The first laparoscopies in pregnancy were performed in the early 1990s. Since then, laparoscopy has been widely adopted as an alternative to laparotomy for the diagnosis and treatment of surgical conditions arising in pregnancy. Accordingly, surgeons should be aware of the distinct physiologic changes during gestation that may require technique modification. With these adjustments, gravidas can benefit from advantages of laparoscopy similar to those experienced by nonpregnant patients.
Laparoscopy was previously considered contraindicated during pregnancy because of concerns regarding its cardiopulmonary impairment and potential trauma to the fetus and gravid uterus. However, surgeons knowledgeable of these consequences can often minimize or avoid their effect.
Laparoscopy produces distinct cardiovascular and pulmonary changes, which may be particularly important for a gravida. These include: (1) absorption of carbon dioxide (CO2) across the peritoneum and into circulation, (2) increased intraabdominal pressure generated by the pneumoperitoneum, and (3) Trendelenburg positioning (Table 15-1). These changes may be exacerbated in pregnancy due to maternal physiologic changes and the gravid uterus.
First, laparoscopy requires abdominal wall elevation, and this is usually achieved by instilling gas into the abdominal cavity. In most cases, CO2 is selected to create this pneumoperitoneum and offers the advantages of low combustibility and rapid absorption. However, absorption of this gas across the peritoneum and into blood can lead to systemic CO2 accumulation and hypercarbia. In turn, hypercarbia produces sympathetic stimulation that raises systemic and pulmonary vascular resistance and increases blood pressure. Moreover, if hypercarbia is not cleared by compensatory ventilation, acidemia develops. From this, direct myocardial contractility depression and decreased cardiac output can follow (Ho, 1995; Reynolds, 2003; Sharma, 1996). Hypercarbia can also lead to tachycardia and arrhythmia. Fortunately, the effects of CO2 are typically compensated by controlled ventilation by anesthesia staff.
Second, insufflation of any gas elevates intraabdominal pressure. Pneumoperitoneum pressures above 10 mm Hg have consistently led to a 25- to 35-percent reduction in cardiac output regardless of patient positioning (Johannsen, 1989; Torrielli, 1990). This decline is attributable to pressure-mediated pooling of blood in the lower extremities, consequent decreased venous return, and a compensatory increase in systemic vascular resistance. Diminished venous return and cardiac output can lower uteroplacental perfusion, which may have fetal effects. In pregnancy, this can be partially compensated by using low insufflation pressures and a maternal left-lateral tilt (p. 248). Of other concerns, a distention pressure of 20 mm Hg reduces renal blood flow, glomerular filtration rate, mesenteric arterial flow, and intestinal mucosal blood flow (Diebel, 1992; Richards, 1983). These hemodynamic changes may hold more significance for those with impaired cardiac function, anemia, or hypovolemia. This may be particularly relevant for acute indications associated with significant bleeding.
Last, the diaphragm is displaced upward by intraabdominal pressure from the pneumoperitoneum. This is accentuated by organs also being pushed cephalad against the diaphragm by the gravid uterus and by Trendelenburg positioning. Moreover, insufflation pressures stiffen the diaphragm and chest wall. Together, these alterations lead to higher required airway pressures to achieve adequate mechanical ventilation. Also, as the diaphragm moves up, lung volume and functional residual capacity are diminished, which in turn reduces the reserve volume for oxygenation. Remember that in pregnancy, functional residual capacity also normally declines. Lower lung volume also favors a tendency for the lung to collapse and to develop atelectasis. This can create ventilation and perfusion mismatching and an increased alveolar-arterial oxygen gradient. Together, all of these factors favor poorer oxygenation.
Despite these physiologic changes, absolute contraindications to pneumoperitoneum are few. These include increased intracranial pressure, acute angle glaucoma, and retinal detachment.
Some of the physiologic limitations of laparoscopy can be mitigated in part by laparoscopic surgery performed without pneumoperitoneum, that is, gasless laparoscopy. With this technique, the abdominal wall is mechanically elevated by fan-blade-like wings. These blades are fanned out once inside the abdomen, are applied against the inner anterior abdominal peritoneum, and are elevated by a mechanical lift. Although infrequently used, gasless laparoscopy may have benefits for the gravida. It eliminates concerns regarding CO2 exposure and pressure-related vascular changes and permits the use of regional anesthesia for pelvic procedures (Pelosi, 1997a). Moreover, because intraperitoneal gas retention is not required during surgery, instruments may be inserted without cannulas. This results in smaller abdominal wall incisions.
