Approximately 1 in 500 women will require nonobstetrical abdominal surgery in pregnancy.1 The most common surgeries include appendectomy and cholecystectomy.1 As laparoscopic surgery becomes more prevalent, it should be a consideration for these women. The benefits of laparoscopy during pregnancy are similar to those benefits in nonpregnant patients: less postoperative pain, less postoperative ileus, decreased length of hospital stay, faster return to daily activities, decreased fetal respiratory depression due to diminished postoperative narcotic requirements, lower risk of wound complications, less postoperative maternal hypoventilation, and decreased risk of thromboembolic event.1,2 All information in this article pertaining to laparoscopic surgery can also be applied to other variants of laparoscopy, such as robotic surgery and single-site laparoscopic (or robotic) surgery.
Safety of Surgery in Pregnancy
Early studies reviewing fetal outcomes after laparoscopic surgery in pregnancy use information from the Swedish Health Registry. Nonobstetric surgeries between 4 and 20 weeks gestation were reviewed which included 2181 laparoscopies and 1522 laparotomies. There was no significant difference in the following outcomes between these 2 groups: birth weight, gestational duration, intrauterine growth restriction, congenital malformation, and stillbirth/neonatal death. When comparing infants born after surgery (laparoscopy or laparotomy) versus all infants born, there was a significant increase in low–birth-weight infants (<2500 g), preterm delivery (<37 wk), and growth-restricted newborns.3 An earlier study also utilizing the Swedish Health Registry reviewed 5405 women with surgery in pregnancy. There was no increase in stillbirths or congenital malformations in these cases, and, notably, almost 42% of surgeries occurred in the first trimester when organogenesis occurs. They did show an increase in low–birth-weight infants (<1500 g; from prematurity and intrauterine growth restriction) and infant deaths within 7 days of birth for all women undergoing nonobstetric surgery in pregnancy.4
A large observational study reviewing 10 years of maternity data from the United Kingdom identified 47,628 pregnant women who underwent nonobstetric surgery. These women did have a higher risk of adverse birth outcomes, although this risk was generally low. These adverse birth outcomes included spontaneous abortion, preterm delivery, maternal death, cesarean section, long inpatient stay, stillbirth, and low–birth-weight. The study was limited by being unable to disentangle the effect of surgery from the effect of the underlying condition itself.5
There are 3 large meta-analyses that review outcomes of surgery for adnexal mass, cholecystectomy, and appendectomy in pregnancy by laparoscopy (LS) or laparotomy (LR) (Table 1). This includes an analysis by Ye et al6 reviewing 985 women undergoing surgery for an adnexal mass (549 LS, 436 LR), an analysis by Sedaghat et al7 reviewing 10,632 women undergoing cholecystectomy (9413 LS, 1219 LR) and an analysis by Prodromidou et al8 reviewing 6210 women undergoing appendectomy (1926 LS, 4284 LR). All 3 reviews found the LS group had shorter hospital stays and there was no difference in operative time between the 2 groups. Individual studies also noted the LS group had lower risk of preterm labor, less blood loss, improved postoperative outcomes, and less maternal, fetal, and surgical complications. The review by Prodromidou of 6210 women having appendectomies showed an increased rate of fetal loss in the laparoscopic group. This review included 20 studies and it was noted that the results of only 1 study influenced this finding of increased fetal loss. Thus, the authors concluded that further studies are needed to support this finding.8 The results of the other 2 large meta-analyses include LS as a feasible alternative for pregnant women with adnexal masses and those needing cholecystectomies.
Maternal Physiology and Surgical Planning
Physiological changes that occur during pregnancy are important factors to consider when surgery becomes necessary. Fortunately, the body of literature accumulated over the years supports the premise that with proper understanding of the uniqueness of pregnancy and appropriate adjustment, minimally invasive surgical approaches are safe and effective.
