Advertisement

Gastric point-of-care ultrasound (PoCUS) during pregnancy and the postpartum period: a systematic review

      Highlights

      • PoCUS is point-of-care ultrasound.
      • Evidence-based suggestions for using gastric PoCUS in obstetrics.
      • Antral cross-sectional area a valid surrogate for gastric fluid volume estimation.
      • Gastric emptying of fluid, not food, appears unaffected by term pregnancy or labour.
      • Gastric PoCUS adds information facilitating individual aspiration risk assessment.

      Abstract

      Personalised risk assessment of the likelihood of pulmonary aspiration is recommended for pregnant women undergoing general anaesthesia and gastric point-of-care ultrasound (PoCUS) may help to achieve this. Traditionally, risk assessment is based upon adherence to fasting times, but gastric emptying may vary during pregnancy and surgery often needs to be expedited. We systematically reviewed the evidence for gastric PoCUS up to August 2018 in pregnant and postpartum women to determine whether it can identify and quantify stomach contents, provide aspiration risk assessment via qualitative or quantitative means, and determine how gastric emptying is affected by pregnancy. Twenty-two articles comprising 1050 participants were included and studies were classified by qualitative or quantitative findings. The evidence suggests that gastric PoCUS is a reliable and feasible method of imaging the stomach in pregnancy in clinical practice. Qualitative assessment via the Perlas grading system can provide rapid assessment of gastric volume states. If fluid is visible, identification of patients at high risk of pulmonary aspiration requires measurement of antral cross-sectional area. Cut-off values of 608 mm2 and 960 mm2 are recommended in the semi-recumbent and right lateral semi-recumbent positions, respectively. Validated methods to quantify stomach volumes are available, however their usefulness is currently restricted to research. Gastric PoCUS also provides evidence that gastric emptying of ingested food is delayed by term pregnancy, labour and during the early postpartum period. However, the passage of fluids through the stomach appears unaffected throughout the peripartum period.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to International Journal of Obstetric Anesthesia
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Lienhart A.
        • Auroy Y.
        • Pequignot F.
        • et al.
        Survey of anesthesia-related mortality in France.
        Anesthesiology. 2006; 105: 1087-1097
        • Mendelson C.L.
        The aspiration of stomach contents into the lungs during obstetric anesthesia.
        Am J Obstet Gynecol. 1946; 52: 191-205
        • Quinn A.C.
        • Milne D.
        • Columb M.
        • Gorton H.
        • Knight M.
        Failed tracheal intubation in obstetric anaesthesia: 2 yr national case-control study in the UK.
        Br J Anaesth. 2013; 110: 74-80
        • Cook T.M.
        • Woodall N.
        • Frerk C.
        Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: anaesthesia.
        Br J Anaesth. 2011; 106: 617-631
      1. Knight M, Nair M, Tuffnell D, et al. on behalf of MBRRACE-UK. Saving Lives, Improving Mothers' Care - Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2013-15. Oxford: National Perinatal Epidemiology Unit, University of Oxford 2017.

        • Vanner R.G.
        • Goodman N.W.
        Gastro-oesophageal reflux in pregnancy at term and after delivery.
        Anaesthesia. 1989; 44: 808-811
        • Van de Putte P.
        • Perlas A.
        The link between gastric volume and aspiration risk. In search of the Holy Grail?.
        Anaesthesia. 2018; 73: 274-279
        • Moher D.
        • Liberati A.
        • Tetzlaff J.
        • Altman D.G.
        Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
        J Clin Epidemiol. 2009; 62: 1006-1012
        • Perlas A.
        • Davis L.
        • Khan M.
        • Mitsakakis N.
        • Chan V.W.
        Gastric sonography in the fasted surgical patient: a prospective descriptive study.
        Anesth Analg. 2011; 113: 93-97
        • Ouzzani M.
        • Hammady H.
        • Fedorowicz Z.
        • Elmagarmid A.
        Rayyan-a web and mobile app for systematic reviews.