Of drawbacks, gasless laparoscopy often provides only limited exposure in morbidly obese women. Also, without the pressure created by a pneumoperitoneum, venous oozing at surgical sites may be increased. Last, because this approach is not widely used, necessary equipment is frequently not available. Overall, the reported use of gasless laparoscopy in pregnancy is limited (Sesti, 2013).
In pregnancy, possible iatrogenic uterine trauma is a concern, and this restricts use of some laparoscopic entry and uterine manipulation techniques. During laparoscopic entry, the uterus may be inadvertently punctured or lacerated, particularly when ports are not placed sufficiently cephalad. Perforation of the gravid uterus can result in miscarriage or premature rupture of membranes, although healthy live pregnancies have been reported (Joumblat, 2012; Kho, 2009). To safely gain abdominal entry, suitable techniques are described on page 248.
In late pregnancy, the enlarged uterus may obscure viewing of the pelvic sidewalls and limit exposure in the pelvis and lower abdomen. A large uterus may also hinder needed instrument mobility. In nonpregnant women, traditional intrauterine manipulators are used to overcome these constraints. However, these enter the uterine cavity and thus are contraindicated for pregnancy. Alternative methods are offered on page 254.
Intraoperatively, laparoscopy provides the surgeon with a panoramic view of the pelvis and upper abdomen to evaluate intraabdominal pathology. Technical advantages include optical magnification, enhanced illumination, and improved viewing of deep structures. In addition, the smaller size of laparoscopic instrumentation and the magnified view aid delicate and precise dissection.
Postoperatively, laparoscopy offers several advantages that stem mainly from the smaller abdominal wall incisions. Compared with laparotomy, these benefits include shorter hospital stays, lower postoperative ileus rates, fewer wound complications, and faster activity resumption (Nieboer, 2009; Pearl, 2011). Diminished postoperative pain also reduces narcotic demands. Less narcotic depression and smaller incisions improve postoperative pulmonary function. For obese patients, who traditionally have demonstrated a high frequency of wound complications, the prospect of avoiding laparotomy carries proven benefit. In addition to these immediate benefits, randomized, prospective animal and human studies show decreased adhesion formation with laparoscopic surgery (Luciano, 1989; Lundorff, 1991).
In experienced hands, laparoscopy can be used to concomitantly diagnose and treat many acute abdominal conditions. In two large institutional reviews, the frequency of intraabdominal surgery in pregnancy for nonobstetric indications approximated 0.2 percent (Allen, 1989; Kort, 1993). In these studies, the most frequent indications were appendicitis, adnexal mass, and cholecystitis.
Of these, acute appendicitis complicated 1 in every 500 to 2000 pregnancies and is the most common indication for laparoscopy in gravidas (Andersen, 1999; Burke, 2015; Mourad, 2000). In studies of nonpregnant women, several randomized trials show lower rates of wound infections, less postoperative pain, and shorter hospital stay with minimally invasive surgery (MIS) compared with laparotomy. Despite these advantages, laparoscopic appendectomy is associated with a higher rate of intraabdominal abscess, longer operative times, and greater hospital charges (Sauerland, 2010). However, in cases in which the diagnosis is less clear but appendicitis is suspected, laparoscopy offers an opportunity to view the entire abdominal cavity for alternative pathology. This compares with the limited view through a typical minilaparotomy incision. This benefit may be especially true if the appendix appears grossly normal.
Notably, the risk of miscarriage may be increased with laparoscopy. One metaanalysis of 11 studies of laparoscopic appendectomy in pregnancy demonstrated an increased relative risk (1.91) for miscarriage following MIS compared with laparotomy to remove the appendix (Wilasrusmee, 2012). Operative times, wound infection rates, preterm delivery rates, ultimate birthweights, and Apgar scores did not differ between the surgery routes. Most procedures were performed in the second trimester, although the range of gestational ages was broad. Notably, this study was criticized for not controlling for confounders such as patient age, fetal gestational age, and complications of appendicitis. Authors of a more recent systematic review indicate that the level of evidence is not strong enough to demonstrate a preferred approach to appendectomy. They concede that laparoscopy may be associated with a higher risk of miscarriage (Walker, 2014).
