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Minimally invasive gynecologic surgery in the pregnant patient: considerations, techniques, and postoperative management per trimester

Dizon, Arthur M.; Carey, Erin T.

Current Opinion in Obstetrics and Gynecology: August 2018 - Volume 30 - Issue 4 - p 267–271
doi: 10.1097/GCO.0000000000000469
MINIMALLY INVASIVE GYNECOLOGIC PROCEDURES: Edited by Matthew T. Siedhoff

Purpose of review Nonobstetric surgery is performed in 1 : 200 to 1 : 500 of pregnant women in the United States annually. Previously, many argued that laparoscopy was contraindicated during pregnancy because of concerns for uterine injury and fetal malperfusion. Because surgeons have gained more experience with laparoscopy, it has become the preferred treatment modality for many surgical diseases in the gravid patient.

Recent findings Specific preoperative considerations, intraoperative techniques, and postoperative management per trimester will be reviewed to optimize patient and surgical outcomes.

Summary The advantages of laparoscopic surgery are similar for pregnant and nonpregnant women. Surgery during pregnancy should minimize risks to both the fetus and the mother. Whenever a pregnant woman undergoes nonobstetric surgery, consultations among her surgical team are important to coordinate management. Both anatomic and physiologic changes related to pregnancy may require modifications in management. Surgeons must be aware of considerations, techniques, and postoperative management used for pregnant patients to optimize outcomes for both the fetus and mother.

Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA

Correspondence to Arthur M. Dizon, MD, MSCR, Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, 4010 Old Clinic Building CB 7570, Chapel Hill, NC 27599, USA. Tel: +1 984 215 3050; fax: +919 595 5648; e-mail: mitchdizon@gmail.com

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INTRODUCTION

Nonobstetric surgery is performed in 1 : 200 to 1 : 500 of pregnant women in the United States annually [1]. The most common nonobstetric surgical intervention is for suspicion of acute appendicitis, but includes treatment of gallbladder disease and adnexal masses/torsion, all of which have been successfully managed with a laparoscopic approach. More advanced laparoscopic procedures, such as radical nephrectomy, splenectomy, mesenteric cyst removal, adrenalectomy, retroperitoneal lymphadenectomy, and ventral hernia repair have also been reported in gravid patients [2–5].

The safety of laparoscopic surgery during pregnancy remains debated, despite the well established benefit of minimally invasive surgery (MIS) in nonpregnant patients [6]. The primary concern is the potential fetal harm, specifically from the mechanics of MIS rise in intra-abdominal pressure during pneumoperitoneum that could decrease utero-placental blood flow resulting in fetal hypoxia, fetal acidosis developing from absorption of carbon dioxide, injury to the fetus if the uterus if perforated with a trocar or Veress needle, or uterine perforation resulting in preterm premature rupture of membranes (PPROM) and preterm labor (PTL). A systematic review in 2010 identified an increased risk of fetal loss in laparoscopic compared to open appendectomy during pregnancy. Although the rate of appendicitis is the same in nonpregnant patients, the likelihood it will progress to perforation is higher in pregnancy, secondary to limited imaging modalities resulting in delays of diagnosis and operative intervention [7–10]. However, despite delay to diagnosis, more recent evidence in the largest study to date, which included nearly 20 000 women undergoing either appendectomy or cholecystectomy, identified open surgery as associated with a higher risk of adverse obstetrical outcome, including miscarriage, when compared with MIS [11▪▪].

Maternal safety must also be considered because of the physiologic changes of pregnancy posing added surgical and anesthetic challenges. Increases in maternal oxygen consumption, decreases in pulmonary functional residual capacity, and physiological edema of oropharyngeal tissues result in increased difficulty in ventilation and airway management of the gravid surgical patient. Changes in lower esophageal sphincter tone and delayed gastric emptying augment the risk of aspiration.

