Guidelines for Diagnosis, Treatment and Use of Laparoscopy for Surgical Problems during Pregnancy

This statement was reviewed and approved by the Board of Governors of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) on May 2017.

Authors

Jonathan P Pearl, Raymond R Price, Allison E Tonkin, William S Richardson, Dimitrios Stefanidis

Preamble

Surgical interventions during pregnancy should minimize fetal risk without compromising the safety of the mother. Favorable outcomes for the pregnant woman and fetus depend on accurate and timely diagnosis with prompt intervention. Surgeons must be aware of data regarding differences in techniques used for pregnant patients to optimize outcomes. This document provides specific recommendations and guidelines to assist physicians in the diagnostic work-up and treatment of surgical conditions in pregnant patients, focusing on the use of laparoscopy.

Disclaimer

Guidelines for clinical practice are intended to indicate preferable approaches to medical problems as established by experts in the field. These recommendations will be based on existing data or a consensus of expert opinion, when little or no data are available.

Guidelines are applicable to all physicians who address the clinical problem(s) without regard to specialty training or interests, and are intended to indicate the preferable, but not necessarily the only, acceptable approaches due to the complexity of the healthcare environment. Guidelines are intended to be flexible. Given the wide range of specifics in any health care problem, the surgeon must always choose the course best suited to the individual patient and the variables in existence at the moment of decision.

Guidelines are developed under the auspices of the Society of American Gastrointestinal Endoscopic Surgeons and its various committees, and approved by the Board of Governors. Each clinical practice guideline has been systematically researched, reviewed and revised by the guidelines committee. The recommendations are therefore considered valid at the time of its production based on the data available. Each guideline is scheduled for periodic review to allow incorporation of pertinent new developments in medical research knowledge and practice.

Literature Review Methodology

This is an update of the guideline that was published in April 2011[1] and whose scope included literature through December 2010. A new systematic literature search using PubMed, Medline, and Cochrane Databases was done between January 2011 and March 2016 to encompass all new literature on the topic. Search strategy was limited to adult human studies in English. The relevance of each study was assessed and those not relevant were dismissed.

KeywordsLaparoscopy, pregnancy, appendectomy, cholecystectomy, splenectomy, adrenalectomy, MRI, CT scan, ultrasound, radiation, ERCP, MRCP, ultrasound, choledocholithiasis, safety, positioning, monitoring, trimester
Study typesRandomized trials, meta-analyses, systematic reviews, prospective, retrospective, editorials, case series, existing and past guidelines
Dates of reviewOctober 2011 to March 2016

154 articles that were published during the search period were identified. Given the small number of articles, all were reviewed to include retrospective reviews and case series. Reviewers manually searched bibliographies to identify any missed additional articles. This search yielded an additional 32 articles.

Both the quality of the evidence and the strength of the recommendation for each of the below guidelines was assessed according to the GRADE system described in Tables 1 and 2. There is a 4-tiered system of quality of evidence (very low (+), low (+), moderate (+++), or high (++++)) and a 2-tiered system for strength of recommendation (weak or strong). Further definitions are provided by SAGES in “The Definitions Document: A Reference of Use of SAGES Guidelines“. Where current literature does not support a conclusion, the opinion of experts in the field is offered to assist the reader in making informed decisions.


I. Introduction

Approximately 1 in 500 women will require non-obstetrical abdominal surgery during pregnancy [2-4]. The most common non-obstetrical surgical emergencies complicating pregnancy are acute appendicitis and cholecystitis [2, 4] . Other conditions that may require operations during pregnancy include ovarian cysts, masses or torsion, symptomatic cholelithiasis, adrenal tumors, splenic disorders, symptomatic hernias, complications of inflammatory bowel diseases, and other rare conditions

Over two decades ago, some argued that laparoscopy was contraindicated during pregnancy due to concerns for uterine injury from trocar placement and fetal malperfusion due to pneumoperitoneum. As surgeons gained more experience and documented their outcomes, laparoscopy has become the preferred treatment modality for many surgical diseases in the gravid patient [5, 6].


II. Diagnosis and Workup

Managing abdominal pain in the gravid patient presents a dilemma in which the clinician must consider the risks and benefits of diagnostic modalities and therapies to both the mother and the fetus. An underlying principle to the workup of abdominal pain is that earlier diagnosis begets a better prognosis [7]. In pregnant women with abdominal pain, fetal outcome depends on the outcome of the mother. Accurate diagnosis usually requires diagnostic imaging to include ultrasound, CT, and/or MRI. A risk-benefit discussion with the patient should occur prior to any diagnostic study.

Ultrasound

Guideline 1: Ultrasound imaging during pregnancy is safe and effective in identifying the etiology of acute abdominal pain in many patients and should be the initial imaging test of choice (+++; Strong).

Abdominal pain in the pregnant patient can be separated into gynecologic and non-gynecologic causes. When radiographic studies are required to establish a diagnosis, ultrasound is considered safe and effective. It is the initial radiographic test of choice for most gynecologic causes of abdominal pain including adnexal mass, torsion, placental abruption, placenta previa, uterine rupture and fetal demise[8, 9]. Ultrasound is up to 80% sensitive and 94% specific for the diagnosis of obstetric and gynecologic causes of abdominal pain including placental abruption, ectopic pregnancy, and ovarian torsion[9].

