© Georg Thieme Verlag KG Stuttgart · New York
Percutaneous endoscopic gastrostomy placement during pregnancy in the critical care setting
21 December 2010 (online)
A 37-year-old woman with a past medical history of untreated hypertension presented with unresponsiveness at 28 weeks of gestation. Computed tomography (CT) revealed a pontine hemorrhage with massive edema. After 2 weeks of nasogastric feeding, the patient received a percutaneous endoscopic gastrostomy (PEG) tube. At 31 weeks, cesarean section was performed and a 1660-g preterm infant was delivered. The patient continued on PEG feeding and slight neurological improvement was seen.
Optimal nutritional requirements are critical in the intensive care unit as evidenced by the critical care and pancreatitis guidelines . During pregnancy, optimal nutrition is essential in order to minimize maternal and neonatal morbidity . Long-term nasogastric feeding is limited by patient tolerability and nasal septal necrosis. The long-term side effects of total parenteral nutrition limit its usage during pregnancy . Thus, PEG becomes an important option for long-term enteral feeding . However, concerns about uterine damage, fetal injury, premature labor, and infections have restricted the application of PEG tube placement in pregnant women. Our study reviews the safety and feasibility of PEG tube placement in pregnancy in the critical care setting.
There were no major complications with PEG tube placement in the 11 reported cases in the literature        , as well as in our case ([Table 1]). PEG enteral nutritional support was provided for an average of 14 weeks in the literature. During pregnancy, PEG tube placement is a feasible procedure for optimal enteral nutrition in the critical care setting. It is also feasible to perform PEG tube placement in the third trimester of pregnancy. Special precautions ([Table 2]) are critical for PEG tube placement during pregnancy, and knowledge of these precautions is essential.
Table 1 Features of cases where a percutaneous endoscopic gastrostomy (PEG) tube was placed during pregnancy. Reference Patient’s age, years Gestational age at presentation, weeks Indication for PEG tube Duration of nutritional support, weeks Delivery type/gestational age, weeks Birth weight, g Maternal and fetal outcome Special precautions taken Koh & Lipkin 1993 24 13 Motor vehicle accident with coma 24 Cesarean section/37 3680 Mother improved; baby well n. a. Shaheen et al. 1997 19 17 Anorexia and odynophagia due to esophagitis 5 Natural vaginal delivery/24 2440 Mother improved; baby well – Ultrasound guidance to define the dome of the uterus– Repeated adjustments were required to avoid pressure necrosis 34 24 Congenital myotonic dystrophy and mental retardation n. a. Cesarean section/30 1080 Both mother and baby well – Same as above– Abdominal binder over PEG tube to guard against accidental dislodgement Godil & Chen 1998 18 16 Anorexia nervosa 10 Natural vaginal delivery/39 2782 Both mother and baby well – Antibiotic prophylaxis– Sedation with midazolam and intravenous meperidine 14 29 Hyperemesis gravidarum 10 Natural vaginal delivery/39 3000 Both mother and baby well Serrano et al. 1998 25 11 Hyperemesis gravidarum 18 Natural vaginal delivery/40 4000 Both mother and baby well – Radiograph with pelvic shielding to verify the position of jejunal tube 25 15 Hyperemesis gravidarum 20 Natural vaginal delivery/36 2750 Both mother and baby well O’Connell et al. 2000 24 11 Chronic malnutrition Cesarean section/33 1620 Both mother and baby well n. a. Wejda et al. 2003 41 8 Apallic syndrome 19 Cesarean section/27 820 Mother continued on nutrition therapy; baby well n. a. Irving 2004 32 17 Severe hyperemesis gravidarum 18 Cesarean section/35 2300 Both mother and baby well – Generalized anesthesia with antibiotic– Continuous ultrasound guidance and monitoring of fetus Fedorka 2004 34 10 Motor vehicle accident 24 Cesarean section/34 2608 Mother continued on vegetative state support; baby well n. a. Senadhi, Chaudhary & Dutta 2010 (current report) 37 27 Intracranial bleed (pontine hemorrhage) 2 Cesarean section/31 1660 Mother continued on nutrition therapy with slight neurological improvement; baby well – Ultrasound guidance with fundal monitoring before the procedure– Continuous fetal monitoring by an obstetric nurse– Operating room ready for precipitated labor n. a., not applicable.
Table 2 Recommendations for percutaneous endoscopic gastrostomy (PEG) tube placement during pregnancy. Recommendations during pregnancy Ultrasound to define the dome of the uterus before the procedure Ultrasound indentation and transillumination displaying PEG can be separated from the rib cage and the uterus Continuous fetal monitoring by an obstetric nurse throughout the procedure Operating room ready for precipitated labor during PEG placement Monitor fetal growth and development through ultrasound, especially in second and third trimester Careful monitoring of the tension on the external bumper of the PEG to avoid excess external bumper pressure as the uterus enlarges Repeated adjustments are needed to avoid pressure necrosis from the tension in the area from the internal and external bumpers Procedural sedation can be safely achieved with propofol (pregnancy category B)
In conclusion, a review of the literature clearly shows that the risk of malnutrition in pregnancy greatly exceeds the risk of PEG placement.
Competing interests: None
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Dr. Viplove Senadhi
Johns Hopkins University/Sinai Hospital Program in Internal Medicine, Sinai Hospital
2401 West Belvedere Avenue
Baltimore, Maryland 21215, USA