Gallstones often develop in pregnancy because of the increased cholesterol saturation of bile and decreased gallbladder motility, which leads to stasis. Acute cholecystitis secondary to stones is also common and is the second most frequent indication for nonobstetric surgery during pregnancy.
Currently, the decision to proceed with surgical treatment of acute cholecystitis is based on the same criteria used for nonpregnant women. In the past, most favored medical therapy. However, the recurrence rate during the same pregnancy is high, and affected women ultimately require cholecystectomy for persistent symptoms. Moreover, if cholecystitis recurs later in gestation, preterm labor is more likely and cholecystectomy is technically more difficult. Date and coworkers (2008) reviewed the literature and found no increased risk of preterm birth or fetal demise for operative compared with conservative management. There was, however, a significantly higher rate of fetal death from gallstone pancreatitis when women were managed conservatively. Thus, most surgeons advocate cholecystectomy upon initial admission for acute cholecystitis due to the high risk of recurrence with conservative management and the overall safety of the procedure.
There should be no reluctance to perform cholecystectomy via laparoscopy for a gravida. This is supported by a large body of evidence regarding the safety and efficacy of laparoscopic cholecystectomy in pregnancy and during any trimester (Eichenberg, 1996; Geburz, 1997; Tarraza, 1997). In an analysis of a large surgical database, laparoscopic cholecystectomy resulted in shorter operative times and lengths of stay and fewer minor complications compared with laparotomy (Cox, 2016). Furthermore, another large database analysis demonstrates that surgeons with high surgical volumes have significantly fewer maternal and fetal complications compared with low-volume surgeons (Kuy, 2009). In sum, the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) endorses laparoscopy as the preferred route for cholecystectomy in pregnant patients in any trimester (Pearl, 2011).
One source of acute pain in pregnancy is torsion of the fallopian tube and ovary. In gravidas, the adnexa may twist with greater frequency. Suggested reasons include the increased laxity of the supportive tissues of the ovaries and fallopian tubes, increased ovarian volume attributable to the corpus luteum, and uterine growth, which can elevate the adnexa from the pelvis.
As discussed and illustrated in Chapter 14 (p. 225), laparoscopy is effective in both the diagnosis and treatment of torsion. For laparoscopy and laparotomy, several series document the safety and efficacy of detorsion and intraoperative observation for reperfusion. This is then followed by cystectomy, adnexectomy, or no further treatment. The decision to retain or excise the affected adnexum are based on the presence of infarction or suspected ovarian pathology (Bider, 1991; Mage, 1989; Morice, 1997). Importantly, if the corpus luteum is excised in the first 10 weeks of pregnancy, exogenous progesterone should be supplemented, and regimens are outlined in Chapter 18 (p. 303) (Csapo, 1973).
These are discovered in approximately 1 to 2 percent of all pregnancies (Leiserowitz, 2006). Most masses are diagnosed during routine first-trimester sonographic examination. Most are benign simple cysts, which resolve by the second trimester. However, indications for surgery during pregnancy include malignant-appearing features seen with imaging or acute symptoms. Acute findings may include intraabdominal bleeding from cyst rupture or pain from torsion or from mass effect. A full discussion of adnexal mass management is provided in Chapter 14 (p. 230). In cases requiring surgery, numerous case reports and series attest to the feasibility and effectiveness of laparoscopic treatment of adnexal masses in pregnancy (Koo, 2012; Parker, 1996; Pelosi, 1997a; Soriano, 1999).
From Duverney’s first report in 1708 through the early 1970s, the spontaneous occurrence of combined intrauterine and tubal gestation had an incidence of 1 in 30,000 pregnancies. With the advent of assisted reproductive technology (ART), treated patients carry a heterotopic gestation risk of 0.09 percent (Perkins, 2015). With early intervention, up to 70 percent of intrauterine gestations have been salvaged (Rojansky, 1996).
Patients may present with pain, and sonography demonstrates an intrauterine pregnancy (IUP) concurrent with a complex adnexal mass or free fluid in the pelvis. Such rupture at presentation is not infrequent, particularly because misdiagnosis is common. In these cases, timely surgical management is critical to avoid hemorrhagic shock.