Ultrasound is also a useful study for many non-gynecologic causes of abdominal pain, including symptomatic gallstones and appendicitis [10-16]. Ultrasound is the diagnostic study of choice for biliary pathology in the gravid patient with diagnostic accuracy above 90%[17]. In pregnant patients with right lower abdominal pain, the appendix can be visualized in up to 60% of cases[17], but exams inconclusive for appendicitis may reach up to 90%[18]. When diagnosis remains uncertain with history, physical examination, and ultrasound, additional imaging should be considered to establish an accurate diagnosis.

Risk of Ionizing Radiation

Guideline 2: Ionizing radiation exposure to the fetus increases the risk of teratogenesis and childhood leukemia. Cumulative radiation dosage should be limited to 50-100 milligray (mGy) during pregnancy (+++; Strong).

Significant radiation exposure of the fetus may lead to chromosomal mutations, neurologic abnormalities, and increased risk of childhood leukemia[19]. Cumulative radiation dosage is the primary risk factor for adverse fetal effects, but fetal age at exposure is also important [12, 13, 20, 21]. Fetal mortality is greatest when exposure occurs within the first week of conception. It has been recommended that the cumulative radiation dose to the conceptus during pregnancy be less than 50-100 mGy [21-23]. As an example, the radiation dose to the conceptus for a plain abdominal radiograph averages 1-3 mGy, while a CT of the pelvis averages less than 30 mGy of exposure[24-26] (see Table 3 for additional radiation doses).

The most sensitive time period for central nervous system teratogenesis is between 10 and 17 weeks gestation, and routine radiographs should be avoided during this time[21, 27]. In later pregnancy the concern shifts from teratogenesis to increasing the risk of childhood hematologic malignancy. The background incidence of childhood cancer and leukemia is approximately 0.2 -0.3%. Radiation may increase that incidence by 0.06% per 10 mGy delivered to the fetus [22, 28].

Exposure of the conceptus to 5 mGy increases the risk of spontaneous abortion, major malformations, and childhood malignancy to one additional case per 6,000 live births above baseline risk[21, 27]. More than 99% of fetuses are unaffected by radiation doses less than 20 mGy [29]. The risk of aberrant teratogenesis is low at 50 mGy or less and that the risk of malformation is significantly increased at doses above 150 mGy. No single diagnostic study should exceed 50 mGy [13, 20, 22, 30-33].

Computed Tomography

Guideline 3: Abdominal CT scan may be used in emergency situations during pregnancy. CT scan should not be the initial imaging test of choice. (++; Weak).

Computed tomography (CT) may be used in the evaluation of abdominal pain in the gravid patient when urgent information is required and other imaging modalities are insufficient [8, 34]. Radiation exposure to the fetus may be as low as 20 mGy for pelvic CT scans but can reach 50 mGy when a full scan of the abdomen and pelvis is performed [12, 35-38]. This radiation dose may affect teratogenesis and increase the risk of developing childhood hematologic malignancies [35].

CT scan should not be the initial imaging modality for the pregnant patient, except when urgent information is required in cases of trauma or acute abdominal pain[27, 39, 40]. Given the utility of ultrasound and MRI in the diagnosis of abdominal pain in the gravid patient, CT should be reserved for emergency cases or when MRI is unavailable[8, 27]. If imaging with ionizing radiation is necessary, specific techniques should be employed to adhere to the ALARA (as low as reasonably achievable) principle[41].

Magnetic Resonance Imaging

Guideline 4: MR Imaging without the use of intravenous Gadolinium can be performed at any stage of pregnancy. MRI is preferred over CT scan for diagnosis of non-obstetric abdominal pain in the gravid patient (++; Weak).

MRI provides excellent soft tissue imaging without ionizing radiation and is safe to use in pregnant patients [8, 9, 42-44]. Intravenous Gadolinium agents cross the placenta and may cause teratogenesis; therefore their use during pregnancy should be confined to select cases where it is considered essential. [45-47]. Some authors express concern about the detrimental effects of the acoustic noise to the fetus[48], but no specific adverse effects of MRI technique on fetal development have been reported [46, 49-52].

Improvements in technique have made MRI the preferred advanced imaging modality in the pregnant patient [42, 43, 53-56]. Faster acquisition and motion-insensitive sequences have enhanced the utility of MRI in the gravid women. As experience with abdominal MRI has increased, diagnostic accuracy has improved [9, 57]. In emergency conditions, MRI demonstrates equivalent or better accuracy in diagnosing non-traumatic abdominal pathology as compared to CT scan or ultrasound [57, 58]. When available, MRI should be used instead of CT scan in the workup of the gravid patient with abdominal pain [8, 9, 56].

Nuclear Medicine

Guideline 5: Administration of radionucleotides for diagnostic studies is safe for mother and fetus (++; Weak).

When considered necessary to treat an urgent medical condition, radiopharmaceuticals can generally be administered at doses that provide whole fetal exposure of less than 5 mGy [59, 60], well within the safe range of fetal exposure. Consultation with a nuclear medicine radiologist or technologist should be considered prior to performing the study.

Cholangiography

Guideline 6: Intraoperative and endoscopic cholangiography exposes the mother and fetus to minimal radiation and may be used selectively during pregnancy. The lower abdomen should be shielded when performing cholangiography during pregnancy to decrease the radiation exposure to the fetus (++; Weak).