The cardiovascular system is also altered in pregnancy as plasma volume, cardiac output, and heart rate increase whereas colloid oncotic pressure and systemic vascular resistance decrease, increasing the risk of pulmonary edema. Despite these physiologic changes, the overall prevalence of major maternal postoperative complications is low [12]. Major maternal postoperative complications were associated with increasing maternal age, medical comorbidities, preoperative functional status, preoperative systemic infection, and operative time [13]. Specific preoperative considerations, intraoperative techniques, and postoperative management by trimester will be reviewed to optimize patient and surgical outcomes (Table 1).

Table 1

Table 1

Box 1

Box 1

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PREOPERATIVE CONSIDERATIONS

MIS can be performed in any trimester [14]. There does not appear to be an increased risk of first trimester loss because of anesthesia exposure. However, as with other types of surgery performed during pregnancy, the optimal time to operate for nonurgent conditions is the early second trimester because of being outside the window of increased miscarriage rates and prior to encountering a larger uterus from advanced gestational age. Whether an MIS procedure is feasible in the third trimester depends upon individual clinical factors, such as the condition being treated, size of the uterus, and comorbid medical and obstetrical conditions. There is no absolute maximum gestational age for performing MIS.

Although procedures performed in the first trimester should be easier technically, it is preferable to introduce an anesthetic agent after the period when spontaneous miscarriages are likely to occur. Literature review suggests that there is no increase in congenital anomalies at birth in women who underwent anesthesia during pregnancy. Many surgical cases cannot be delayed from the first to the second trimester because of acuity. Additionally, many surgeries have been successfully performed late in the third trimester without increasing the risk of preterm labor or fetal demise [15,16]. Regardless of gestational age, postponing necessary operations, such as appendectomy for appendicitis, until after parturition has been shown in some cases, to increase the rates of complications for both mother and fetus [16–18].

Pregnant patients who require surgery should be evaluated preoperatively in the same manner as nonpregnant patients. Additional testing is not indicated in an uncomplicated pregnancy. A thorough history should document underlying medical and obstetrical conditions, and physical examination should include detailed assessment of the airway. Laboratory and other testing should be performed as indicated by the patient's medical problems and the proposed surgery.

Preparation of pregnant women takes into account risks of aspiration, difficult intubation, thromboembolism, and the wellbeing of the fetus. In the event central access is needed, pregnant patients have a greater risk of carotid puncture during central venous catheterization because of the tendency of the internal jugular vein to overlie the carotid artery in pregnancy [19].

Pneumatic compression devices are typically placed on the lower limbs of pregnant women undergoing laparoscopic procedures. There are no data from randomized trials on the use of unfractionated or low molecular weight heparin or intermittent pneumatic compression for venous thromboembolism prophylaxis in pregnant patients undergoing laparoscopy. For laparoscopic procedure (gynecologic or general surgical) likely to take more than 45 min, use of low molecular weight heparin is suggested; mechanical thromboprophylaxis is a reasonable alternative for shorter procedures [20].

There is no evidence to support the routine use of prophylactic tocolytics or glucocorticoids. However, these drugs may be indicated in management of threatened preterm delivery, especially patients undergoing surgery for infectious causes such as acute appendicitis or cholecystitis. A course of antenatal glucocorticoids 24–48 h prior to surgery between 24 and 34 weeks of gestation can reduce perinatal morbidity/mortality if preterm birth occurs. This decision depends upon the urgency of the surgery, and the physician's estimate of whether the patient is at increased risk of preterm birth because of the underlying disease or the planned procedure.

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INTRAOPERATIVE CARE

An oro- or nasogastric tube is inserted into the stomach to prevent perforation of a distended stomach and to reduce the risk of aspiration of gastric contents. A Foley catheter is placed in the urinary bladder.

The patient should be placed in the supine or low lithotomy position with a left lateral tilt (after 16 weeks of gestation) to avoid significant compression of the aorta and inferior vena cava. Left lateral rotation of the operating table may also help to displace the uterus adequately.