Ideally, heterotopic gestations are diagnosed early and prior to tubal pregnancy rupture. In such cases, conservative medical treatment of the ectopic pregnancy, however, is not an option. This is because of methotrexate’s teratogenicity to the IUP.
With surgical treatment of the ectopic tubal pregnancy, goals include hemodynamic support of the patient, removal of all ectopic trophoblastic tissue, repair or excision of the damaged tube, and preservation of fertility and of the IUP in those so desiring. For most women, laparoscopic salpingectomy may be preferred as it is definitive and diminishes the risk of reintervention. This may be especially the case because monitoring for persistent trophoblastic tissue is indeterminate due to human chorionic gonadotropin contributions from the IUP. The surgical steps for laparoscopic salpingectomy are found in Chapter 8 (p. 118). Notably, for women with ruptured ectopic pregnancies who are hemodynamically unstable or in those with contraindications to laparoscopy, laparotomy offers fast entry into the abdomen for control of bleeding.
As described in Chapter 11 (p. 174), permanent transabdominal cerclage may be placed for women who are not suitable candidates for transvaginal cerclage. Such patients may have an amputated or scarred cervix or have undergone a prior transvaginal cerclage operation that failed to maintain the pregnancy. Transabdominal cerclage can be placed laparoscopically and ideally before conception. During pregnancy, placement becomes increasingly difficult as the uterus grows. Therefore, cerclage is best placed before pregnancy or at 11 to 14 weeks’ gestation. This gestational age allows for the higher miscarriage rates seen earlier in the first trimester. It also permits initial screening for aneuploidy and obvious malformation (Rand, 2003).
As discussed in Chapter 16 (p. 260), a growing body of research demonstrates promising outcomes using intrauterine endoscopy for specific fetal conditions. Termed fetoscopy, indications for the surgical treatment of severe anomalies continues to grow (Peiro, 2009). More common procedures include endoscopic ablation of aberrant vessels in twin-twin transfusion syndrome, with vasa previa, or in twin reversed arterial perfusion (TRAP) sequence. Another indication is endoscopic release of strangulating amnion strands in amnionic band syndrome. Of reconstructive surgeries, some centers are completing antenatal spina bifida closures laparoscopically. Yet, despite the intuitive fetal benefits of fetoscopic surgery, preterm labor and preterm rupture of membranes remain persistent risks (Danzer, 2003; Sala, 2014).
Limits to laparoscopic surgery can stem from characteristics of the given pathology, from surgeon skill or facility barriers, or from maternal comorbidities. Of pathology considerations, prolonged operations are avoided to minimize the exposure of both mother and fetus to anesthesia and pneumoperitoneum. Specifically, large masses or dense adhesions may obscure viewing, hinder access, increase collateral organ injury risks, and lengthen surgeries. In addition, large solid masses or cysts suspicious for cancer may be difficult to extirpate intact without significantly enlarging initial laparoscopy incisions. Diagnostic laparoscopy also may reveal a condition best approached by laparotomy. One example is unsuspected malignancy that requires surgical staging.
Of facility limitations, appropriate laparoscopic tools may not be available. Moreover, unforeseen equipment malfunction or surgical complications can develop that warrant conversion to laparotomy. In certain situations, a multidisciplinary team of anesthesiologists, obstetricians, pediatricians, and nursing staff may be needed to optimize maternal and fetal outcomes. If these requisites are not available, then the benefits of laparoscopy are weighed against those provided by laparotomy.
Maternal characteristics can often limit or complicate laparoscopic surgery. Of these, uterine size may pose a prominent obstacle by restricting visualization and limiting access and organ manipulation. Moreover, a large uterus can aggravate some of the cardiopulmonary changes described on page 240.
In the past, obesity was considered a relative contraindication for laparoscopy. However, in more recent studies, healthy obese women experienced less pain, quicker recovery, and fewer postoperative complications, such as wound infections and postoperative ileus, after laparoscopy compared with laparotomy (Eltabbakh, 1999; Scribner, 2002). That said, some outcomes may be adversely affected in obese women undergoing laparoscopy compared with normal-weight patients. Of these, higher conversion rates to laparotomy, longer operating times, and longer hospitalizations have been noted (Chopin, 2009; Heinberg, 2004; Thomas, 2006). However, this has not been found by all investigators, and overall outcomes may be superior to laparotomy (Camanni, 2010; O’Hanlan, 2003; Shah, 2015).