During pregnancy, there is a 20% increase in oxygen consumption and a 20% decrease in pulmonary functional residual capacity. These changes result in a rapid decrease in PO2 during maternal apnea which is particularly important to manage during anesthetic induction and emergence. Other risk factors such as preeclampsia and maternal obesity can magnify the risk of hypoxemia during apnea.9 Patient positioning for laparoscopy can also affect functional residual capacity. Specifically, Trendelenburg position further increases intrathoracic pressure and intensifies the physiological respiratory changes in pregnancy.10 Pneumoperitoneum used for laparoscopy exacerbates the already upwardly displaced pregnant patient’s diaphragm and the functional residual capacity can be further decreased.11 While some have advocated for maintaining intra-abdominal insufflation to <12 mm Hg to minimize the insult to the patient’s functional residual capacity during laparoscopic surgery in a pregnant patient, this level of insufflation may not provide adequate visualization for a surgery to be safely performed. Current guidelines by the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) endorse maintaining intra-abdominal insufflation to levels up to 15 mm Hg based on intraoperative maternal response.1
Airway management can be particularly difficult in the pregnant patient. Failed endotracheal intubation is a complication of anesthesia in pregnancy, and rates of failure have remained unchanged over the past 4 decades.12 Difficulties with patient intubation and intraoperative ventilation can be encountered in the pregnant patient due to swelling of oropharyngeal tissue and decreased caliber of the glottic opening. These issues worsen toward the end of pregnancy, but it is important to note that higher Mallampati classes were found in 12% of women in the first trimester and up to 20% in the second trimester.11 In pregnancy, heartburn is common, and is caused by acidic reflux into the lower esophagus. Decreased gastroesophageal junction tone contributes to this issue.13 This physiological change particular to pregnancy necessitates vigilance in protecting an airway during surgical intervention due to the increased risk of aspiration during general anesthesia.
Several cardiovascular changes in pregnancy need to be considered when approaching the pregnant patient having surgery. On a fundamental level, maintenance of normal maternal blood pressure is very important to ensure sufficient uteroplacental circulation during a surgical procedure.9 Without adequate uteroplacental perfusion, most substances essential for appropriate growth and health would not be available to the developing fetus.13 The gravid uterus compresses the vena cava in the supine position of a pregnant patient undergoing laparoscopic surgery. This decreased venous return causes decreased cardiac output, maternal hypotension, and resultant decreased uteroplacental profusion. Reverse Trendelenburg positioning can exacerbate the effect of the gravid uterus on venous return.10 The pregnant patient undergoing laparoscopic surgery during the second or third trimesters should be placed in the left lateral decubitus position to shift the uterine weight off of the vena cava and improve venous return and cardiac output. Reverse Trendelenburg positioning should be achieved slowly to allow for monitoring of maternal hypotension. The pregnant uterus in the first trimester is not large enough to cause significant alteration in venous return and thus no changes in patient positioning are necessary at that stage of pregnancy.1
Both SAGES and ACOG recommend screening for and appropriate use of perioperative prophylaxis against venous thromboembolism. Hemostatic changes in pregnancy include estrogen stimulation of synthesis of procoagulant proteins and venous stasis from progesterone effects and mechanical compression by the gravid uterus.14 Use of general principles of VTE prophylaxis for laparoscopic surgery can be used to guide decision making. At a minimum, intraoperative and postoperative pneumatic compression devices are recommended as is early postoperative ambulation. Use of unfractionated or low–molecular-weight heparin can also be considered in the appropriate clinical setting.1
Concern regarding the potential teratogenic effects of anesthetic drugs has been an important factor when considering nonobstetric surgery in the pregnant patient. Broadly, the risk of teratogenicity on fetal development is based on the inherent toxicity of the agent being used, the dosage of the agent used and the length of exposure of the fetus, and what period of fetal development is ongoing during administration of the agent.9 There has long been concern regarding the potential teratogenic effect of agents commonly used for anesthesia, especially in terms of central nervous system and brain development. The American College of Obstetricians and Gynecologists’ Committee on Obstetric Practice in conjunction with the American Society of Anesthesiologists, note that there is a lack of evidence to support any teratogenic effects of currently used anesthetic agents at usual doses regardless of gestational age of the fetus. In addition, despite concerns, there has been no evidence supporting a deleterious effect of exposure to anesthetic or sedative agents on the fetal brain.15