All patients undergoing laparoscopy are at risk of trocar injury. The gravid uterus makes trocar insertion and creation of a pneumoperitoneum more difficult and potentially more hazardous. Both the Hasson (open) technique and the Veress needle technique can been used for establishing a pneumoperitoneum in pregnant patients. Given the feasibility of both methods, a surgeon should use the technique with which they the most experience and comfort. Supraumbilical primary trocar placement can be utilized to provide an adequate distance between the tip of the laparoscope and the uterus to allow optimal visualization and instrumentation. Use of a subxiphoid, left upper quadrant, or right upper quadrant entry point can help to avoid the enlarged uterus. A sponge stick may be placed in the vagina and used to exert gentle cephalad pressure on the uterus, if necessary. Transcervical instruments should not be used to manipulate the uterus.

Intraabdominal pressure between 8 and 12 mm Hg and not exceeding 15 mmHg should be maintained [21,22]. This allows for adequate visualization while also avoiding the possible adverse effects on the hemodynamic and respiratory physiology of the gravid patient. The patient's position can be adjusted further to allow gravity to aid with visualization. As an example, varying degrees of Trendelenburg position can move the intestines cephalad and thus improve visualization for procedures in the pelvis. The amount of Trendelenburg position that a pregnant woman will tolerate depends on the patient's habitus, comorbid risk factors, and gestational age of the pregnancy.

Because of the pneumoperitoneum, transabdominal fetal monitoring is usually not possible during laparoscopy in the second trimester. If fetal monitoring is necessary during the procedure, transabdominal fetal monitoring may be possible through the left abdominal wall with the patient in a steep leftward tilt [23]. Another option is transvaginal ultrasound assessment of the fetal heart rate. The decision to monitor during surgery should be discussed with the patient regarding intervention if a potentially nonreassuring fetal heart tracing occurred for a fetus of early viability.

If maternal acidosis is suspected and confirmed, it can be reversed by immediately hyperventilating the mother and decreasing intraabdominal pressure. These measures can help to resuscitate the fetus by improving placental blood flow and fetal oxygenation [24].

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POSTOPERATIVE CARE

After surgery, thromboprophylaxis is continued until the patient is fully mobile. Early mobilization is encouraged to minimize the risk of venous thromboembolism.

Postoperative vaginal or intramuscular progesterone supplementation is recommended when the corpus luteum is removed before 9 weeks of gestation. Oral progesterone seems less effective [25–27]. Luteal support is shifted from the corpus luteum of the ovary to the placenta (called the luteoplacental shift) between seven and 9 weeks of gestation; therefore, after 9 weeks, progesterone supplementation to replace corpus luteum progesterone production is no longer needed.

After deflation of the pneumoperitoneum, uterine blood flow returns to normal, and the fetal partial pressure of carbon dioxide and pH changes resolve within 1 h. However, fetal oxygen saturation and content remained depressed, and fetal cardiovascular status continue to decline during the 2-h postinsufflation period. Fetal heart rate and uterine activity should be monitored in the recovery room, as appropriate for gestational age. A hand-held Doppler device is used for the first and early second trimester to check fetal heart rate prior to discharge. A nonstress test can be used in the late second and third trimester during viability.

Opioids and antiemetics can be used, as needed, to control postoperative pain and nausea. Nonsteroidal antiinflammatory drugs should be avoided, especially after 32 weeks of gestation, because they may cause premature closure of the fetal ductus arteriosus. Cesarean delivery is performed for standard obstetric indications; the presence of a recent abdominal incision does not preclude pushing in the second stage of labor [28].

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CONCLUSION

MIS can be performed safely and effectively in pregnant women.

Traditionally, the recommendation for optimal timing of nonemergent procedures was the second trimester. These recommendations are not supported by good quality evidence; literature has demonstrated that pregnant patients may undergo laparoscopic surgery safely during any trimester without an increased risk to the mother or fetus [22,29]. Careful preoperative and intraoperative planning can help to optimize both maternal and fetal outcomes.

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Acknowledgements

None.

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Financial support and sponsorship

None.

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Conflicts of interest

M.D. is a consultant for Teleflex. E.T.C. is a consultant for Teleflex.

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REFERENCES AND RECOMMENDED READING

Papers of particular interest, published within the annual period of review, have been highlighted as:

  • ▪ of special interest
  • ▪▪ of outstanding interest
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REFERENCES

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Keywords:

laparoscopy; pregnancy; surgery

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