Certain operative parameters are altered in obese women undergoing laparoscopy. First, adequate ventilation may be difficult. In general, obese patients display reduced lung compliance that is proportional to their body mass index. Moreover, abdominal wall adiposity lowers abdominal wall compliance, which in turn elevates the pneumoperitoneum pressure required for adequate surgical space. Also, fattier omentum and mesenteric fat add to the bulk forced against the diaphragm in Trendelenburg position. As a result, increases in inspiratory resistance and decreased pulmonary compliance should be anticipated.
To assess a patient’s tolerance of these physiologic changes, a “tilt test” can be performed prior to initiation of the procedure. Following induction of general anesthesia, the patient is slowly placed into steep Trendelenburg, and cardiopulmonary parameters are briefly observed. Testing the patient’s tolerance of this position may help anticipate difficulties with airway and cardiopulmonary management, even prior to abdominal insufflation.
With morbid obesity, another surgical challenge is the anatomic distortion of the abdominal wall. In obese patients, the umbilicus remains the thinnest portion of the anterior abdominal wall and allows optimal access to the abdomen. But in these patients, anatomic landmarks can be displaced caudally and may hinder normal laparoscopic access. For this reason, the position of the umbilicus relative to underlying structures is assessed, and accommodation for deviation is made to ensure safe laparoscopic entry (Hurd, 1991; Pelosi, 1998). In addition, an open technique for laparoscopic access may be considered in cases with advanced gestational age. Access at a subxiphoid site or in the left or right upper quadrants can also be employed.
Obese patients have a higher risk of postoperative hernia development at former port sites. This rate may be higher in cases in which extensive traction is placed on the ports. Preventively, fascial closure of port sites is considered and strongly recommended in sites measuring 10 mm or greater.
Previous abdominal or pelvic surgery is a well-known risk factor for intraperitoneal adhesions. During abdominal entry with laparoscopy, adhesive disease increases the risk of visceral and vascular injury. Adhesions are also associated with higher conversion rates to laparotomy because tedious adhesiolysis may be completed by some surgeons more safely and expeditiously with open surgical dissection. Thus, careful questioning regarding prior perioperative infection, hematoma, or extensive adhesiolysis can provide meaningful information before a planned procedure. Similarly, a history of endometriosis, pelvic inflammatory disease, or radiation treatment may predispose to adhesions.
During preoperative physical examination, a surgeon notes the location of previous surgical scars. In addition, abdominal wall hernias, hernia repairs, and reparative mesh are identified and avoided during trocar insertion. If concerns for abdominal adhesive disease arise, plans for entry at a site other than the umbilicus are considered to avoid organ injury.
Urgently indicated surgery should proceed regardless of fetal gestational age (Table 15-2). Purely elective surgery should be delayed until after pregnancy. If surgery in pregnancy can be timed, intraabdominal surgery is optimally completed early in the second trimester. Postponing surgery to the second trimester avoids exposure to potential teratogens during organogenesis, preterm contractions, and the higher incidence of spontaneous abortion normally seen during the first trimester. Moreover, many women undergo first-trimester screening with serum analytes, nuchal translucency, and/or free fetal-DNA evaluation to identify fetal anomalies. Early second-trimester surgery also lowers the risk for preterm labor, which is seen more commonly with late second- or third-trimester surgery. Finally, operative field exposure is not yet compromised by encroachment of the gravid uterus into the mid- and upper abdomen (Fig. 15-1).
