Key Abbreviations
As low as reasonably achievable ALARA
American College of Obstetricians and Gynecologists ACOG
Association of Professors of Gynecology and Obstetrics APGO
Computed tomography CT
Fetal heart rate FHR
Intrauterine growth restriction IUGR
Last menstrual period LMP
Magnetic resonance imaging MRI
Society of American Gastrointestinal and Endoscopic Surgeons SAGES
Approximately 1 in 500 women will require nonobstetric surgery during pregnancy. The care of the pregnant surgical patient requires a multidisciplinary approach that involves the obstetrician, surgeon, anesthesiologist, and pediatrician. Numerous unique challenges arise when caring for a pregnant woman who presents with symptoms that may require surgery. Evaluation of these patients is often confounded by the various changes in maternal physiology, concern for fetal well-being, and the potential risk to the continuing pregnancy. The introduction of new imaging diagnostic modalities has increased our diagnostic capabilities; however, their safety for use during pregnancy continues to be evaluated. In this chapter, we focus on (1) specific physiologic and anatomic adaptations to pregnancy that the clinician needs to be aware of when evaluating a gravid patient; (2) the diagnostic challenges concerning evaluation of a pregnant woman, with specific attention to radiologic studies; (3) the unique issues that arise when providing surgical anesthesia during pregnancy; and (4) the potential risks to the pregnancy that are assumed when nonobstetric surgery becomes necessary. Finally, although some of the more common indications for surgery in pregnancy—such as trauma, appendicitis, and cholecystitis—are addressed in more detail elsewhere ( Chapters 26 , 47 , and 48 ), we address clinical circumstances that are being seen with increasing frequency during pregnancy, including the use of laparoscopy, the evaluation and treatment of adnexal masses, issues related to obesity and bariatric surgery, and the challenges associated with cardiac and neurosurgery in pregnancy.
Maternal Physiology
Pregnancy-induced changes in maternal physiology and anatomy can confuse the clinical picture when evaluating the gravid patient who presents with abdominal symptoms. Abdominal discomfort, nausea, vomiting, diarrhea, and constipation are often encountered in pregnancy in the absence of intraabdominal pathology. Furthermore, laboratory changes commonly seen as abnormal in the nonpregnant surgical patient may be normal in the gravid state. Therefore familiarity with these changes is essential when evaluating pregnant women who present with abdominal discomfort and gastrointestinal symptoms (see Chapter 3 ).
Pregnancy causes profound changes in cardiovascular, hematologic, and respiratory physiology. Cardiovascular adaptations to pregnancy include a significant increase in cardiac output, heart rate, and intravascular volume. Because the heart rate increases by up to 15 to 20 beats/min compared with the nongravid state, it may be difficult to determine whether a mild tachycardia is physiologic or related to an underlying pathologic condition.
Respiratory physiology is also altered in pregnancy. The gravid uterus leads to a decrease in functional residual capacity and total lung capacity. In addition, the stimulatory effect of progesterone on respiratory drive leads to an increase in tidal volume and minute ventilation. Of note, the respiratory rate remains unchanged. As a result, pregnancy is associated with a state of relative hyperventilation and mild respiratory alkalosis.
The physical examination of the pregnant abdomen may present a unique challenge. The enlarging gravid uterus becomes an abdominal organ after 12 weeks’ gestation and may displace or compress other intraabdominal organs, making localization of pain difficult. For example, progressive upward displacement of the appendix occurs, and the appendix does not return to its original position until 1 to 2 weeks postpartum. However, despite the altered location, the most consistent and reliable symptom in pregnant women with appendicitis remains right lower quadrant pain. Many other classic signs and symptoms of appendicitis—such as nausea, vomiting, and leukocytosis—may be normal findings in pregnancy. Similarly, physical examination findings of rebound and guarding may not be reliable indicators of intraperitoneal inflammation in pregnancy. In addition, abdominal tenderness may be a sign of a pregnancy-specific complication, such as chorioamnionitis or placental abruption. Thus the evaluation of abdominal pain in pregnancy can present a challenging diagnostic dilemma.
