Abdominal Surgery in Pregnancy
an Interdisciplinary Challenge
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Background: Abdominal operations are performed during ca. 2% of all pregnancies. They represent an unusual situation not only for the patient, but also for the involved surgeons and anesthesiologists. Appendectomy, followed by cholecystectomy are the two most common types of operation performed during pregnancy. Special questions arise with regard to the peri- and intraoperative management and the optimal surgical approach.
Methods: This review is based on pertinent articles retrieved by a selective search in the PubMed database.
Results: The question of laparoscopy versus laparotomy during pregnancy has been addressed to date only in case series and a few meta-analyses. Two meta-analyses have shown a significantly higher rate of miscarriage after laparoscopic, compared to open, appendectomy (relative risk [RR] 1.91, 95% confidence interval [CI] 1.31–2.77). The risk of preterm birth is also somewhat higher after laparoscopic appendectomy according to one meta-analysis on this subject (RR 1.44, 95% CI 0.78–1.76), but significantly lower according to another meta-analysis (2.1% vs. 8.1%, p<0.0001). For cholecystectomy, laparoscopy was associated with a lower miscarriage rate than laparotomy (1 in 89 cases, versus 2 in 69 cases), but with a somewhat higher preterm birth rate (6 in 89 cases, versus 2 in 69 cases). Delay or non-performance of surgery in a patient with appendicitis or cholecystitis can lead to additional hospitalizations, a higher miscarriage rate, premature rupture of the membranes, and preterm birth.
Conclusion: Laparoscopy in experienced hands is safe even during pregnancy, with the recognized advantages of minimally invasive surgery, yet it carries a higher miscarriage rate than laparotomy, with a comparable preterm birth rate. Before surgery, patients should be thoroughly informed about the operation they are about to undergo and the advantages and disadvantages of the available surgical approaches.
The physiologic and anatomic changes during pregnancy are so significant that an anesthesiologist would place a non-pregnant patient with the same parameters in a higher perioperative risk group. Many of these changes are based on hormonal factors as well as the mechanical effect of the enlarged uterus; they have important consequences for the surgeon and the anesthesiologist (Table 1).
If a pregnant patient requires abdominal surgery, the major issue
The goal of this review is to identify the indications and limitations of both laparoscopy (Box 1) and laparotomy during pregnancy. The discussion takes into consideration the need for an interdisciplinary approach to such patients. Anesthetic and obstetric challenges and risks, as well as their management, are included.
A literature search was performed in PubMed. The search includes all meta-
Indications and operative approaches
The most common non-obstetric operation during pregnancy is an appendectomy (44%), followed by a cholecystectomy (22.3%). In the USA, 64.8% of these intraperitoneal procedures are performed via laparoscopy (3). There is no data on this frequency from Germany. There are no randomized controlled trials (RCTs) for any of the indications discussed below addressing either conservative versus operative management or laparoscopy versus laparotomy. Most publications dealing with these issues are case series. Thus, the level of evidence for the various interventions discussed below is low (Box 2).
McGory et al. discussed 454 pregnant patients who underwent laparoscopy—the largest patient collective stud
The literature contains conflicting information on this issue. In most other series, the method of approach did not influence the risk of a preterm birth. In one case series, patients who underwent laparoscopy had a preterm birth rate (<37 gestational week) of 18.1%; the stage of pregnancy during which the procedure was performed seemed to play no role (5).
About 33% of the patients in whom appendicitis was suspected had a normal appendix on operation; this is higher than usually encountered (5). Balanced against the frequent unremarkable appendices are those cases that smolder and come to operation late with dramatic consequences.
Two recent meta-analyses have confirmed the statistically significantly increased risk of miscarriages with laparoscopic appendectomy as compared to an open procedure. In the study of Wilasrusmee et al. from 2012 on 3415 women (n = 599 laparoscopies versus n = 2816 laparotomies), the relative risk for a miscarriage following laparoscopy was RR = 1.91 (95% CI: 1.31–2.77). The risk of a preterm birth was also elevated but not to a statistically significant degree (RR = 1.44, 95% CI: 0.78–1.76). This study showed no statistically significant differences in length of hospitalization, wound infection rate, birth weight, length of operation, or Apgar score.
