Anaesthesiologists Seek Guidance for Pre-sugammadex Pregnancy Testing

According to the American Society of Anesthesiologists (2021), pre-procedure pregnancy testing should be offered but not mandated in females of childbearing age.[1] According to the American College of Obstetricians and Gynecologists’ Committee on Obstetric Practice in collaboration with the American Society of Anesthesiologists (2019), none of the currently used anaesthetic agents is a teratogen.[2] However, the question is whether they included sugammadex in their generalisation. Moreover, it is unclear whether the debatable risk of early pregnancy loss may also be considered teratogenicity. According to the Society for Obstetric Anesthesia and Perinatology (2019), sugammadex should be avoided in patients in early pregnancy; however, the Society for Obstetric Anesthesia and Perinatology (2019) has also stated that sugammadex use is safe in females of childbearing age provided that they have been counselled preoperatively and/or postoperatively about using additional non-hormonal contraception for 7 days after sugammadex use.[3] Herein lies the dilemma for anaesthesiologists who are nowadays more likely to use sugammadex for reversing intraoperative neuromuscular blockade. The dilemma is that without pre-procedure pregnancy testing, early pregnancy precluding the use of sugammadex will not get detected. Thus, the anaesthesiologists should seek guidance from their societies regarding the available options for them when planning to use sugammadex. There may be a few options. First, females of childbearing age scheduled to undergo procedures without neuromuscular blockade may be able to refuse the offered pre-procedure pregnancy testing. Second, females of childbearing age scheduled to undergo procedures with neuromuscular blockade may be counselled about the need to detect incidental early pregnancy so as to avoid the use of sugammadex if detected to be pregnant. However, females of childbearing age refusing pre-procedure pregnancy testing can have intraoperative neuromuscular blockade reversed with a traditional combination of neostigmine and atropine or glycopyrrolate. Finally, it may have to be considered whether females of childbearing age can be counselled preoperatively about potential intraoperative urine sample collection from an indwelling (Foley) catheter or intermittent (straight) catheter. This may allow intraoperative pre-sugammadex pregnancy testing when emergent neuromuscular blockade reversal with sugammadex may be warranted despite no documented pre-procedure pregnancy testing. Interestingly, irrefutable scientific evidence in pregnant humans deeming sugammadex use safe during any stage of pregnancy is still missing because the true incidence of early pregnancy loss with sugammadex use is still unknown; theoretical risks based on pre-clinical studies have not been clinically refuted yet because clinical studies to date have been small sized.[4–7] In the interim, the above-mentioned dilemma and corresponding options should inspire societies of anaesthesiologists as well as obstetricians and gynaecologists to update their consensus statements for including their recommendations about pre-sugammadex pregnancy testing. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.