The gravid uterus may also limit diagnostic imaging of abdominal organs. After the first trimester, the maternal adnexa are displaced cephalad and may be difficult to image with ultrasound. Some anatomic changes related to the growing uterus may confound the interpretation of diagnostic imaging. For example, mild to moderate hydroureter is commonly encountered in pregnancy secondary to compression of the distal ureters by the uterus and progesterone-induced smooth muscle relaxation. Because the incidence of both pyelonephritis and nephrolithiasis is increased in pregnancy, it is important to recognize that a degree of dilation of the upper urinary tract is often a normal finding.
Laboratory values are also altered in normal pregnancy (see Chapter 58 ). Maternal blood volume is increased out of proportion to the increase in red blood cell mass. This leads to a dilutional anemia of pregnancy, especially in the later stages. This physiologic anemia may be mistaken for occult blood loss in the patient being evaluated for a surgical abdomen. Pregnancy is also associated with a progressive rise in peripheral white blood cell count, with a mean value of 14,000 cells/mm 3 during the second trimester. This physiologic leukocytosis, in conjunction with tachycardia and anemia, may confound the clinical picture and lead to an incorrect diagnosis. Other laboratory values—such as D-dimer, serum creatinine, and alkaline phosphatase—are significantly altered in pregnancy, which limits their role in the diagnostic evaluation of the pregnant patient.
These significant changes in normal maternal physiology and diagnostic evaluation can complicate the evaluation of the pregnant patient who presents with concerning symptoms. The utmost vigilance is necessary to identify true pathology and arrive at the correct diagnosis in a timely fashion so that the appropriate management can be implemented.
Diagnostic Imaging
A common concern that arises when evaluating a pregnant woman is the safety of diagnostic radiologic tests. When considering the potential risks related to imaging, it is important to balance any potential for harm against the significant risks associated with an erroneous or delayed diagnosis. It is important to recognize that failure to accurately diagnose a serious condition in a timely manner can cause significant harm to the woman and her fetus.
Ionizing Radiation
The overwhelming concern related to diagnostic imaging is exposure of the developing fetus to ionizing radiation. The critical factors that determine the risk to the fetus are the dose of radiation to which the fetus is exposed and the gestational age at the time of the exposure ( Table 25-1 ; see Chapter 8 ). Very early in gestation, within the first 2 weeks of conception, any significant cell damage caused by radiation is generally believed to result in miscarriage. This is believed to be an “all or none” phenomenon; that is, if the fetus remains viable after this early exposure, no adverse effects are expected. Radiation doses greater than 50 to 100 mGy (5 to 10 rad [1 mGy = 0.1 rad]) are likely necessary to cause embryonic death. Postconception weeks 2 through 8 are particularly sensitive to teratogenicity because this is the period of organogenesis. At this stage, the embryo is more resistant to radiation-induced death, and doses of more than 250 to 500 mGy (25 to 50 rad) are necessary to cause fetal demise.
| GESTATIONAL AGE (FROM LMP) | ADVERSE EFFECT | ESTIMATED MINIMUM RADIATION DOSE |
|---|---|---|
| Weeks 3-4 (first 2 weeks post-conception) | Embryonal demise (all or none) | 5-20 cGy |
| Weeks 5-8 | Death, congenital anomalies, IUGR | 20-50 cGy |
| Weeks 9-15 * | IUGR, microcephaly, severe mental retardation † | 6-50 cGy |
| Weeks 16-25 | Mental retardation | 25-150 cGy |
* Period of neuronal development that is most sensitive to radiation damage.
† Exposure to 1 Gy of radiation during this period has been associated with a loss of 30 IQ points.
