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To present the currently available literature on surgical interventions in pregnancy was one of the aims of our review. Prof. Berger criticizes the data quality of some studies. This criticism is to some extent justified as there are no randomized controlled studies available comparing different surgical approaches (laparotomy versus laparoscopy) in pregnancy. The study results presented in detail in our article are based on two meta-analyses and numerous other research studies, most of them case control studies. Prof. Berger has rightly criticizes that—not unexpectedly—some of these studies had methodological shortcomings. Nevertheless, in the age of evidence-based medicine it is crucial to inform the patient based on the available study data.

Prof. Crombach has once again pointed out the risks associated with trocar placement during laparoscopy. As mentioned in the article, we would like to re-emphasize that trocar placement should be adapted to the size of the uterus, even if that requires to deviate from the standard procedure typically performed in a hospital. To what extent such “open” laparoscopy can minimize the risk of injury to the uterus in pregnancy—as noted by Prof. Crombach—cannot conclusively by derived from the available data and is subject to controversy (1). Therefore, the authors are of the opinion that surgeons should insert the trocar into the abdomen in the way they regard as safest for them.

Prof. Crombach has mentioned two cases of (apparently intraoperative) intrauterine fetal death and believes that our article is lacking a recommendation to carry out intraoperative fetal monitoring.

In his correspondence item, he described two methods available for intraoperative fetal monitoring (e.g. sterile ultrasound or cardiotocography [CTG] checks). The authors cannot give a general recommendation for intraoperative fetal monitoring. One reason is that settings without intrauterine fetal monitoring form the basis of most experiences/study results. As mentioned in our paper, the fetus is also under anesthesia intraoperatively/in the uterus. This results in changes, for example, in the fetal heart rate (and consequently in CTGs or ultrasounds). The possibility of an increase in the preterm birth rate as the result of a lack of experience in the interpretation of these monitoring techniques in the anesthetized fetus, cannot be ruled out. In addition, the available literature on intraoperative monitoring shows that intraoperative monitoring does not improve mortality (2, 3). Furthermore, the US guideline only recommends pre- and postoperative monitoring (1).

Nevertheless, pregnant women should undergo surgery in perinatal centers with proper interdisciplinary experiences, as emphasized by Prof. Crombach.

DOI: 10.3238/arztebl.2015.0146

PD Dr. med. Ingolf Juhasz-Böss

Klinik für Frauenheilkunde, Geburtshilfe und Reproduktionsmedizin

Universitätsklinikum des Saarlandes, Homburg/Saar

ingolf.juhasz-boess@uks.eu

Conflict of interest statement
The author declares that no conflict of interest exists.

1.
Pearl J, Price R, Richardson W, Fanelli R: Guidelines for diagnosis, treatment, and use of laparoscopy for surgical problems during pregnancy. Surg Endosc 2011; 25: 3479–92. CrossRef MEDLINE
2.
Glasgow RE, Visser BC, Harris HW, Patti MG, Kilpatrick SJ, Mulvihill SJ: Changing management of gallstone disease during pregnancy. Surg Endosc 1998; 12: 241–6. CrossRef
3.
Graham G, Baxi L, Tharakan T: Laparoscopic cholecystectomy during pregnancy: a case series and review of the literature. Obstet Gynecol Surg 1998; 53: 566–74. CrossRef
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
1.Pearl J, Price R, Richardson W, Fanelli R: Guidelines for diagnosis, treatment, and use of laparoscopy for surgical problems during pregnancy. Surg Endosc 2011; 25: 3479–92. CrossRef MEDLINE
2.Glasgow RE, Visser BC, Harris HW, Patti MG, Kilpatrick SJ, Mulvihill SJ: Changing management of gallstone disease during pregnancy. Surg Endosc 1998; 12: 241–6. CrossRef
3.Graham G, Baxi L, Tharakan T: Laparoscopic cholecystectomy during pregnancy: a case series and review of the literature. Obstet Gynecol Surg 1998; 53: 566–74. CrossRef
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

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