Radiation exposure during cholangiography is estimated to be 20-50 mGy[61]. Fluoroscopy generally delivers a radiation dose of up to 200 mGy/minute, but varies depending on the x-ray equipment used, patient positioning, and patient size. During cholangiography, the fetus should be shielded by placing a protective device between the source of ionizing radiation and the patient [62, 63]. Efforts should be made to shield the fetus from radiation exposure without compromising the field of view necessary for proper imaging. No adverse effects to pregnant patients or their fetuses have been reported specifically from cholangiography.

The radiation exposure during endoscopic retrograde cholangiopancreatography (ERCP) averages 20-120 mGy, but can be substantially higher for long procedures[64]. ERCP also carries risks beyond the radiation exposure such as bleeding and pancreatitis. In non-pregnant patients, the risk of bleeding is 1.3% and risk of pancreatitis is 3.5%-11%[65]. These additional risks warrant the same careful risk-benefit analysis and discussion with the patient as other operative and procedural interventions [12, 32, 66-68].

Alternatives to fluoroscopy for imaging the biliary tree include endoscopic ultrasound and choledochoscopy [69-71]. These are both acceptable methods provided the surgeon has the appropriate equipment and skills to accurately perform the procedures.

Diagnostic Laparoscopy

Guideline 7: In the absence of access to imaging modalities, laparoscopy may be used selectively in the workup and treatment of acute abdominal processes in pregnancy (++, weak).

Imaging is preferred over diagnostic laparoscopy for the workup of abdominal processes during pregnancy [8, 39, 58, 72]. When imaging is unavailable or inconclusive, using laparoscopy as a diagnostic tool may be considered. Laparoscopy should be used judiciously, as there may be an increased risk of preterm labor and fetal demise after negative laparoscopy for presumed appendicitis [73, 74]. The risks and benefits of diagnostic laparoscopy for other conditions during pregnancy have not been well documented and require further study.

Establishing an accurate and timely diagnosis of abdominal conditions during pregnancy optimizes maternal and fetal outcomes. When available resources preclude prompt imaging for diagnosis, or imaging is inconclusive, diagnostic laparoscopy may be considered. The risks of delayed diagnosis should be weighed against the risk of possible negative laparoscopy. The surgeon should be prepared to treat conditions diagnosed at laparoscopy.


III. Patient Selection

Pre-operative Decision Making

Guideline 8: Laparoscopic treatment of acute abdominal disease offers similar benefits to pregnant and non-pregnant patients compared to laparotomy (+++; Strong).

Once the decision to operate has been made, the surgical approach (laparotomy versus laparoscopy) should be determined based on the skills of the surgeon and the availability of the appropriate staff and equipment. Benefits of laparoscopy during pregnancy appear similar to those benefits in non-pregnant patients including less postoperative pain, less postoperative ileus, decreased length of hospital stays, and faster return to work [75-80]. Other advantages of laparoscopy in the pregnant patient include decreased fetal respiratory depression due to diminished postoperative narcotic requirements [77, 81-83], lower risk of wound complications [81, 84, 85], diminished postoperative maternal hypoventilation [81, 82], and decreased risk of thromboembolic events. The improved visualization in laparoscopy may reduce the risk of uterine irritability by decreasing the need for uterine manipulation [86].

Laparoscopy and Trimester of Pregnancy

Guideline 9: Laparoscopy can be safely performed during any trimester of pregnancy when operation is indicated (+++; Strong).

Traditionally, the recommendation for non-emergent procedures during pregnancy has been to avoid surgery during the first and third trimesters to minimize the risk of spontaneous abortion and preterm labor, respectively. This has led some authors to suggest delaying surgery until the second trimester [87] and that the gestational age limit for successful completion of laparoscopic surgery during pregnancy should be 26 to 28 weeks [88]. These recommendations are not supported by good quality evidence; recent literature has demonstrated that pregnant patients may undergo laparoscopic surgery safely during any trimester without an increased risk to the mother or fetus [79, 80, 89-94].

Both laparoscopic cholecystectomy and appendectomy have been successfully performed late in the third trimester without increasing the risk of preterm labor or fetal demise [28, 91, 93, 95]. Importantly, postponing necessary operations until after parturition has been shown in some cases, to increase the rates of complications for both mother and fetus [90, 96-98].


IV. Treatment

Patient Positioning

Guideline 10: Gravid patients beyond the first trimester should be placed in the left lateral decubitus position or partial left lateral decubitus position to minimize compression of the vena cava (++; Strong).

When the pregnant patient is placed in a supine position, the gravid uterus places pressure on the inferior vena cava resulting in decreased venous return to the heart. This decrease in venous return leads to reduction in cardiac output with concomitant maternal hypotension and decreased placental perfusion during surgery [99-101]. Placing the patient in a left lateral decubitus position will shift the uterus off the vena cava improving venous return and cardiac output [99, 100]. If abdominal access is compromised in the full decubitus position, the partial left lateral decubitus position can be used. Pregnant patients in their first trimester do not require altered positioning, as the small size of the uterus does not compromise venous return.

Initial Port Placement

Guideline 11: Initial abdominal access can be safely accomplished with an open (Hasson), Veress needle, or optical trocar technique, by surgeons experienced with these techniques, if the location is adjusted according to fundal height (++; weak).