Walsh et al. analyzed 28 studies including 637 patients who underwent laparoscopic appendectomy. Their data also showed a significantly higher miscarriage rate for laparoscopy with 5.6% as comparted to laparotomy with 3.1%. In contrast to the first meta-analysis, the preterm birth rate was significantly higher with laparotomy as compared to laparoscopy (8.1% versus 2.1%). The miscarriage rate and preterm birth rate did not significantly vary with the trimester (Miscarriage rate in 1st trimester 3.8%; in 2nd trimester, 2.6%; in 3rd trimester, 0%; p = 0.55; preterm birth rate in 1st trimester 4.3%; in 2nd trimester, 11.3%; in 3rd trimester, 13.6%; p = 0.32) (6, 7).
Because of the increased risk of miscarriage following a laparoscopic appendectomy, an open approach should be favored. Nevertheless, the guidelines of the Society of American Gastrointestinal and Endoscopic Surgeons recommend laparoscopic surgery for a pregnant women with suspected appendicitis (8). There are no other guidelines addressing this issue or the other indications discussed below.
Laparoscopic cholecystectomy is the approach recommended by the above-mentioned US guidelines for pregnant patients with gall bladder disease, regardless of the stage of pregnancy (8). Although in the past a conservative approach was preferred for symptomatic cholelithiasis, today early surgical intervention is favored (8). A conservative approach may lead to recurrent symptoms later in pregnancy; the risk varies with the stage of pregnancy and the disorder, but for example 92% of women with gall stones in the first trimester can expect further troubles (9). Delayed or neglected surgical intervention leads to increased hospitalization rates, a higher miscarriage rate, premature rupture of membranes, and an increased rate of preterm births (10–13). Conservative management of symptomatic gall stones in pregnancy leads to recurrent symptoms in more than 50% of cases. In a study of almost 30 000 pregnancies, 47 women (0.16%) had symptoms including biliary colic (n = 33), acute cholecystitis (n = 12) or pancreatitis (n = 2). In 36% of cases, after a trial of conservative management, an operation was required for biliary colic (n = 10), acute cholecystitis (n = 6) or pancreatitis (n = 1) (14). Pancreatitis during pregnancy leads to a miscarriage in 0–60% of cases (15, 16). The most common causes for acute pancreatitis during pregnancy are gall stones (60–100%), alcohol abuse and hypertriglyceridemia (17).
Because of the increased morbidity associated with untreated gall bladder disease during pregnancy as described below, surgical intervention is recommended. Women who are first treated conservatively during pregnancy have a significantly higher rate of recurrent symptoms (60% versus 13%), are more likely to be hospitalized (1.5 versus 1.2 hospitalizations), and visit their physician more often (1.7 versus 1.1 visits) (18). Because of the good results and lower morbidity, primary laparoscopic surgery is recommended (8, 19). A review of several case series comparing laparoscopy with laparotomy identified a lower miscarriage rate for laparoscopy (1/89 cases with laparoscopy versus 2/69 after laparotomy) but somewhat more preterm births (6/89 with laparoscopy versus 2/69 after laparotomy) (9). Once again, we emphasize that there are no RCTs comparing laparoscopic versus open cholecystectomy during pregnancy.
Perioperative care including management of complications
Positioning during surgery
In order to avoid an aortocaval compression syndrome, it is recommended to routinely place the patient in the left lateral position (8). There are neither RCTs nor case series addressing this issue; the recommendation is based on the clinical experience of operating teams. While compression of the vena cava can lead to reduced venous return and hypotension in the mother, partial compression of the aorta when the mother is in the supine position is even more dangerous for the fetus than the mother, because the mother’s arterial blood pressure may remain stable even though arterial hypotension is found in the uterine artery. Depending on the position of the fetus, employing a right lateral position or close monitoring with prompt corrective measures (expanding volume, medications) can improve the hemodynamic status.
