogenesis of first trimester.

You could utilize a succinylcholine gtt.

 

[gunnershow]

Do you really need the roc after sux wears off? By that point, baby is out and you can give opioid

 

[mdo1738]

Do you really need the roc after sux wears off? By that point, baby is out and you can give opioid

I don’t think OP is talking about C-sections…probably referring to the not-infrequent occurrence of non-obstetric surgery on pregnant patients. I did tons of ortho trauma cases in residency on pregnant women who had been in MVCs, and usually did neo/atropine precisely for the reason you said above. Though I had a few attendings who did sugammadex in that situation.

My opinion is, I don’t deal in theoreticals, but rather evidence, so I’m not concerned about the progesterone/sugammadex thing, which has no evidence. However, neo/atropine works just fine and, from a medicolegal perspective, is what you probably should do in most cases, as it wouldn’t be fun to defend sugammadex in court if something happened to the baby. But if the risk/reward ratio of a patient means you absolutely have to have guaranteed full reversal (like a 500 pound pregnant patient; these women do indeed reproduce through some mystery of physics), I would say the benefit of sugammadex outweighs any theoretical risk.