This article is primarily concerned with the question of optimal surgical approach (laparoscopy versus laparotomy) and well worth reading. I like to add three points which are important for the clinical management:
Both the miscarriage rate and the preterm birth rate are not only influenced by the surgical approach, but also by the underlying condition. For instance, frequently a peritoneal inflammatory response (e.g. appendicitis) triggers uterine contractions (1). The literature review leaves it open whether the studies included in their analysis took the effect into account that the extent of inflammation had on the complication rate.
The authors highlight the risk of injury to the uterus associated with the insertion of the Veres needle or trocar during laparoscopic procedures performed in pregnancy. By performing an “open” laparoscopy, this risk can be eliminated. Here, the approach (for example supra-umbilical) should be decided based on fundal height and, consequently, gestational age.
According to the article, fetal and uterine status should be followed after the 16th week of pregnancy with “pre- and post-operative monitoring and documentation“. There is no recommendation for intraoperative monitoring (2) which is still a matter of controversy. From my personal experience, I know two cases of intrauterine fetal death associated with thrombectomy and the surgical removal of an abdominal tumor, respectively (both occurred between the 28th and 30th week of pregnancy). Chances are that both cases could have been avoided if intraoperative fetal monitoring had been carried out, with the team on standby to intervene immediately, if required. Intermittent or continuous cardiotocography- or ultrasound-based fetal monitoring can be performed with the transducer or ultrasound probe wrapped in sterile drapes (3). Prerequisites include adequate preoperative information of the patient and an infrastructure ensuring the availability of the necessary professional expertise and interdisciplinary cooperation (level I–II perinatal center).
Prof. Dr. med. Gerd Crombach
St. Marien-Hospitals Düren
|1.||Tracey M, Fletcher HS: Appendicitis in pregnancy. Am Surg 2000; 66: 555–9. MEDLINE|
|2.||Shaver SM, Shaver DC: Perioperative assessment of the obstetric patient undergoing abdominal surgery. J Perianesth Nurs 2005; 20: 160–6. CrossRef|
|3.||Sakata Y, Oshima T, Tsutsui M, Fukuda I, Satoh T: Laparoscopic choelcystectomy under general anesthesia for a woman in the 28th week of gestation. Jpn J Anesthesiol 2003; 52: 1233–5. MEDLINE|
|4.||Juhasz-Böss I, Solomayer E, Strik M, Raspé C: Abdominal surgery in pregnancy—an interdisciplinary challenge. Dtsch Arztebl Int 2014; 111: 465–72. VOLLTEXT|