Safe abdominal access for laparoscopy can be accomplished using either an open or closed technique, when used appropriately. The concern for use of closed access techniques (Veress needle or optical entry) has largely been based on the potentially higher risk for injury to the uterus or other intraabdominal organs [102, 103]. Because the intraabdominal domain is altered during the second and third trimester, to improve access safety, trocar placement should be altered from the standard configuration to account for the increased size of the uterus [104-106]. If the site of initial abdominal access is adjusted according to fundal height and the abdominal wall is elevated during insertion, both the Hassan technique and Veress needle have been safely and effectively used [91, 93, 107]. Initial access to the abdomen via a subcostal approach using either the open or closed technique has been recommended to avoid the uterus [86, 91, 93, 95]. Ultrasound guided trocar placement has been described in the literature as an additional safeguard to avoid uterine injury [108].

Insufflation Pressure

Guideline 12: CO2 insufflation of 10-15 mmHg can be safely used for laparoscopy in the pregnant patient. The level of insufflation pressure should be adjusted to the patient’s physiology (++; weak).

The pregnant patient’s diaphragm is upwardly displaced by the growing fetus, which results in decreased residual lung volume and functional residual capacity [109]. Upward displacement of the diaphragm by pneumoperitoneum is more worrisome in a pregnant patient with existing restrictive pulmonary physiology. Some have recommended intraabdominal insufflation pressures be maintained at less than 12 mmHg to avoid worsening pulmonary physiology in gravid women [105, 110]. Others have argued that insufflation less than 12 mmHg may not provide adequate visualization of the intra-abdominal cavity [91, 93]. Pressures of 15 mmHg have been used during laparoscopy in pregnant patients without increasing adverse outcomes to the patient or her fetus [91, 93].

Because CO2 exchange occurs with intraperitoneal insufflation there has been concern for deleterious effects to the fetus from pneumoperitoneum. Some animal studies have confirmed fetal acidosis with associated tachycardia, hypertension and hypercapnia during CO2 pneumoperitoneum [111-113], while other animal studies contradict these findings[114]. There are no data showing detrimental effects to human fetuses from CO2 pneumoperitoneum [88].

Intra-operative CO2 Monitoring

Guideline 13: Intraoperative CO2 monitoring by capnography should be used during laparoscopy in the pregnant patient (+++; Strong).

Fetal acidosis and associated fetal instability in CO2 pneumoperitoneum have been documented in animal studies, though no long-term effects from these changes have been identified [111-113, 115]. Fetal acidosis with insufflation has not been documented in the human fetus, but concerns over potential detrimental effects of acidosis have led to the recommendation for maternal CO2 monitoring [116, 117]. Initially, there was debate over maternal blood gas monitoring of arterial carbon dioxide (PaCO2) versus end-tidal carbon dioxide (ETCO2) monitoring, but the less invasive capnography has been demonstrated to adequately reflect maternal acid-base status in humans [118]. Several large studies have documented the safety and efficacy of ETCO2 measurements in pregnant women [88, 91, 93] making routine blood gas monitoring unnecessary.

Venous Thromboembolic (VTE) Prophylaxis

Guideline 14: Intraoperative and postoperative pneumatic compression devices and early postoperative ambulation are recommended prophylaxis for deep venous thrombosis in the gravid patient (++; weak).

Pregnancy is a hypercoagulable state with a 0.1-0.2% incidence of deep venous thrombosis [119]. CO2 pneumoperitoneum may increase the risk of deep venous thrombosis by predisposing to venous stasis. Insufflation of 12 mmHg causes a significant decrease in blood flow that cannot be completely reversed with intermittent pneumatic compression devices [120].

Although there is little research on prophylaxis for deep venous thrombosis in the pregnant patient, general principles for laparoscopic surgery apply. Because of the increased risk of thrombosis, prophylaxis with pneumatic compression devices both intraoperatively and postoperatively and early postoperative ambulation are recommended. There are no data regarding use of unfractionated or low molecular weight heparin for prophylaxis in pregnant patients undergoing laparoscopy, though its use has been suggested in patients undergoing extended major operations [121]. In patients who require anticoagulation during pregnancy, unfractionated heparin has proven safe and is the agent of choice [122].

Gallbladder Disease

Guideline 15: Laparoscopic cholecystectomy is the treatment of choice in the pregnant patient with symptomatic gallbladder disease, regardless of trimester (++; weak).

In the past, non-operative management of symptomatic cholelithiasis in pregnancy has been recommended [96, 123-125]. At present, early surgical management is the treatment of choice. Laparoscopic cholecystectomy during pregnancy is associated with shorter length of stay, shorter operative times, and fewer complications compared to open cholecystectomy [6]. There have been no reports of fetal demise for laparoscopic cholecystectomy performed during the first and second trimesters [126]. Furthermore, decreased rates of spontaneous abortion and preterm labor have been reported after laparoscopic cholecystectomy when compared to laparotomy [127].