        Syst Rev. 2016; 5: 210
        • Higgins J.P.
        • Altman D.G.
        • Gotzsche P.C.
        • et al.
        The Cochrane Collaboration's tool for assessing risk of bias in randomised trials.
        BMJ. 2011; 343d5928
        • Wang Y.R.
        • Fu X.C.
        • Zheng Z.
        • et al.
        Relationship between intake volume of carbohydrates solution and gastric emptying time in termed parturients.
        Zhonghua Yi Xue Za Zhi. 2018; 98: 2083-2087
        • Sakurai Y.
        • Uchida M.
        • Mimura F.
        • Aiba J.
        Ultrasound assessment of gastric content in cesarean delivery patients: an observational study.
        Masui. 2014; 63: 1097-1102
        • Van de Putte P.V.
        • Perlas A.
        Term pregnant patients have similar gastric volumes to non-pregnant females: a single-centre cohort study.
        Br J Anaesth. 2019; 122: 79-85
        • Scrutton M.J.
        • Metcalfe G.A.
        • Lowy C.
        • Seed P.T.
        • O'Sullivan G.
        Eating in labour. A randomised controlled trial assessing the risks and benefits.
        Anaesthesia. 1999; 54: 329-334
        • Radberg G.
        • Asztely M.
        • Cantor P.
        • Rehfeld J.F.
        • Jarnfeldt-Samsioe A.
        • Svanvik J.
        Gastric and gallbladder emptying in relation to the secretion of cholecystokinin after a meal in late pregnancy.
        Digestion. 1989; 42: 174-180
        • Vial F.
        • Hime N.
        • Feugeas J.
        • Thilly N.
        • Guerci P.
        • Bouaziz H.
        Ultrasound assessment of gastric content in the immediate postpartum period: a prospective observational descriptive study.
        Acta Anaesthesiol Scand. 2017; 61: 730-739
        • Bataille A.
        • Rousset J.
        • Marret E.
        • Bonnet F.
        Ultrasonographic evaluation of gastric content during labour under epidural analgesia: a prospective cohort study.
        Br J Anaesth. 2014; 112: 703-707
        • Vallejo M.C.
        • Cobb B.T.
        • Steen T.L.
        • Singh S.
        • Phelps A.L.
        Maternal outcomes in women supplemented with a high-protein drink in labour.
        Aust N Z J Obstet Gynaecol. 2013; 53: 369-374
        • Kubli M.
        • Scrutton M.J.
        • Seed P.T.
        • O'Sullivan G.
        An evaluation of isotonic “sport drinks” during labor.
        Anesth Analg. 2002; 94: 404-408
        • Barboni E.
        • Mancinelli P.
        • Bitossi U.
        • et al.
        Ultrasound evaluation of the stomach and gastric emptying in pregnant women at term: a case-control study.
        Minerva Anestesiol. 2016; 82: 543-549
        • Chiloiro M.
        • Darconza G.
        • Piccioli E.
        • De Carne M.
        • Clemente C.
        • Riezzo G.
        Gastric emptying and orocecal transit time in pregnancy.
        J Gastroenterol. 2001; 36: 538-543
        • Wong C.A.
        • Loffredi M.
        • Ganchiff J.N.
        • Zhao J.
        • Wang Z.
        • Avram M.J.
        Gastric emptying of water in term pregnancy.
        Anesthesiology. 2002; 96: 1395-1400
        • Wong C.A.
        • McCarthy R.J.
        • Fitzgerald P.C.
        • Raikoff K.
        • Avram M.J.
        Gastric emptying of water in obese pregnant women at term.
        Anesth Analg. 2007; 105: 751-755
        • Arzola C.
        • Cubillos J.
        • Perlas A.
        • Downey K.
        • Carvalho J.C.
        Interrater reliability of qualitative ultrasound assessment of gastric content in the third trimester of pregnancy.
        Br J Anaesth. 2014; 113: 1018-1023
        • Carp H.