The fetal central nervous system is sensitive to radiation damage between 8 and 25 weeks and particularly during weeks 8 to 15 because this is a period of rapid neuronal development. However, increasingly high doses of radiation are necessary to result in any significant damage. After 25 weeks, the fetus is fairly resistant to radiation-induced abnormalities.
In addition to teratogenic risk, a concern remains for potential carcinogenic effects of ionizing radiation to the developing fetus. Some authors have estimated that the incidence of childhood leukemia and other cancers may increase by about 0.06% from baseline with each centigray of exposure. Given the low background risk, diagnostic doses of radiation do not appear to significantly increase the absolute risk to the fetus. Also, the causative link between fetal exposure to diagnostic radiation and childhood leukemia has been called into question.
Table 25-2 shows the estimated doses of fetal radiation exposure from various commonly used diagnostic imaging examinations. It is important to note that the amount of radiation exposure from any of these diagnostic studies is well below the dose threshold for teratogenic risk. Therefore when evaluating a pregnant woman who presents with significant symptoms, the patient should be reassured that the radiation exposure to the fetus from diagnostic imaging does not confer a significant risk for fetal harm. It is important for the clinician to be familiar with the relative radiation doses delivered by commonly ordered tests because this information may aid in the decision to choose one modality over another. When clinically appropriate, consideration should be given to other diagnostic modalities, such as ultrasound or magnetic resonance imaging (MRI), that do not involve ionizing radiation. The general principle of ALARA (as low as reasonably achievable) applies to both mother and baby. Optimization of computed tomography (CT) scan protocols, appropriate shielding, and judicious use of radiation-based imaging remains an important principle.
| RADIOLOGIC STUDY | ESTIMATED FETAL DOSE * (cGy) |
|---|---|
| Chest radiograph (posteroanterior, lateral) | 0.0002 |
| Abdominal radiograph | 0.1-0.3 |
| Head CT | 0.0005 |
| Chest CT | 0.002-0.02 |
| Abdominal CT | 0.4-0.8 |
| Abdominopelvic CT | 2.5-3.5 |
| Abdominopelvic CT (stone protocol) | 1 |
| Ventilation scan | 0.007-0.05 |
| Perfusion scan | 0.04 |
| Intravenous pyelography | 0.6-1.0 |
| Bone scan | 0.3-0.5 |
| Positron emission scan | 1.0-1.5 |
| Thyroid scan | 0.01-0.02 |
| Mammography | 0.007-0.02 |
| Small bowel series | 0.7 |
| Barium enema | 0.7 |
* Fetal dose can vary significantly based on a variety of patient and imaging parameters. If necessary, more precise estimates can be obtained through consultation with a radiation safety officer or radiation physicist.
Although much attention is given to potential risks of fetal exposure, it is thought that the pregnant woman may have an increased sensitivity to radiation compared with other adults. For example, when evaluating a pregnant woman for a suspected pulmonary embolus, current recommendations often favor a ventilation-perfusion study over a CT scan in patients with normal chest radiographs. Despite similarly low fetal radiation exposures, the exposure to the maternal breasts and lungs is significantly higher with a CT scan. Therefore, although patients should be counseled that no single diagnostic test should be considered harmful to the fetus, justification of the need for imaging should be confirmed with respect to maternal benefit.
Fluoroscopy, which uses real-time radiography, has been increasingly used in numerous diagnostic and therapeutic procedures. For example, cardiovascular comorbidities are increasingly common in pregnancy, and diagnostic cardiac catheterization, electrophysiology studies, ablation procedures, and cardiac valve interventions all use fluoroscopic guidance. The absolute fetal exposure varies greatly among procedures, but most can be safely performed during pregnancy. Numerous variables can be controlled for in order to limit the maternal and fetal exposure to radiation and to comply with the ALARA principle during pregnancy.