| Preoperative Considerations | |
| Surgical approach | Laparoscopic treatment of acute abdominal processes has the same indications in pregnant and nonpregnant patients |
| Pregnancy trimester | Laparoscopy can be safely performed during any trimester of pregnancy, but if able, ideally in 2nd trimester |
| Intraoperative Care | |
| Patient positioning | Gravidas are placed in the left lateral recumbent position to minimize compression of the vena cava and the aorta |
| Initial port placement | Initial access can be safely accomplished with open (Hasson), Veress needle, or optical trocar technique if the location is adjusted according to fundal height, prior incisions, and surgeon experience |
| Insufflation pressure | CO2 insufflation of 10–15 mm Hg can be safely used for laparoscopy in pregnancy. Intraabdominal pressure is maintained at the minimum level sufficient to allow adequate visualization |
| CO2 monitoring | Intraoperative CO2 monitoring by capnography is used during laparoscopy in pregnancy |
| VTE prophylaxis | Intraoperative and postoperative pneumatic compression devices and early postoperative ambulation are recommended for deep-vein thrombosis prophylaxis in pregnancy |
| Perioperative Care | |
| Fetal heart monitoring | Fetal heart rate is monitored pre- and postoperatively in the setting of urgent abdominal surgery during pregnancy |
| Obstetric consultation | Obstetric consultation can be obtained pre- and/or postoperatively based on the acuity of the patient’s disease, gestational age, and consultant availability. For viable pregnancies, obstetric consultation includes discussion of what fetal indications would prompt intraoperative delivery |
| Tocolytics | Tocolytics are not used prophylactically but may be considered perioperatively, in coordination with obstetric consultation, when signs of preterm labor are present |
FIGURE 15-1
With increasing gestational age and uterine growth, intraabdominal organs are moved cephalad. Importantly, uterine growth must be considered for safe laparoscopic trocar placement. Changing anatomy will also alter the clinical presentation of many conditions. One example is appendicitis.
The intraabdominal process requiring surgery often represents a real risk to the well-being of the patient and her fetus. In early studies, however, general anesthesia used for operations in the first trimester was implicated in subsequent spontaneous abortion. Notably, these investigations failed to control for the effects of the intraabdominal process itself or for its severity (Knill-Jones, 1975). Subsequently, no strong evidence supports higher miscarriage rates in women exposed to anesthetics (Cohen-Kerem, 2005). Furthermore, in their literature review, the American College of Obstetricians and Gynecologists (2015) states that no currently used anesthetic agents are teratogenic when used in standard dosages at any gestational age.
The immediate and delayed fetal effects of the CO2 pneumoperitoneum continue to be a concern. Particular worries include diminished uterine blood flow due to pelvic vascular compression, changes in maternal hemodynamics, and transperitoneal CO2 absorption. However, in pregnant baboons, no changes in Doppler blood flow to the fetus are found with pneumoperitoneum pressures of 20 mm Hg (Reedy, 1995). In one study of gravid ewes, an intraabdominal pressure of 20 mm Hg led to diminished maternal placental blood flow but no change in fetal lamb placental perfusion, fetal organ blood flow, blood pH, or blood gas values (Barnard, 1995). In another study, pregnant ewes were insufflated to a pneumoperitoneum pressure of 15 mm Hg. The fetal lamb had transient hypotension and tachycardia. These changes were minimized by inducing maternal respiratory alkalosis via hyperventilation (Hunter, 1995). All these data should be kept in context. Namely, pneumoperitoneum pressures of 20 mm Hg, especially in smaller animals, may not reflect actual changes that develop during most laparoscopies in humans.
In humans, insufflation pressures are generally maintained at 12 to 15 mm Hg or at the minimum pressure required for adequate viewing and instrument manipulation. Prospective randomized studies are lacking, and thus our understanding of the relative risks and benefits of laparoscopy during pregnancy are limited to case series, retrospective analyses of registry data, and a few metaanalyses. This growing body of literature regarding CO2 pneumoperitoneum in pregnancy does not reflect a teratogenic or otherwise detrimental effect of CO2 on human newborns. Further, investigators that followed a small cohort of children to up to age 8 years found no evidence of growth or developmental delays (Rizzo, 2003). As a pneumoperitoneum alternative, gasless laparoscopy avoids these concerns and is described on page 241.
Current best evidence regarding laparoscopy’s safety is derived from large retrospective analyses of pregnancy outcomes. In one such study, investigators examined 2181 laparoscopies and 1522 laparotomies in pregnant patients prior to 20 weeks’ gestation. Encouragingly, birthweight, gestational age at delivery, and rates of congenital malformation, stillbirth, or neonatal death did not differ between the two surgical groups (Reedy, 1997b). However, in comparison to the total obstetric population, both surgical groups demonstrated an increased risk for birthweight <2500 g, delivery before 37 weeks, and fetal growth restriction. Counseling patients regarding the potential for perioperative fetal morbidity and mortality is ideally based on institution-specific outcomes data, if they are available. Prognosis for fetal survival and neonatal outcomes requires accurate knowledge of gestational age and fetal weight (Phelan, 1990).