For patients undergoing a laparoscopic surgery, creation of pneumoperitoneum with CO2 gas allows for adequate visualization such that surgery can be performed safely and efficiently. CO2 gas exchange has been shown to occur from intraperitoneal insufflation to the fetus. The concern for such an exchange is resultant fetal acidosis and associated tachycardia, hypertension, and hypercapnia. While some animal studies have shown these results, no data exist showing detrimental effects to human fetuses from pneumoperitoneum from CO2 gas. However, due to the potential effects, it is recommended that maternal end-tidal carbon dioxide monitoring be performed during laparoscopy in the pregnant patient. Capnography is sufficient evaluation and more invasive blood gas monitoring has not found to be necessary.1 During surgery, maternal end-tidal CO2 should be kept within a normal range by manipulating the ventilatory rate.16 One study recommends this value to be 32 to 34 mm Hg.10
Devroe and colleagues reviewed the charts of 171 Belgian women who underwent nonobstetric surgical interventions requiring anesthesia over a 16-year observation period. The study found that these women more frequently delivered preterm versus case-matched women who had not undergone a nonobstetric surgery during their pregnancy. Use of general anesthesia was associated with a higher frequency of low birth rate babies in the study population, although causation could not be established.17 Despite this and other studies showing similar findings, no good evidence exists to support the use of prophylactic tocolytic agents in pregnant women undergoing surgery. Rather, the decision to start tocolysis in the perioperative period should be based on the presence of preterm labor. Monitoring a patient in the perioperative period for signs and symptoms of preterm labor allows for the appropriate use of tocolysis which can be effective in preventing preterm birth.1,15 Consideration should also be given to the use of corticosteroids for fetal benefit in women with viable premature gestations undergoing nonobstetric surgery.15 The decision to use tocolytics and corticosteroids should be made on an individual basis.
The timing and extent of fetal monitoring for nonobstetric surgery in pregnancy is dependent on the gestational age of the patient and the ability to interpret and act on concerning results. Before fetal viability, it is sufficient to determine fetal heart rate by Doppler before and after surgery. After viability, electronic fetal heart monitoring and concomitant contraction monitoring should be performed at a minimum, before and after surgery. If feasible, based on the type of surgery being performed, intraoperative electronic fetal monitoring could be considered but should be done only if an obstetrics provider is available, the patient consents to emergent cesarean delivery for fetal indications, monitoring can physically be performed, and the nature of the surgery allows safe interruption or alteration of the procedure to provide access to perform emergency delivery.15 While intraoperative fetal heart rate monitoring may be presumed to be the most accurate method of fetal evaluation, the current surgical standard of care is preoperative and postoperative monitoring of a viable fetus. No increased fetal morbidity has been reported in the absence of intraoperative fetal heart rate monitoring.1
Traditionally, the recommendation for nonemergent procedures during pregnancy had been to avoid first and third trimesters to minimize the risk of spontaneous abortion and preterm labor, respectively. Recent literature has shown that pregnant patients may undergo laparoscopic surgery safely during any trimester without an increased risk to mother or fetus.1 A pregnant woman should never be denied medically necessary surgery or have that surgery delayed regardless of trimester because this can adversely affect the pregnant woman and her fetus.15
Obesity is a global problem and creates another challenge when operating on a pregnant patient. There is a paucity of studies specifically addressing laparoscopy in the obese pregnant patient, thus information presented is extrapolated from the nonpregnant population. When comparing hysterectomy in the obese population, a laparoscopic approach is superior to laparotomy due to improved rates of wound dehiscence and infection and shorter lengths of hospital admission. All hysterectomy routes in the obese population are associated with increased blood loss, surgical time, and perioperative complications.18
Positioning of a patient during laparoscopic surgery minimizes risk of nerve injury, allows maneuverability during the case, and optimizes the surgical view. For an obese patient, both weight and size must be considered. Standard operating room tables have a capacity of 205 to 455 kg. To ensure a patient stays secure to the table in Trendelenburg position, a gel or foam pad, nonslip mattress, surgical bean bag, or positioning kit can be utilized. Padded boot-type stirrups are often used in gynecologic surgery when patients are in lithotomy position. These stirrups have a standard capacity of 227 kg.18,19 In pregnancy, the patient does not necessarily need to be placed in lithotomy since there is no uterine manipulator being used. With laparoscopic surgery, the patient’s arms are often tucked at their sides to reduce the risk of ulnar nerve and brachial plexus injury as well as to allow improved positioning for the surgeon.18 With the obese patient, the table may not be wide enough thus a bed extender or arm sled/shield can be used.