Recurrent gallbladder symptoms develop in 92% of patients managed non-operatively who present in the first trimester, 64% who present in the second trimester, and 44% who present in the third trimester [128, 129]. If the biliary disease remains uncomplicated, the rates of preterm labor and spontaneous abortion are similar for operative and non-operative management [129]. However, approximately 50% of patients with recurrent symptoms require hospitalization [130] and up to 23% of such patients develop acute cholecystitis, cholangitis, or gallstone pancreatitis [90, 131]. Complicated gallstone disease results in preterm labor in up to 20% of cases and fetal loss in 10% to 60% of cases, depending on severity [132, 133].

Delaying cholecystectomy until after delivery leads to high rates of recurrent symptoms, emergency department visits, and recurrent hospitalizations [130, 134, 135]. Given the low risk of laparoscopic cholecystectomy to the pregnant woman and fetus, the procedure should be considered for all gravid women with symptomatic gallstones.

Choledocholithiasis

Guideline 16: Choledocholithiasis during pregnancy can be managed safely with preoperative endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy followed by laparoscopic cholecystectomy, laparoscopic common bile duct exploration at the time of cholecystectomy, or postoperative ERCP. Comparative studies are lacking. (++; weak).

ERCP for choledocholithiasis during pregnancy has been shown to be safe and effective [63, 136, 137]. Complications associated with choledocholithiasis, such as preterm labor and spontaneous abortion, are uncommon during pregnancy [138, 139]. There have been no trials comparing common bile duct exploration at the time of laparoscopic cholecystectomy to ERCP followed by cholecystectomy in pregnant patients. When choledocholithiasis progresses to cholangitis, preterm labor or spontaneous abortion may occur in up to 10% of cases [140].

Good outcomes have been described with intraoperative common bile duct exploration, but few cases have been reported [141]. Multiple studies have demonstrated safe and effective management of common bile duct stones with preoperative ERCP followed by laparoscopic cholecystectomy [142-148]. Although radiation exposure is low during ERCP, endoscopic stone extraction without radiation can be performed using endoscopic ultrasound and choledochoscopy [70, 71, 149]. Endoscopic stenting without stone extraction is another alternative that can be accomplished using minimal radiation [150].

Depending on local expertise, the least invasive procedure that extracts common duct stones should be performed. Both ERCP and laparoscopic common duct exploration are safe in pregnant women.

Laparoscopic Appendectomy

Guideline 17: Laparoscopic appendectomy is the treatment of choice for pregnant patients with acute appendicitis (++; Weak).

The laparoscopic approach is the preferred treatment for pregnant patients with acute appendicitis [151, 152].The preponderance of studies have shown the technique to be safe and effective [91, 93, 153-159]. These retrospective series have shown very low rates of preterm delivery and, in most series, no reports of fetal demise. There is no role for non-operative management of uncomplicated acute appendicitis in pregnant women because of a higher rate of peritonitis, fetal demise shock, and venous thromboembolism as compared to operative management [74, 160]. Recent evidence for the use of antibiotics alone for treating acute appendicitis has not been extended to the gravid patient.

Weak evidence-level data suggest an increase in maternal morbidity, preterm labor, and fetal loss in cases of negative laparoscopy for presumed appendicitis, compared to laparoscopic appendectomy for acute uncomplicated appendicitis [73, 74]. The possible cause of increased morbidity in negative laparoscopy is unclear and has not been further investigated in prospective studies.

The observation that negative laparoscopy might increase morbidity highlights the need for accurate and timely diagnosis of appendicitis in the gravid patient. When the diagnosis remains uncertain with clinical findings and ultrasound, MRI is the preferred adjunct to establish an accurate diagnosis. Use of MRI during the workup of pregnant patients with suspected appendicitis reduces the negative exploration rate by 50%[161]. CT scan may be used when MRI is unavailable, but the risks of ionizing radiation exposure must be considered.

Solid Organ Resection

Guideline 18: Laparoscopic adrenalectomy, nephrectomy and splenectomy are safe procedures in appropriately selected pregnant patients (+; Weak).

Laparoscopic adrenalectomy during pregnancy has proven effective in the management of primary hyperaldosteronism [162], Cushing’s syndrome [163-166], and pheochromocytoma [167-173]. Laparoscopic splenectomy has also become an increasingly accepted surgical approach in pregnancy [174-176]. Gravid patients with antiphospholipid syndrome [177], hereditary spherocytosis [178], and autoimmune thrombocytopenia purpura [174, 179, 180] have undergone laparoscopic splenectomy with good outcomes for mother and fetus. Several cases of laparoscopic nephrectomy during pregnancy have been reported without complications [181-186].

Given the paucity of data on laparoscopic solid organ exploration in pregnant patients, each case should be individualized. If solid organ operation can be delayed until after parturition, it should be. Pathologic surgical conditions of the adrenal gland, kidney, and spleen that are endangering a mother or fetus should be attempted laparoscopically.

Adnexal Masses

Guideline 19: Laparoscopy is a safe and effective treatment in gravid patients with symptomatic ovarian cystic masses. Observation is acceptable for all other cystic lesions provided ultrasound is not concerning for malignancy and tumor markers are normal. Initial observation is warranted for most cystic lesions < 6 cm in size (++; Weak).

The incidence of adnexal masses during pregnancy is 2% [187-190]. Most of these adnexal masses discovered during the first trimester are functional cysts that resolve spontaneously by the second trimester [104]. 80% to 95% of adnexal masses < 6cm in diameter in pregnant patients spontaneously resolve; therefore non-operative management is warranted in such cases. [190, 191].