In gravidas undergoing laparoscopy, no data from randomized studies currently support the routine use of prophylactic tocolysis for the prevention of preterm labor. Additionally, routine prophylactic-dose glucocorticoids are not recommended to hasten fetal lung maturity. However, these may be considered and used as indicated in response to preterm labor that may complicate laparoscopic surgery. In such circumstances, rare contraindications to their use would be sepsis or active systemic infection.
Fetal heart rate should be identified and documented before and after surgery. In a pregnancy that has not yet reached a viable age, this may be performed using a handheld Doppler device. In even earlier pregnancies, targeted bedside sonography may be needed to document the heartbeat. For fetuses that have attained a viable age, both fetal heart rate and uterine activity are electronically monitored preoperatively and postoperatively. For intraoperative fetal monitoring, the American College of Obstetricians and Gynecologists (2015) states that this should be individualized. It may aid “maternal positioning and cardiorespiratory management, and may influence the decision to deliver the fetus.”
In general, intraoperative fetal monitoring may be considered if the fetus is a viable age and if the woman has consented to emergency cesarean delivery. Moreover, an obstetrician must be available and willing to intervene for fetal indications, and the index surgery must permit safe emergency delivery. If fetal monitoring is implemented during surgery, a Doppler device or sonographic transducer can be placed directly against the patient’s anterior abdominal wall. Alternatively, a transvaginal transducer may be placed. This method avoids encroachment on the surgical field.
In response to general anesthesia, fetal heart rate pattern typically shows reduced variability. The fetal heart rate baseline also may be lower but still lies within normal range. If changes suggest jeopardized fetal well-being, then uteroplacental perfusion can be augmented. Steps include releasing the pneumoperitoneum to diminish intraabdominal pressure against perfusing vessels and further shifting the mother’s left-lateral tilt to relieve uterine compression of the vena cava. Ventilation can also be adjusted to favor maternal normocarbia.
A collaborative team approach to the care of the obstetric patient undergoing surgery is essential and involves consultation between obstetric, surgical, anesthesiology, and neonatal teams to optimize maternal and newborn outcomes. In cases involving a pregnancy that has reached a viable age, surgery should take place in an institution with neonatal and pediatric services and with an obstetric team.
A thorough history and physical examination should seek information regarding prior surgical procedures and maternal medical complications such as cardiac disease, pulmonary disorders, obesity, and diabetes mellitus. Pertinent laboratory testing is done, and results are compared with values anticipated during pregnancy. Preoperative sonographic assessment for fetal viability, gestational age, and lethal anomalies is prudent. In pregnancies of viable age, sonography also adds information regarding fetal position and placental location should delivery be indicated. Gentle cervical examination provides baseline status of dilatation and effacement. This is especially valuable if postoperative contractions ensue. Vaginal bleeding, if present, mandates a thorough evaluation for its source, including placental localization to exclude placenta previa or abruption.
During the consenting process for laparoscopy, a surgeon reviews goals and risks of the specific procedure. Laparoscopy itself is typically associated with few complications. Of these, organ injury caused by puncture or by electrosurgical tools is the most common major complication and is discussed on page 256. Patients are also counseled regarding a possible need to complete the operation via laparotomy. Reasons for conversion include failure to gain abdominal access, organ injury during entry, or extensive adhesions.
External pneumatic compression stockings are routinely applied to the lower extremities to reduce venous pooling and to augment return venous flow. However, no randomized trials address unfractionated or low-molecular-weight heparin use or placement of intermittent pneumatic compression devices in pregnancy to prevent venous thromboembolism. SAGES recommends placement of pneumatic compression devices around the lower extremities (Pearl, 2011). In general, the American College of Chest Physicians recommends pharmacologic thromboprophylaxis in laparoscopic procedures anticipated to last longer than 45 minutes but mechanical thromboprophylaxis for shorter cases (Guyatt, 2012).
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