        • Jayaram A.
        • Stoll M.
        Ultrasound examination of the stomach contents of parturients.
        Anesth Analg. 1992; 74: 683-687
        • Jayaram A.
        • Bowen M.P.
        • Deshpande S.
        • Carp H.M.
        Ultrasound examination of the stomach contents of women in the postpartum period.
        Anesth Analg. 1997; 84: 522-526
        • Arzola C.
        • Perlas A.
        • Siddiqui N.T.
        • Carvalho J.C.
        Bedside Gastric Ultrasonography in term pregnant women before elective cesarean delivery: A prospective cohort study.
        Anesth Analg. 2015; 121: 752-758
        • Arzola C.
        • Perlas A.
        • Siddiqui N.T.
        • Downey K.
        • Ye X.Y.
        • Carvalho J.C.A.
        Gastric ultrasound in the third trimester of pregnancy: a randomised controlled trial to develop a predictive model of volume assessment.
        Anaesthesia. 2018; 73: 295-303
        • Hakak S.
        • McCaul C.L.
        • Crowley L.
        Ultrasonographic evaluation of gastric contents in term pregnant women fasted for six hours.
        Int J Obstet Anesth. 2018; 34: 15-20
        • Rouget C.
        • Chassard D.
        • Bonnard C.
        • Pop M.
        • Desgranges F.P.
        • Bouvet L.
        Changes in qualitative and quantitative ultrasound assessment of the gastric antrum before and after elective caesarean section in term pregnant women: a prospective cohort study.
        Anaesthesia. 2016; 71: 1284-1290
        • Roukhomovsky M.
        • Zieleskiewicz L.
        • Diaz A.
        • et al.
        Ultrasound examination of the antrum to predict gastric content volume in the third trimester of pregnancy as assessed by MRI: a prospective cohort study.
        Eur J Anaesthesiol. 2018; 35: 379-389
        • Zieleskiewicz L.
        • Boghossian M.C.
        • Delmas A.C.
        • et al.
        Ultrasonographic measurement of antral area for estimating gastric fluid volume in parturients.
        Br J Anaesth. 2016; 117: 198-205
        • Jay L.
        • Zieleskiewicz L.
        • Desgranges F.P.
        • et al.
        Determination of a cut-off value of antral area measured in the supine position for the fast diagnosis of an empty stomach in the parturient: a prospective cohort study.
        Eur J Anaesthesiol. 2017; 34: 150-157
        • Desgranges F.P.
        • Simonin M.
        • Barnoud S.
        • et al.
        Prevalence and prediction of higher estimated gastric content in parturients at full cervical dilatation: A prospective cohort study.
        Acta Anaesthesiol Scand. 2019; 63: 27-33
        • Van de Putte P.
        • Perlas A.
        Ultrasound assessment of gastric content and volume.
        Br J Anaesth. 2014; 113: 12-22
        • Perlas A.
        • Van de Putte P.
        • Van Houwe P.
        • Chan V.W.
        I-AIM framework for point-of-care gastric ultrasound.
        Br J Anaesth. 2016; 116: 7-11
        • Bolondi L.
        • Bortolotti M.
        • Santi V.
        • Calletti T.
        • Gaiani S.
        • Labo G.
        Measurement of gastric emptying time by real-time ultrasonography.
        Gastroenterology. 1985; 89: 752-759
        • Perlas A.
        • Mitsakakis N.
        • Liu L.
        • et al.
        Validation of a mathematical model for ultrasound assessment of gastric volume by gastroscopic examination.
        Anesth Analg. 2013; 116: 357-363
        • Bouvet L.
        • Desgranges F.P.
        • Chassard D.
        • Zieleskiewicz L.
        Using a composite ultrasound scale to assess gastric contents.
        Anaesthesia. 2018; 73: 909-910
        • Bouvet L.
        • Mazoit J.X.
        • Chassard D.
        • Allaouchiche B.
        • Boselli E.
        • Benhamou D.