Overall, the use of diagnostic radiation in pregnant women requires adequate patient counseling to allay concerns of fetal harm and to balance any small potential risk against the need to arrive at an accurate and timely diagnosis. According to the American College of Obstetricians and Gynecologists (ACOG), “Women should be counseled that x-ray exposure from a single diagnostic procedure does not result in harmful fetal effects. Specifically, exposure to less than 50 mGy (5 rads) has not been associated with an increase in fetal anomalies or pregnancy loss.”
Ultrasound
Ultrasound remains the initial imaging modality of choice in the evaluation of the pregnant woman who presents with acute abdominal pain. Ultrasound involves the use of sound waves and is not a form of ionizing radiation. Although ultrasound does have the potential to transfer energy to the tissues being imaged, no confirmed adverse fetal effects of diagnostic ultrasound procedures have been reported. Nonetheless, attention should be given to the thermal and mechanical indices in pregnancy. Overall, the safety and versatility of ultrasonography makes it the first-line diagnostic tool during pregnancy whenever appropriate to address the clinical question at hand.
Magnetic Resonance Imaging
There are numerous advantages to MRI use during pregnancy. Like ultrasound, MRI does not use ionizing radiation, and no harmful effects to the mother or fetus have been reported. In recent years, the use of MRI has expanded greatly as the image quality and availability have increased. For example, MRI has proved useful for evaluation of pathologies such as adrenal tumors, uterine and ovarian masses, gastrointestinal lesions, and retroperitoneal space evaluation while avoiding the radiation exposure associated with CT scanning.
Contrast in Pregnancy
Commonly used radiocontrast, such as low-osmolarity iodinated contrast media, is known to cross the placenta and be excreted in the fetal urine. Overall, the small quantities and transient exposure is not believed to have any teratogenic effects on the fetus. Theoretic effects on fetal thyroid function have not been observed using clinical doses, and no specific neonatal surveillance is warranted for fetuses exposed to these agents in pregnancy.
No known adverse effects have been observed using gadolinium-based contrast in pregnancy. In addition, the limited data from exposed pregnancies have not revealed any proven harm; therefore gadolinium can be considered in clinical scenarios where the potential exists for significant benefit to the patient or fetus that outweighs the theoretic harms. However, given that gadolinium can concentrate in the amniotic fluid with a potentially long half-life, current recommendations do not support routine use of gadolinium in pregnancy.
Anesthesia during Nonobstetric Surgery
When anesthesia is required during pregnancy, the concern for possible adverse effects exists. However, it is also important to consider the physiologic changes of pregnancy that affect the delivery of safe and effective anesthesia.
Anesthesia and Teratogenicity
As is the case when examining the potential teratogenicity of any prenatal exposure, much of the data are limited to retrospective information from case series and registries. However, because prospective research focused on the teratogenicity of a medication is not ethically or logistically feasible, patients must be counseled based on the existing data, with acknowledgment of the inherent limitations.
Several early studies raised the possibility that exposure to anesthesia in the first trimester may be associated with an increased risk for central nervous system malformations. However, the methodologies used to arrive at these conclusions have been challenged and are not supported by subsequent studies.
Most studies have been reassuring and have concluded that a significant risk for congenital malformations is unlikely when surgery is performed during the first trimester. For example, Mazze and Kallen described 5405 women from the Swedish Birth Registry who underwent nonobstetric surgery during pregnancy, 40% of which occurred during the first trimester. They found no significant difference in the rate of congenital malformations compared with women who had no exposure to surgery during pregnancy. Furthermore, a more recent systematic review of the literature identified more than 12,000 pregnancies exposed to nonobstetric surgery and reported an overall 2% incidence of congenital malformations, 3.9% when surgery occurred in the first trimester. Although no control group was available in this review, the observed rate of malformations falls within the expected range in the general population. Whereas the best available data support the lack of a significantly increased risk for malformations among pregnancies exposed to nonobstetric surgery and anesthesia, it may be preferable to defer most surgical interventions until the second trimester, when the theoretic risk of teratogenicity—as well as the established risk of spontaneous miscarriage—is further decreased.
