Diagnosis, Treatment, And Use Of Laparoscopy For Surgical Problems During Pregnancy
Publication Date: May 1, 2017
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
Disclaimer
Overview
Title
Diagnosis, Treatment, And Use Of Laparoscopy For Surgical Problems During Pregnancy
Authoring Organization
Society of American Gastrointestinal and Endoscopic Surgeons
Publication Month/Year
May 1, 2017
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
Intended Users
Nurse, nurse practitioner, physician, physician assistant
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