        Clinical assessment of the ultrasonographic measurement of antral area for estimating preoperative gastric content and volume.
        Anesthesiology. 2011; 114: 1086-1092
        • Engelhardt T.
        • Webster N.R.
        Pulmonary aspiration of gastric contents in anaesthesia.
        Br J Anaesth. 1999; 83: 453-460
        • Read M.S.
        • Vaughan R.S.
        Allowing pre-operative patients to drink: effects on patients' safety and comfort of unlimited oral water until 2 hours before anaesthesia.
        Acta Anaesthesiol Scand. 1991; 35: 591-595
        • Phillips S.
        • Hutchinson S.
        • Davidson T.
        Preoperative drinking does not affect gastric contents.
        Br J Anaesth. 1993; 70: 6-9
        • Harter R.L.
        • Kelly W.B.
        • Kramer M.G.
        • Perez C.E.
        • Dzwonczyk R.R.
        A comparison of the volume and pH of gastric contents of obese and lean surgical patients.
        Anesth Analg. 1998; 86: 147-152
        • Hausel J.
        • Nygren J.
        • Lagerkranser M.
        • et al.
        A carbohydrate-rich drink reduces preoperative discomfort in elective surgery patients.
        Anesth Analg. 2001; 93: 1344-1350
        • Holt S.
        • Cervantes J.
        • Wilkinson A.A.
        • Wallace J.H.
        Measurement of gastric emptying rate in humans by real-time ultrasound.
        Gastroenterology. 1986; 90: 918-923
        • Bateman D.N.
        • Whittingham T.A.
        Measurement of gastric emptying by real-time ultrasound.
        Gut. 1982; 23: 524-527
        • Ishigami S.
        • Yoshinaka H.
        • Sakamoto F.
        • et al.
        Preoperative assessment of the depth of early gastric cancer invasion by transabdominal ultrasound sonography (TUS): a comparison with endoscopic ultrasound sonography (EUS).
        Hepatogastroenterology. 2004; 51: 1202-1205
        • Wong M.
        • Shum S.
        • Chau W.
        • Cheng C.
        Carcinoma of stomach detected by routine transabdominal ultrasound.
        Biomed Imaging Intervention. 2010; 6e39
        • Perlas A.
        • Arzola C.
        • Van de Putte P.
        Point-of-care gastric ultrasound and aspiration risk assessment: a narrative review.
        Can J Anaesth. 2018; 65: 437-448
        • Lucas D.N.
        • Elton C.D.
        Through a glass darkly – ultrasound imaging in obstetric anaesthesia.
        Anaesthesia. 2016; 71: 617-622
        • Kruisselbrink R.
        • Arzola C.
        • Endersby R.
        • Tse C.
        • Chan V.
        • Perlas A.
        Intra- and interrater reliability of ultrasound assessment of gastric volume.
        Anesthesiology. 2014; 121: 46-51
        • Arzola C.
        • Carvalho J.C.
        • Cubillos J.
        • Ye X.Y.
        • Perlas A.
        Anesthesiologists' learning curves for bedside qualitative ultrasound assessment of gastric content: a cohort study.
        Can J Anaesth. 2013; 60: 771-779
        • Han T.H.
        • Brimacombe J.
        • Lee E.J.
        • Yang H.S.
        The laryngeal mask airway is effective (and probably safe) in selected healthy parturients for elective Cesarean section: a prospective study of 1067 cases.
        Can J Anaesth. 2001; 48: 1117-1121
        • Yao W.Y.
        • Li S.Y.
        • Sng B.L.
        • Lim Y.
        • Sia A.T.
        The LMA Supreme in 700 parturients undergoing Cesarean delivery: an observational study.
        Can J Anaesth. 2012; 59: 648-654
        • Smith I.
        • Kranke P.
        • Murat I.
        • et al.
        Perioperative fasting in adults and children: guidelines from the European Society of Anaesthesiology.
        Eur J Anaesthesiol. 2011; 28: 556-569