Anesthesia and Pregnancy Physiology
As discussed earlier (see Chapter 16 ), many significant physiologic changes occur in pregnancy that can have a profound impact on the delivery of safe and effective anesthesia in pregnancy. For example, several physiologic changes contribute to the increased risk for aspiration in pregnant women who undergo general anesthesia. Gastric emptying time is prolonged in pregnancy, especially in the third trimester and in obese women. In addition, progesterone-mediated diminished tone is present at the gastroesophageal junction. Therefore strategies to decrease the risk for aspiration are essential, such as preoperative fasting, antacid prophylaxis (e.g., 30 mL of sodium citrate), and airway protection. In some situations, administration of a histamine 2 (H 2 ) blocker or a gastric motility agent such as metoclopramide, or both, should be considered as well.
Oropharyngeal edema and narrowing of the opening of the glottis are common in pregnancy and can affect the safe access to the airway in a pregnant patient, especially in an emergency situation. The Mallampati airway examination is often used to assess the airway and predict the degree of difficulty of intubation, with progression from low-risk airways (class I) to high-risk airways (class IV; Fig. 25-1 ). A 34% increase in the frequency of class IV Mallampati airways is seen at term compared with the first trimester. These changes are more pronounced in the third trimester, in obese women, and in women with preeclampsia.
One of the most significant physiologic phenomena in pregnancy is related to aortocaval compression by the gravid uterus, especially in the supine position. In the latter half of pregnancy, this leads to a decreased preload and cardiac output with a resultant decrease in uterine and placental perfusion. In addition, venous stasis in the lower extremities increases the risk for venous thromboembolism. Thus it is essential for pregnant women who undergo a surgical procedure to be positioned with a lateral tilt to relieve some of this compression by displacing the gravid uterus to the side. This can often be accomplished by placing a wedge under the right hip.
Nonobstetric Surgery and Pregnancy Outcome
The largest study to explore pregnancy outcomes in women undergoing nonobstetric surgery was based on the Swedish Birth Registry. Mazze and Kallen identified 5405 nonobstetric surgeries from more than 720,000 births between 1973 and 1981, a prevalence of 0.75%. The nonobstetric surgeries included 1331 abdominal surgeries, 1008 genitourinary or gynecologic procedures, and 868 laparoscopies. Out of 2929 procedures (54% of all cases) performed under general anesthesia, the type of anesthesia was documented for only 68% of cases. The authors found no increased risk for congenital malformations or stillbirth compared with a control population. However, the rates of low birthweight (<2500 g) and very low birthweight (<1500 g) were significantly higher in the surgical group, with odds ratios of 2.0 and 2.2, respectively. The authors noted that the observed reduced birthweight was due to both fetal growth restriction and prematurity. The incidence of preterm birth was increased in the surgery group (7.5% vs. 5.1%; P <.001). Another significant finding was an increased rate of neonatal death within 7 days (incidence, 1%; odds ratio [OR], 2.1; 95% confidence interval [CI], 1.6 to 2.7). However, it is difficult to separate the multiple confounding factors that could potentially play a causative role in the development of these adverse pregnancy outcomes, such as type of operation, anesthesia method, and underlying indication for surgery. Because the authors did not identify a specific surgical procedure or mode of anesthesia that had a significantly increased rate of adverse outcome, they concluded that the underlying condition that led to the surgery likely played an important role in determining the outcome.
Cohen-Kerem and coworkers reviewed the literature from 1966 to 2002 and identified 12,452 pregnancies that underwent nonobstetric surgery. The incidence of major birth defects was 2%, and the rate of prematurity was 8.2%. Overall, they found that surgical intervention led to delivery of the fetus in 3.5% of cases, although they could not differentiate whether this was caused by the procedure itself or the underlying condition that necessitated surgical intervention. Although the lack of matched controls limits the interpretation of their data, it does support the conclusion that most pregnancies that undergo nonobstetric surgery will have favorable outcomes.