With an increased anterior abdominal wall size, there is a higher chance of failed entry or preperitoneal insufflation with the entry technique.18,19 Umbilical entry is often preferred in the obese patient since this is the thinnest portion of the anterior abdominal wall; however, this may not be a reliable landmark since the umbilicus may be positioned more caudally due to the obese abdomen.18 The gravid uterus, even in the first trimester, may be penetrated with umbilical entry of the obese abdomen since the umbilical position may be more caudal than in someone with a normal body mass index. If the umbilical position is distorted, the bony landmarks can be used to decide on an entry point (halfway between xyphoid and pubic symphysis in midline). Displacement of the umbilicus by a large pannus may also prevent adequate triangulation with the pelvis. Other entry points may need to be considered for the obese gravid patient.18
The increased weight of the abdominal wall may cause the initial CO2 pressure to be high when primary entry into the abdomen occurs and it can make ventilation with pneumoperitoneum and Trendelenburg positioning difficult. Maximum Trendelenburg is often unattainable due to difficult ventilation. If the pneumoperitoneal pressure needs to be decreased, it often compromises surgical visualization. Potential solutions include releasing pneumoperitoneum at intervals to improve ventilation, using ancillary trocars for bowel retraction, and the use of a mechanical device to help elevate the abdomen. An example of a mechanical device includes the “foley lap-lift” where a foley catheter is placed in the abdomen, balloon filled, placed under tension, and attached to a retractor on the side of the operating table. This mechanically lifts the abdominal wall and allows for lower intraperitoneal pressure.20
Other considerations when operating on the obese pregnant patient is the use of extra-long veress needle (150 mm length vs. standard length of 120 mm), long trocars, trocars with intra-abdominal balloon to prevent slippage out of the abdomen, and bariatric laparoscopic equipment (graspers, needle drivers, laparoscope).18,19
In patients with cervical insufficiency, treatment options include transvaginal and transabdominal cervical cerclage. Transabdominal cervicoisthmic cerclage can be placed in those patients when there are anatomic limitations to a transvaginal approach (ie, after trachelectomy) or for those patients with a failed transvaginal cervical cerclage that resulted in second trimester pregnancy loss.21 Transabdominal cerclage (TAC) can be performed by laparotomy or laparoscopy and can be placed either in early pregnancy (late first trimester or early second trimester) or in the nonpregnant state. The cerclage can be left in place between pregnancies with delivery being by cesarean section.21 TAC carries a higher risk of hemorrhage when compared with the transvaginal approach, in addition to the other risks associated with abdominal and laparoscopic surgery.21
In a systematic review, 1116 patients (in 26 studies) with TAC by laparotomy were compared with 728 patients (in 15 studies) with TAC by laparoscopy. In the laparotomy group, 18.6% (160 patients) of TAC were placed before pregnancy and 81.4% (702 patients) were placed postconception. In the laparoscopy group, 71% (517 patients) of TAC were placed before pregnancy and 28.9% (211 patients) were placed postconception. There was no significant difference in overall neonatal survival between the laparotomy and laparoscopy groups. The laparoscopy group had a higher rate of delivery at a gestational age greater than 34 weeks and a lower rate of deliveries at a gestational age of 23.0 to 33.6 weeks. Pregnancy complications were similar in both groups (pelvic infection, small bowel injury, bladder injury, uterine vein laceration) with 1.0% occurring with laparoscopy and 1.2% with laparotomy. The perioperative postconceptional miscarriage rate (up to 2 wk after surgery) was 1.2% for laparoscopy and 3% for laparotomy. The overall risk profile is comparable for these 2 groups.2
In reviewing the technique for laparoscopic cerclage placement, many surgeons will use 4 trocars and 5 mm mersilene suture (or another nonresorbable suture). The suture needle is either kept curved or straightened and many dissect the uterovesical and paravesical spaces and create a broad ligament window.2,21 There is not a clear trend in regard to the location of the cerclage knot being placed anteriorly versus posteriorly2 (Figs. 1–3).
Rupture of membranes is a risk of laparoscopic cerclage placement in the gravid uterus. A dilation and curettage for evacuation of a failed pregnancy can be done while leaving the cerclage in situ.22 Consider performing dilation and curettage under ultrasound guidance if the cerclage is being left in place and with preparation for potential cerclage removal, if needed.