Persistent masses are most commonly functional cysts with very low rates of malignancy or mature cystic teratomas with rates of malignancy reported at 2% to 6% [192]. Historically, the concern over malignant potential and risks associated with emergency surgery have led to elective removal of masses that persist after 16 weeks and are > 6 cm in diameter [191-193]. Recent literature supports the safety of close observation in these patients when ultrasound findings are not concerning for malignancy, tumor markers (CA125, LDH) are normal, and the patient is asymptomatic [190, 194-198]. In the event that surgery is indicated, various case reports support the use of laparoscopy in the management of adnexal masses in every trimester [198-206].

Adnexal Torsion

Guideline 20: Laparoscopy is recommended for both diagnosis and treatment of adnexal torsion (++; Strong).

Ten to 15% of adnexal masses undergo torsion [207]. Laparoscopy is the preferred method of both diagnosis and treatment in the gravid patient with adnexal torsion [198, 208, 209]. Multiple case reports have confirmed safety and efficacy of laparoscopy for adnexal torsion in pregnant patients [210-214]. If diagnosed before tissue necrosis, adnexal torsion may be managed by simple laparoscopic detorsion [215]. However, with late diagnosis of torsion adnexal infarction may ensue, which can result in peritonitis, spontaneous abortion, preterm delivery and death [193, 216]. The gangrenous adnexa should be completely resected [217] and progesterone therapy initiated after removal of the corpus luteum, if less than 12 weeks gestation [215]. Laparotomy may be necessary as dictated by the patient’s clinical condition and operative findings [218].


V. Perioperative Care

Fetal Heart Monitoring

Guideline 21: Fetal heart monitoring of a fetus considered viable should occur preoperatively and postoperatively in the setting of urgent abdominal surgery during pregnancy (++; Weak).

While intraoperative fetal heart rate monitoring was once thought to be the most accurate method to detect fetal distress during laparoscopy, no intraoperative fetal heart rate abnormalities have been reported in the literature [90, 127]. Preoperative and postoperative monitoring of the fetal heart rate for a fetus considered viable is the current standard, with no increased fetal morbidity having been reported [91, 93, 219].The current lower limit of viability is between 22 weeks and 24 weeks[220, 221].

Tocolytics

Guideline 22: Tocolytics should not be used prophylactically in pregnant women undergoing surgery but should be considered perioperatively when signs of preterm labor are present (++++; Strong).

Threatened preterm labor can be successfully managed with tocolytic therapy. The specific agent and indications for the use of tocolytics should be individualized and based on the recommendation of an obstetrician [222-225]. No literature supports the use of prophylactic tocolytics [226, 227].

Limitations of available literature

More data have accumulated recently as laparoscopy has become common during pregnancy. Most of the data are found in case series and retrospective reviews that limit the ability to provide definitive recommendations. There are no prospective comparative studies that evaluate common abdominal conditions during pregnancy, such as cholelithiasis and appendicitis. Further controlled clinical studies are needed to clarify these guidelines, and revision may be necessary as new data appear. The current recommendations for laparoscopy during pregnancy are:


VI. Summary of Recommendations

Diagnosis and Workup

Ultrasound

Guideline 1: Ultrasound imaging during pregnancy is safe and effective in identifying the etiology of acute abdominal pain in many patients and should be the initial imaging test of choice (+++; Strong).

Risk of Ionizing Radiation

Guideline 2: Ionizing radiation exposure to the fetus increases the risk of teratogenesis and childhood leukemia. Cumulative radiation dosage should be limited to 50-100 mGy during pregnancy (+++; Strong).

Computed Tomography

Guideline 3: Abdominal CT scan may be used in emergency situations during pregnancy. CT scan should not be the initial imaging test of choice. (++: Weak).

Magnetic Resonance Imaging

Guideline 4: MR Imaging without the use of intravenous Gadolinium can be performed at any stage of pregnancy. MRI is preferred over CT scan for diagnosis of non-obstetric abdominal pain in the gravid patient (++; Strong).

Nuclear Medicine

Guideline 5: Administration of radionucleotides for diagnostic studies is safe for mother and fetus (++; Weak).

Cholangiography

Guideline 6: Intraoperative and endoscopic cholangiography exposes the mother and fetus to minimal radiation and may be used selectively during pregnancy. The lower abdomen should be shielded when performing cholangiography during pregnancy to decrease the radiation exposure to the fetus (++; Weak).

Diagnostic Laparoscopy

Guideline 7: In the absence of access to imaging modalities, laparoscopy may be used selectively in the workup and treatment of acute abdominal processes in pregnancy (++, weak).

Patient Selection

Pre-operative Decision Making

Guideline 8: Laparoscopic treatment of acute abdominal disease offers similar benefits to pregnant and non-pregnant patients compared to laparotomy (+++; Strong).

Laparoscopy and Trimester of Pregnancy

Guideline 9: Laparoscopy can be safely performed during any trimester of pregnancy when operation is indicated (+++; Strong).

Treatment

Patient Positioning

Guideline 10: Gravid patients beyond the first trimester should be placed in the left lateral decubitus position or partial left lateral decubitus position to minimize compression of the vena cava (++; Strong).