Taken together, it would seem reasonable to reassure pregnant patients faced with the need for surgery in pregnancy that the rate of adverse perinatal outcome is relatively low. In addition, although the risk for low birthweight, preterm birth, and neonatal demise may be increased, these risks may be associated with complications related to the underlying indication for surgery. In cases of semielective surgery, such as for an enlarged adnexal mass or refractory biliary colic, it is still prudent to defer surgery until after the first trimester, when the risk for spontaneous miscarriage is decreased and the theoretic concerns of teratogenicity are avoided. Similarly, surgery in the late-second and third trimesters may affect intraoperative visibility and lead to an increased risk for preterm birth. Therefore the early second trimester is considered the optimal time for elective surgery that cannot be safely deferred until after the pregnancy.
Fetal Monitoring
The question of whether continuous intraoperative fetal monitoring should be used when a pregnant woman requires nonobstetric surgical intervention is a matter of debate. Factors in favor of monitoring include the potential for changes in fetal heart rate (FHR) and uterine activity during the surgery, the potential for fetal well-being to serve as an indicator of maternal status, and the potential to intervene in a case of persistently nonreassuring fetal status. On the other hand, interpretation of the FHR tracing may be particularly unreliable in the very preterm fetus. In addition, the changes in FHR tracing occasionally seen—such as a decreased variability and lower baseline heart rate—are often transient and are not necessarily an indication of fetal compromise. Thus continuous intraoperative fetal monitoring may lead to an unnecessary emergent cesarean delivery with significant risk for both maternal and neonatal morbidity. Furthermore, performing an emergent cesarean delivery can significantly complicate the nonobstetric surgery being conducted and has the potential to significantly increase maternal morbidity. A recent survey of the Association of Professors of Gynecology and Obstetrics (APGO) found that most respondents do not routinely perform intraoperative fetal monitoring but simply monitor the fetus before and after the procedure. Accordingly, the American College of Obstetricians and Gynecologists (ACOG) recommends that at a minimum, fetal monitoring should be conducted before and after the procedure in cases with a viable fetus. However, in select cases, intraoperative monitoring may be performed after consultation with an obstetrician who can properly counsel the pregnant woman facing surgery and individualize the decision based on factors such as gestational age, type of surgery, and facilities available.
Laparoscopy in Pregnancy
Although the safety of laparoscopy in pregnancy is widely accepted, several important considerations specific to pregnancy must be considered. Pneumoperitoneum further decreases functional residual capacity and can cause ventilation-perfusion mismatch and hypercapnia. These effects can be further exacerbated by Trendelenburg positioning. Bhavani-Shankar and colleagues prospectively demonstrated that end-tidal carbon dioxide pressures correlate well with arterial PCO 2 and that maintaining an end-tidal CO 2 of about 32 mm Hg and a systolic blood pressure within 20% of baseline was effective in preventing respiratory acidosis during laparoscopy. Once again, a left lateral maternal position is essential to displace the gravid uterus and helps to relieve aortocaval compression and also optimizes cardiac output.
The intraabdominal pressure required to obtain adequate laparoscopic visualization during surgery can have significant physiologic effects for both the pregnant woman and the fetus. Early animal studies showed that cardiac output decreases with increasing intraperitoneal pressure. Reedy and colleagues performed laparoscopic baboon studies and compared intraabdominal pressures of 10 and 20 mm Hg. At the higher pressure, a significant increase was seen in pulmonary capillary wedge pressure, central venous pressure, pulmonary artery pressure, and peak airway pressure. In addition, a significant increase in ventilator rate was required to maintain oxygenation and end-tidal CO 2 . A pressure of 20 mm Hg was also associated with an increased risk for respiratory acidosis. Similar studies have shown significant changes in both maternal and fetal physiology at pressures greater than 15 mm Hg. Therefore although lower insufflation pressures may lead to limited surgical visualization, it is important to try and keep insufflation pressures below 15 mm Hg. If higher pressures are required to safely complete the procedure, it would be advisable to periodically release the pneumoperitoneum to allow for physiologic recovery. This is particularly important in obese patients, who often require higher pressures to counteract the weight of the anterior abdominal wall. Although various techniques, such as gasless laparoscopy and mechanical lift retractors, have been proposed to avoid high intraabdominal pressures during laparoscopy, they are not widely utilized.