When laparoscopic cerclage is performed in a nonpregnant patient, a uterine manipulator is often used. In the gravid patient, an intrauterine manipulator cannot be utilized due to presence of a fetus. Other options for manipulation of the uterus during laparoscopic cerclage placement include using an Endo Paddle retractor (Covidien)22 or diamond-flex triangular retractor (Snowden Pencer),23 which is also known as a liver retractor or snake retractor. Some manipulation can be obtained vaginally by use of Koh vaginal fornices delineator22 or by having an assistant provide digital vaginal manipulation. An angled laparoscope (ie, 30 degrees) can also improve visualization around the gravid uterus.
Large Adnexal Masses
If a benign adnexal mass needs to be surgically addressed in pregnancy, a minimally invasive approach should be considered. This approach includes laparoscopy and mini-laparotomy. If laparoscopy is being performed, both the size of the gravid uterus and the size of the adnexal mass need to be considered to avoid injury to the uterus or perforation of the adnexal mass. If a laparoscopic adnexal mass removal is accomplished with the cyst intact, the specimen can then be placed in an extraction bag, and cyst drained within the bag and removed from the abdomen.
The remainder of this section will specifically address minimally invasive approaches to the large adnexal mass, where the size of the cyst obstructs visualization and drainage is necessary before cystectomy or oophorectomy. The first approach is to perform the surgery laparoscopically in its entirety. Once the laparoscope and ancillary trocars are placed, the cyst can be drained via a laparoscopic aspiration needle, veress needle, or spinal needle. We recommend that the needle is attached to wall suction instead of using a 60 mL syringe to suction. Although a syringe may work well with a small cyst, a larger cyst will contain >60 mL of fluid, thus necessitating detachment of the syringe multiple times to accommodate the cyst fluid volume. This would create more opportunities for the needle to slip out of the cyst. Once the cyst has been adequately decompressed, a laparoscopic grasper can hold the cyst adjacent to the site of drainage and the needle can be removed. This drainage site can then be extended large enough to accommodate a suction/irrigator device that is blunt tipped and can drain the remainder of the cyst in safe manner. If a cystectomy is planned, this can then be started. If an oophorectomy is planned, a suture or endoloop can be placed around the site of cyst drainage to avoid any spillage of fluid while the adnexa is being manipulated. Once the cystectomy or oophorectomy is completed, the specimen can be placed in an extraction bag and removed through a port site. The bag can either be attached to an endoscopic delivery device or a separate containment bag.24 The choice of bag depends on cyst size and surgeon preference.
The second approach would be to drain the cyst extracorporeally and perform the remainder of the surgery laparoscopically. Entry into the abdomen would be the same as if performing a Hasson trocar entry with incision through skin, subcutaneous fat, fascia, and peritoneum directly over the mass. The cyst is then drained through the incision. Handheld or a disposable wound retractor (ie, Alexis wound protector/retractor, Applied Medical) can be used to help with visualization. Drainage can be performed as described previously with a needle attached to wall suction. Once enough of the cyst volume has drained to give the cyst wall laxity, it can be grasped with hemostats and pulled out through the incision. The needle is then removed, drainage site extended, and a blunt tipped suction placed to evacuate the remaining cyst fluid. This drainage site can then be sutured closed and replaced in the abdomen. Hasson trocar (or gel port) can then be placed through this incision and the remainder of the surgery done laparoscopically.
The third approach would be to perform the entire surgery extracorporeally through a mini-laparotomy incision. A small incision is made (2 to 4 cm length) and once access is gained to the abdominal cavity, retractors are placed to optimize visualization as described above. Cyst drainage is performed extracorporeally as previously described. Once the cyst is drained, if a cystectomy is planned, this can then be performed extracorporeally. If an oophorectomy is planned, the drainage site can be sutured closed and the adnexa pulled out and surgery completed through this incision. Careful planning in regard to incision location needs to occur preoperatively to ensure the adnexa can be pulled through the incision. This incision in the nongravid patient is usually in the suprapubic area.
In regard to which surgical approach to use, the size of the gravid uterus, size of the adnexal mass, and nature of adnexal mass [unilocular cyst vs. complex adnexal mass (ie, dermoid)] needs to be taken into consideration. All of the approaches described can be performed without spillage of cyst fluid in the abdominal cavity. However, if a cystectomy is being performed, cyst spillage may be more likely. If there is inadvertent cyst spillage, especially with a teratoma, copious intra-abdominal irrigation is recommended. Incomplete removal of teratoma contents can result in rare complications: chemical peritonitis (<0.2%), abscess formation, and small bowel obstruction.24 It can also be theorized that with a gravid uterus, preterm contractions could occur due to uterine irritability. If spillage does occur, it may be difficult to irrigate and suction all cyst contents due to the size of the gravid uterus.