During laparoscopic surgery a steep head-down position is often needed. When the uterus is enlarged as in pregnancy or when the adnexal structures are difficult to visualize, it may help to employ a head-down lateral positioning which improves the view of the contralateral adnexal structures. The anesthetic aspects of a head-down positioning are discussed below.
Intra-abdominal pressure / alterations in acid–base status
The US guidelines recommend a pneumoperitoneal pressure of <15 mm Hg. This helps reduce utero-placental hypoperfusion and maternal cardiac overload, as well as to reduce the increase in paCO2 during capnoperitoneum (19–21).
When creating the CO2-pneumoperitoneum (capnoperitoneum), one generally notices an increase in the arterial CO2 partial pressure (paCO2) which is primarily caused by increased trans-peritoneal absorption of CO2. If this increase is unrecognized, it can lead to hypercapnia and respiratory acidosis which in turn may cause stimulation of the sympathetic nervous system and cardiac arrhythmias, as well as fetal acidosis (22). Therefore, during laparoscopy measuring the end expiratory CO2 levels (capnometry) should be routine, with the ventilation adjusted to the CO2 levels (8, 20, 21, 23–26). If the maternal history or peripartum complications raise the suspicion of possible gas exchange abnormalities, then there should be no hesitancy in employing perioperative arterial paO2 monitoring (8).
A clear increase in oxygen consumption and a simultaneous reduction in the functional residual capacity and thus in the oxygen reserve mean that during the induction and maintenance of anesthesia in a pregnant women, a critical hypoxemia can develop, especially when positioning or use of a capnoperitoneum leads to a dislocation of the endotracheal tube or a reduction in respiratory compliance. During laparoscopy in particular, a correctly placed endotracheal tube may be accidently displaced by the head-down positioning and the increased intra-abdominal pressure and wind up in the right main bronchus, resulting in unilateral ventilation (22, 27). After each change in the patient’s position, auscultation should be used to confirm the correct position of the endotracheal tube.
Miscarriages and preterm births
Although there is no increase in the fetal malformation rate following surgical procedures under general anesthesia, studies indicate that there is a slight increase in the miscarriage rate (28, 29). It is unclear if the surgical procedure or the anesthesia is responisble. Brodsky et al. (28) compared 187 women who had a surgical procedure under anesthesia in the first trimester to a control group of 8654 pregnant woman; they found a miscarriage rate that was significantly higher than that in controls (8.0% versus 5.1%) (2nd trimester 6.5% versus 1.4%). The largest published study is that of Mazze and Källén which includes 720 000 pregnant women including 5405 who underwent surgery with anesthesia. The number of children with a reduced birth weight was increased, both because of intrauterine growth retardation as well as an increase in preterm births. This study failed to identify any specific surgical and anesthetic approach as associated with worse results.
A letter survey of laparoscopic surgeons revealed that in 413 laparoscopic procedures during pregnancy there were only 15 cases with perioperative complications (11). Reedy et al. in Sweden studied two million pregnancies over a period of 20 years (10). Their collective included 2181 laparoscopies and 1522 laparotomies (4–20 weeks of gestation). Preterm births, developmental problems, and reduced birth weight were much more common in children of operated mothers than children whose mothers had not undergone surgery, supporting other studies. However, no differences were found between patients undergoing laparoscopy versus laparotomy.
There are numerous studies that indicate fetal advantages of laparoscopy over laparotomy in pregnancy. But the data on miscarriages and preterm births is contradictory, as seen in the meta-analyses discussed in the section on appendectomy which show a significantly increased rate of miscarriages with laparoscopy but no significant differences in preterm birth rates (6,7, 30) (Table 2).
