MIS can be performed in any trimester . 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 .
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 .
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.
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 . 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 .
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 .
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.
Financial support and sponsorship
Conflicts of interest
M.D. is a consultant for Teleflex. E.T.C. is a consultant for Teleflex.
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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Keywords:Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.
laparoscopy; pregnancy; surgery