Initial Port Placement

Guideline 11: Initial abdominal access can be safely accomplished with an open (Hasson), Veress needle, or optical trocar technique, by surgeons experienced with these techniques, if the location is adjusted according to fundal height (++; weak).

Insufflation Pressure

Guideline 12: CO2 insufflation of 10-15 mmHg can be safely used for laparoscopy in the pregnant patient. The level of insufflation pressure should be adjusted to the patient’s physiology (++; weak).

Intra-operative CO2 monitoring

Guideline 13: Intraoperative CO2 monitoring by capnography should be used during laparoscopy in the pregnant patient (+++; Strong).

Venous Thromboembolic (VTE) Prophylaxis

Guideline 14: Intraoperative and postoperative pneumatic compression devices and early postoperative ambulation are recommended prophylaxis for deep venous thrombosis in the gravid patient (++; weak).

Gallbladder Disease

Guideline 15: Laparoscopic cholecystectomy is the treatment of choice in the pregnant patient with symptomatic gallbladder disease, regardless of trimester (++; weak).

Choledocholithiasis

Guideline 16: Choledocholithiasis during pregnancy can be managed safely with preoperative endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy followed by laparoscopic cholecystectomy, laparoscopic common bile duct exploration at the time of cholecystectomy, or postoperative ERCP. Comparative studies are lacking. (++; Weak).

Laparoscopic Appendectomy

Guideline 17: Laparoscopic appendectomy may be performed safely in pregnant patients with acute appendicitis (+++; Strong).

Solid Organ Resection

Guideline 18: Laparoscopic adrenalectomy, nephrectomy, splenectomy and mesenteric cyst excision are safe procedures in pregnant patients (+; Weak).

Adnexal Mass

Guideline 19: Laparoscopy is a safe and effective treatment in gravid patients with symptomatic ovarian cystic masses. Observation is acceptable for all other cystic lesions provided ultrasound is not concerning for malignancy and tumor markers are normal. Initial observation is warranted for most cystic lesions < 6 cm in size (++; weak).

Adnexal Torsion

Guideline 20: Laparoscopy is recommended for both diagnosis and treatment of adnexal torsion (++; Strong).

Perioperative care

Fetal Heart Monitoring

Guideline 21: Fetal heart monitoring of a fetus considered viable should occur preoperatively and postoperatively in the setting of urgent abdominal surgery during pregnancy (++; weak).

Tocolytics

Guideline 22: Tocolytics should not be used prophylactically in pregnant women undergoing surgery but should be considered perioperatively when signs of preterm labor are present (+++, Strong).


