Last updated March 14, 2022

Diagnosis, Treatment, And Use Of Laparoscopy For Surgical Problems During Pregnancy

Summary of Recommendations

Diagnosis and Workup

Ultrasound

Ultrasound imaging during pregnancy is safe and effective in identifying the etiology of acute abdominal pain in many patients and should be the initial imaging test of choice. (Moderate, Strong)
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Risk of Ionizing Radiation

Ionizing radiation exposure to the fetus increases the risk of teratogenesis and childhood leukemia. Cumulative radiation dosage should be limited to 50-100 mGy during pregnancy. (Moderate, Strong)
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Computed Tomography

Abdominal CT scan may be used in emergency situations during pregnancy. CT scan should not be the initial imaging test of choice. (Low, Weak)
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Magnetic Resonance Imaging

MR Imaging without the use of intravenous Gadolinium can be performed at any stage of pregnancy. MRI is preferred over CT scan for diagnosis of non-obstetric abdominal pain in the gravid patient. (Low, Strong)
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Nuclear Medicine

Administration of radionucleotides for diagnostic studies is safe for mother and fetus. (Low, Weak)
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Cholangiography

Intraoperative and endoscopic cholangiography exposes the mother and fetus to minimal radiation and may be used selectively during pregnancy. The lower abdomen should be shielded when performing cholangiography during pregnancy to decrease the radiation exposure to the fetus. (Low, Weak)
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Diagnostic Laparoscopy

In the absence of access to imaging modalities, laparoscopy may be used selectively in the workup and treatment of acute abdominal processes in pregnancy. (Low, Weak)
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Patient Selection

Pre-operative Decision Making

Laparoscopic treatment of acute abdominal disease offers similar benefits to pregnant and non-pregnant patients compared to laparotomy. (Moderate, Strong)
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Laparoscopy and Trimester of Pregnancy

Laparoscopy can be safely performed during any trimester of pregnancy when operation is indicated. (Moderate, Strong)
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Treatment

Patient Positioning

Gravid patients beyond the first trimester should be placed in the left lateral decubitus position or partial left lateral decubitus position to minimize compression of the vena cava. (Low, Strong)
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Initial Port Placement

Initial abdominal access can be safely accomplished with an open (Hasson), Veress needle, or optical trocar technique, by surgeons experienced with these techniques, if the location is adjusted according to fundal height. (Low, Weak)
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Insufflation Pressure

CO2 insufflation of 10-15 mmHg can be safely used for laparoscopy in the pregnant patient. The level of insufflation pressure should be adjusted to the patient’s physiology. (Low, Weak)
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Intra-operative CO2 monitoring

Intraoperative CO2 monitoring by capnography should be used during laparoscopy in the pregnant patient. (Moderate, Strong)
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Venous Thromboembolic (VTE) Prophylaxis

Intraoperative and postoperative pneumatic compression devices and early postoperative ambulation are recommended prophylaxis for deep venous thrombosis in the gravid patient. (Low, Weak)
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Gallbladder Disease

Laparoscopic cholecystectomy is the treatment of choice in the pregnant patient with symptomatic gallbladder disease, regardless of trimester. (Low, Weak)
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Choledocholithiasis

Choledocholithiasis during pregnancy can be managed safely with preoperative endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy followed by laparoscopic cholecystectomy, laparoscopic common bile duct exploration at the time of cholecystectomy, or postoperative ERCP. Comparative studies are lacking. (Low, Weak)
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Laparoscopic Appendectomy

Laparoscopic appendectomy may be performed safely in pregnant patients with acute appendicitis. (Moderate, Strong)
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Solid Organ Resection

Laparoscopic adrenalectomy, nephrectomy, splenectomy and mesenteric cyst excision are safe procedures in pregnant patients. (Very Low, Weak)
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Adnexal Mass

Laparoscopy is a safe and effective treatment in gravid patients with symptomatic ovarian cystic masses. Observation is acceptable for all other cystic lesions provided ultrasound is not concerning for malignancy and tumor markers are normal. Initial observation is warranted for most cystic lesions < 6 cm in size. (Low, Weak)
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Adnexal Torsion

Laparoscopy is recommended for both diagnosis and treatment of adnexal torsion. (Low, Strong)
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Perioperative care

Fetal Heart Monitoring

Fetal heart monitoring of a fetus considered viable should occur preoperatively and postoperatively in the setting of urgent abdominal surgery during pregnancy. (Low, Weak)
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Tocolytics

Tocolytics should not be used prophylactically in pregnant women undergoing surgery but should be considered perioperatively when signs of preterm labor are present. (Moderate, Strong)
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Recommendation Grading

Overview

Title

Diagnosis, Treatment, And Use Of Laparoscopy For Surgical Problems During Pregnancy

Authoring Organization

Publication Month/Year

May 1, 2017

Supplemental Implementation Tools

Webinar, Webinar, Webinar, Webinar, Patient Information, Video

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

Surgical interventions during pregnancy should minimize fetal risk without compromising the safety of the mother. Favorable outcomes for the pregnant woman and fetus depend on accurate and timely diagnosis with prompt intervention. Surgeons must be aware of data regarding differences in techniques used for pregnant patients to optimize outcomes. This document provides specific recommendations and guidelines to assist physicians in the diagnostic work-up and treatment of surgical conditions in pregnant patients, focusing on the use of laparoscopy.

Target Patient Population

Pregnant patients required surgery

Inclusion Criteria

Female, Adult

Health Care Settings

Ambulatory, Hospital, Operating and recovery room, Outpatient

Scope

Assessment and screening, Diagnosis, Management, Treatment

Diseases/Conditions (MeSH)

D013502 - General Surgery, D013513 - Obstetric Surgical Procedures, D010535 - Laparoscopy, D020706 - Laparoscopes, D007743 - Labor, Obstetric

Keywords

surgery, pregnancy, Pregnancy care, laparoscopy

Source Citation

Https://www.sages.org/publications/guidelines/guidelines-for-diagnosis-treatment-and-use-of-laparoscopy-for-surgical-problems-during-pregnancy/

Methodology

Number of Source Documents
227
Literature Search Start Date
October 1, 2011
Literature Search End Date
March 31, 2016
Description of External Review Process
Guidelines are developed under the auspices of the Society of American Gastrointestinal Endoscopic Surgeons and its various committees, and approved by the Board of Governors.
Specialties Involved
Gastroenterology, Obstetrics And Gynecology, Surgery General
Description of Systematic Review
A new systematic literature search using PubMed, Medline, and Cochrane Databases was done between January 2011 and March 2016 to encompass all new literature on the topic. Search strategy was limited to adult human studies in English. The relevance of each study was assessed and those not relevant were dismissed.
Description of Study Criteria
A list of key words, study type, and dates of review are provided. There is no inclusion criteria or exclusion criteria.
Description of Search Strategy
A new systematic literature search using PubMed, Medline, and Cochrane Databases was done between January 2011 and March 2016 to encompass all new literature on the topic. Search strategy was limited to adult human studies in English. The relevance of each study was assessed and those not relevant were dismissed.
Description of Study Selection
The relevance of each study was assessed and those not relevant were dismissed.
Description of Evidence Analysis Methods
Consensus.
Description of Evidence Grading
SAGES has a standardized methodology.
Description of Recommendation Grading
SAGES has a standardized methodology.
Description of Funding Source
SAGES funded Guideline Development
Company/Author Disclosures
All Authors disclosed their conflicts of interest in the publication.
Percentage of Authors Reporting COI
100