The fetal and uterine status should be followed as in the US guidelines after the 16th week of pregnancy with both pre- and post-operative monitoring and documentation (8). Intra-operative monitoring does not improve the mortality (14, 20, 21, 31). Monitoring makes it possible to identify fetal problems early and institute measures to improve uterine perfusion (correction of hypoxemia, increasing blood pressure, re-positioning). When evaluating the fetus, one must remember that under general anesthesia the fetus is also anesthetized. Cardiotocography (CTG) or electronic fetal monitoring may reveal a marked reduced variability in fetal heart rate and oscillation which can be mistaken for an adverse cardiac event by individuals not familiar with the phenomenon. The reduced variability may persist post-operatively as the half-life of many anesthetics is longer in the fetus. An obstetrician should always be involved perioperatively. Postoperatively depending on the week of gestation either electronic fetal monitoring or sonography may be useful.
Intra-abdominal procedures may lead to manipulation and displacement of the uterus which often leads to premature contractions (32). No study has identified an influence of anesthesia or given anesthetic agents on the frequency of preterm births (32). Some of the anesthetic agents, including many of the inhaled agents, are potent inhibitors of uterine contraction.
Although tocolytics like indomethacin suppositories (33) have no influence on anesthesia, beta-mimetic agents can have circulatory effects in the mother and cross-react or even potentiate drugs used during anesthesia (34). In the post-operative period, the combination of wound pain and administration of analgesic agents makes it difficult to identify premature contractions. The US guidelines recommend tocolytic ther
Antibiotics, lung maturity and Rh prophylaxis
Antibiotics should be chosen depending on the indications for the planned operation, following the same recommendations as if the patient was not pregnant; however, teratogenic antibiotics should be avoided. If the clinical situation allows it, respiratory distress syndrome prophylaxis (pharmacological stimulation of fetal lung maturity) should be considered, depending on the week of gestation.
In addition, the need for Rh prophylaxis should be evaluated. Even in the absence of visible intra-uterine bleeding, the manipulation of the pregnant uterus or adjacent organs during a procedure can lead to placental microtrauma or bleeding.
Many studies report on the advantages of laparoscopy over laparotomy in pregnant women. These include reduction in the fetal respiratory depression because of less need for maternal postoperative analgesics (38–40, e1), fewer wound infections (39, e2, e3) and less manipulation of the uterus to obtain better visualization (e4). Additional advantages of laparoscopy include a shorter hospital stay and reduced risk of thromboembolic events (8). On the other hand, perforation of the uterus is one of the main risks of laparoscopy during pregnancy and is especially likely to occur as the trocar is introduced into the abdominal cavity (5). Accidental intrauterine insufflation with gas through a Veres needle increases the risk of preterm birth (11). Finally, laparoscopy is associated with a higher miscarriage rate than laparotomy, especially when employed for appendicitis (10), so that an open approach should be chosen in this clinical situation in order to maximize fetal safety.
The localization of the trochar is crucial for the laparoscopic surgeon in order to minimize the risk of injuring the uterus. The site of trochar placement depends on the size of the uterus as well as the planned operation and the preferences of the surgeon (e5).
Risk of aspiration/ anesthesia
Additional practical guidance on reducing the risk of aspiration as well as on the use of inhalation and intravenous anesthetics during pregnancy can be found in the eBox.
Conflict of interest statement
The authors declare that no conflicts of interest exist.
Manuscript received on 29 September 2013, revised version accepted on 10 April 2014.
Translated from the original German by Walter Burgdorf, MD.
PD Dr. med. Ingolf Juhasz-Böss
Klinik für Frauenheilkunde, Geburtshilfe
Universitätsklinikum des Saarlandes
66424 Homburg/Saar, Germany
@For eReferences please refer to:
J Reprod Med 1995; 40: 243–5.
Department of Surgery and Surgical Oncology, HELIOS-Klinikum Berlin-Buch:
Prof. Dr. med. Strik
Department of Anaesthesiology and Surgical Intensive Care, University Hospital of Halle (Saale):
apl. Prof. Dr. med. Raspé
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