If there is concern for malignancy preoperatively, referral should be made to a gynecologic oncologist.
One of the risks of laparoscopy in pregnancy is uterine perforation. This is a rare but potentially severe complication. One case report notes uterine injury from veress needle entry with subsequent pneumoamnion that was not initially recognized (21 wk gestation). She subsequently had a repeat laparoscopy, ultrasound, and computerized tomography due to worsening pain. Normal amniotic fluid volume was noted as well as pneumoamnion. She then ruptured her membranes and delivered a stillborn25 (Table 2).
Another case report notes 3 patients with “incidental fetoscopy” during nonobstetric laparoscopy in pregnancy. One case was converted to laparotomy with repair of 3 uterine perforations (19 wk gestation) and the other 2 cases (32 wk with singleton pregnancy and 17 wk with twin pregnancy) completed laparoscopic surgeries without repair of the uterine perforations. These patients then delivered at 32 5/7 weeks (PPROM), 36 5/7 weeks (PPROM), and 30 6/7 weeks gestation (preeclampsia), respectively26 (Table 2).
It is important to determine fundal height and make the decision for entry location based on this. Fundal location may be difficult to determine in the obese patient or those with pelvic pathology (ie, leiomyoma, adnexal mass). If the fundus cannot be clearly identified, consider ultrasound to determine fundal location and mark the patient’s abdomen.26 The management of uterine perforation can be extrapolated from our current practice of operative fetoscopy. Fetoscopy utilizes 2 to 4 mm trocars through the uterus and amniotic cavity to access the fetus, placenta, or umbilical cord. After the fetal surgery is completed, the trocars are removed and sites of uterine trocar placement are usually not repaired. Additional suturing of the gravid uterus may cause more harm by increasing the risk of amniotic membrane rupture. The risks of operative fetoscopy include PPROM, oligohydramnios, preterm delivery, chorioamnionitis, fetal injury, and pregnancy loss.26
If uterine perforation does occur at the time of laparoscopy in the pregnant patient, it is reasonable to conclude that it may be best to expectantly manage a perforation if it is hemostatic and there is minimal leakage of amniotic fluid. If uterine repair is indicated, a delayed absorbable suture could be used. Conversion to laparotomy is not necessary if adequate inspection of the uterus can be performed laparoscopically. Postoperatively, ultrasound should be performed to assess amniotic fluid volume and confirm fetal viability. These patients should be monitored for PPROM, preterm labor, and placental abruption. If a patient is Rh negative, anti-D immunoglobulin should be given. Corticosteriods can be considered for fetal benefit.26 Consider consultation as well with a maternal fetal medicine specialist.
The Society of American Gastrointestinal and Endoscopic Surgeons published their most recent guidelines for the use of laparoscopy during pregnancy in 2017 (Table 3). These guidelines state that laparoscopy can be safely performed during any trimester when surgery is indicated. Patients beyond the first trimester should be placed in left lateral decubitus position to minimize compression of the vena cava. Initial entry for laparoscopy can be safely performed by any technique [open (Hasson), Veress needle, or optical trocar], however, the location of the fundus must be determined and entry location adjusted based on this finding.1 An insufflation pressure of 15 mm Hg or less can be safely used and end-tidal CO2 and maternal blood pressure should be kept in a normal range.1,9,16
Although laparoscopy can be performed at any time during pregnancy, the third trimester may pose the greatest challenge due to the size of the gravid uterus. Abdominal entry location and technique should be adjusted appropriately. Consider the use of an angled laparoscope to improve visualization around the large uterus as well as nonintrauterine retractors (Endo Paddle retractor (Covidien) 22 or diamond-flex triangular (liver/snake) retractor (Snowden Pencer).23 A skilled surgeon with laparoscopic experience is necessary as well. In summary, a pregnant woman should never be denied medically necessary surgery or have that surgery delayed regardless of trimester because this can adversely affect the pregnant woman and her fetus.15
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