Laparoscopic Entry Techniques in Pregnancy
Although the conventional entry approach has been using a Veress needle, a variety of other closed and open techniques have been proposed in an effort to decrease the incidence of entry complications in nonobstetric laparoscopic procedures. However, review of the literature fails to support a significant difference in complications between the various approaches. Nonetheless, accidental placement of a Veress needle into a 21-week uterus with subsequent pneumoamnion and pregnancy loss has been reported. Thus it may be prudent to use an open approach in the latter half of pregnancy. The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) guidelines support laparoscopic entry with any technique provided that the location of the entry is adjusted to account for the gravid uterus ( Box 25-1 ). Procedures performed in the later stages of pregnancy may require a left upper quadrant insertion of the initial trocar. The upper limit of gestational age up to which a laparoscopic approach can be performed safely in pregnancy has not been determined. Concerns related to the space occupied by the gravid uterus have led some to recommend that laparoscopy be avoided in the third trimester. However, current practice guidelines do not impose such a limitation, and the decision regarding the optimal surgical approach should therefore be individualized.
- •
Diagnostic laparoscopy is safe and effective when used selectively in the workup and treatment of acute abdominal processes in pregnancy.
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Laparoscopic treatment of acute abdominal processes has the same indications in pregnant and nonpregnant patients.
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Laparoscopy can be safely performed during any trimester of pregnancy.
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Gravid patients should be placed in the left lateral recumbent position to minimize compression of the vena cava and the aorta.
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Initial access can be safely accomplished with open (Hassan), Veress needle, or optical trocar technique if the location is adjusted according to fundal height, previous incisions, and experience of the surgeon.
- •
CO 2 insufflation of 10 to 15 mm Hg can be safely used for laparoscopy in the pregnant patient. Intraabdominal pressure should be sufficient to allow for adequate visualization.
- •
Intraoperative CO 2 monitoring by capnography should be used during laparoscopy in the pregnant patient.
- •
Intraoperative and postoperative pneumatic compression devices and early postoperative ambulation are recommended prophylaxis for deep venous thrombosis in the gravid patient.
- •
Laparoscopic cholecystectomy is the treatment of choice in the pregnant patient with gallbladder disease regardless of trimester.
- •
Laparoscopic appendectomy may be performed safely in pregnant patients with suspicion of appendicitis.
- •
Laparoscopic adrenalectomy, nephrectomy, and splenectomy are safe procedures in pregnant patients when indicated, and standard precautions are taken.
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Laparoscopy is safe and effective treatment in gravid patients with symptomatic adnexal cystic masses. Observation is acceptable for all other adnexal cystic lesions provided ultrasound is not worrisome for malignancy and tumor markers are normal. Initial observation is warranted for most adnexal cystic lesions smaller than 6 cm.
- •
Laparoscopy is recommended for both diagnosis and treatment of adnexal torsion unless clinical severity warrants laparotomy.
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Fetal heart monitoring should occur before and after operation in the setting of urgent abdominal surgery during pregnancy.
- •
Obstetric consultation can be obtained before and after operation based on the acuteness of the patient’s disease, gestational age, and availability of the consultant.
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Tocolytics should not be used prophylactically but should be considered perioperatively, in coordination with obstetric consultation, when signs of preterm labor are present.
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