References

  1. Pearl J, Price R, Richardson W, Fanelli R, Society of American Gastrointestinal Endoscopic S (2011) Guidelines for diagnosis, treatment, and use of laparoscopy for surgical problems during pregnancy. Surg Endosc 25:3479-3492
  2. Kammerer WS (1979) Nonobstetric surgery during pregnancy. Med Clin North Am 63:1157-1164
  3. Kort B, Katz VL, Watson WJ (1993) The effect of nonobstetric operation during pregnancy. Surgery, gynecology & obstetrics 177:371-376
  4. Augustin G, Majerovic M (2007) Non-obstetrical acute abdomen during pregnancy. Eur J Obstet Gynecol Reprod Biol 131:4-12
  5. Fallon WF, Jr., Newman JS, Fallon GL, Malangoni MA (1995) The surgical management of intra-abdominal inflammatory conditions during pregnancy. Surg Clin North Am 75:15-31
  6. Cox TC, Huntington CR, Blair LJ, Prasad T, Lincourt AE, Augenstein VA, Heniford BT (2016) Laparoscopic appendectomy and cholecystectomy versus open: a study in 1999 pregnant patients. Surg Endosc 30:593-602
  7. Baer J (1932) Appendicitis in pregnancy with changes in position and axis of the normal appendix in pregnancy. JAMA 98:1359-1364
  8. Masselli G, Derme M, Laghi F, Framarino-dei-Malatesta M, Gualdi G (2015) Evaluating the Acute Abdomen in the Pregnant Patient. Radiol Clin North Am 53:1309-1325
  9. Masselli G, Brunelli R, Monti R, Guida M, Laghi F, Casciani E, Polettini E, Gualdi G (2014) Imaging for acute pelvic pain in pregnancy. Insights Imaging 5:165-181
  10. Eyvazzadeh AD, Levine D (2006) Imaging of pelvic pain in the first trimester of pregnancy. Radiologic clinics of North America 44:863-877
  11. (1977) Medical radiation exposure of pregnant and potentially pregnant women. National Council on Radiation Protection and Measurements report no. 54, Bethesda, MD
  12. Kennedy A (2000) Assessment of acute abdominal pain in the pregnant patient. Seminars in ultrasound, CT, and MR 21:64-77
  13. Toppenberg KS, Hill DA, Miller DP (1999) Safety of radiographic imaging during pregnancy. Am Fam Physician 59:1813-1818, 1820
  14. Moore C, Promes SB (2004) Ultrasound in pregnancy. Emergency medicine clinics of North America 22:697-722
  15. Lim HK, Bae SH, Seo GS (1992) Diagnosis of acute appendicitis in pregnant women: value of sonography. Ajr 159:539-542
  16. Nelson MJ, Cavalieri R, Graham D, Sanders RC (1986) Cysts in pregnancy discovered by sonography. J Clin Ultrasound 14:509-512
  17. Katz DS, Klein MA, Ganson G, Hines JJ (2012) Imaging of abdominal pain in pregnancy. Radiol Clin North Am 50:149-171
  18. Ramalingam V, LeBedis C, Kelly JR, Uyeda J, Soto JA, Anderson SW (2015) Evaluation of a sequential multi-modality imaging algorithm for the diagnosis of acute appendicitis in the pregnant female. Emerg Radiol 22:125-132
  19. Brent RL (2015) Protection of the gametes embryo/fetus from prenatal radiation exposure. Health Phys 108:242-274
  20. Timins JK (2001) Radiation during pregnancy. N J Med 98:29-33
  21. Goldberg-Stein SA, Liu B, Hahn PF, Lee SI (2012) Radiation dose management: part 2, estimating fetal radiation risk from CT during pregnancy. AJR Am J Roentgenol 198:W352-356
  22. Karam PA (2000) Determining and reporting fetal radiation exposure from diagnostic radiation. Health Phys 79:S85-90
  23. Gomes M, Matias A, Macedo F (2015) Risks to the fetus from diagnostic imaging during pregnancy: review and proposal of a clinical protocol. Pediatr Radiol 45:1916-1929
  24. Chen MM CF, Kaimal A, Laros Jr RK (2008) Guidelines for computed tomography and magnetic resonance imaging use during pregnancy and lactation. Obstet Gynecol 112
  25. Damilakis J, Perisinakis K, Tzedakis A, Papadakis AE, Karantanas A (2010) Radiation dose to the conceptus from multidetector CT during early gestation: a method that allows for variations in maternal body size and conceptus position. Radiology 257:483-489
  26. Angel E, Wellnitz CV, Goodsitt MM, Yaghmai N, DeMarco JJ, Cagnon CH, Sayre JW, Cody DD, Stevens DM, Primak AN, McCollough CH, McNitt-Gray MF (2008) Radiation dose to the fetus for pregnant patients undergoing multidetector CT imaging: Monte Carlo simulations estimating fetal dose for a range of gestational age and patient size. Radiology 249:220-227
  27. Groen RS, Bae JY, Lim KJ (2012) Fear of the unknown: ionizing radiation exposure during pregnancy. Am J Obstet Gynecol 206:456-462
  28. Stepp K, Falcone T (2004) Laparoscopy in the second trimester of pregnancy. Obstet Gynecol Clin North Am 31:485-496, vii
  29. McCollough CH, Schueler BA, Atwell TD, Braun NN, Regner DM, Brown DL, LeRoy AJ (2007) Radiation exposure and pregnancy: when should we be concerned? Radiographics 27:909-917; discussion 917-908
  30. (1977) Medical radiation exposure of pregnant and potentially pregnant women. National Council on Radiation Protection and Measurements report No 54: Bethesda, MD
  31. Doll R, Wakeford R (1997) Risk of childhood cancer from fetal irradiation. Br J Radiol 70:130-139
  32. Osei EK, Faulkner K (1999) Fetal doses from radiological examinations. Br J Radiol 72:773-780
  33. Lowe SA (2004) Diagnostic radiography in pregnancy: risks and reality. Aust N Z J Obstet Gynaecol 44:191-196
  34. Menias CO, Elsayes KM, Peterson CM, Huete A, Gratz BI, Bhalla S (2007) CT of pregnancy-related complications. Emerg Radiol
  35. Hurwitz LM, Yoshizumi T, Reiman RE, Goodman PC, Paulson EK, Frush DP, Toncheva G, Nguyen G, Barnes L (2006) Radiation dose to the fetus from body MDCT during early gestation. AJR Am J Roentgenol 186:871-876
  36. Forsted DH, Kalbhen CL (2002) CT of pregnant women for urinary tract calculi, pulmonary thromboembolism, and acute appendicitis. Ajr 178:1285
  37. Cook TS, Hilton S, Papanicolaou N (2013) Perspectives on radiation dose in abdominal imaging. Abdom Imaging 38:1190-1196
  38. Moore W, Bonvento MJ, Lee D, Dunkin J, Bhattacharji P (2015) Reduction of fetal dose in computed tomography using anterior shields. J Comput Assist Tomogr 39:298-300
  39. Masselli G, Derchi L, McHugo J, Rockall A, Vock P, Weston M, Spencer J, Subcommittee EFPI (2013) Acute abdominal and pelvic pain in pregnancy: ESUR recommendations. Eur Radiol 23:3485-3500
  40. Katz DS, Khalid M, Coronel EE, Mazzie JP (2013) Computed tomography imaging of the acute pelvis in females. Can Assoc Radiol J 64:108-118
  41. Karamat MI (2015) Strategies and Scientific Basis of Dose Reduction on State-of-the-Art Multirow Detector X-Ray CT Systems. Crit Rev Biomed Eng 43:33-59
  42. Furey EA, Bailey AA, Pedrosa I (2014) Magnetic resonance imaging of acute abdominal and pelvic pain in pregnancy. Top Magn Reson Imaging 23:225-242
  43. Karul M, Berliner C, Keller S, Tsui TY, Yamamura J (2014) Imaging of appendicitis in adults. Rofo 186:551-558
  44. Fonseca AL, Schuster KM, Kaplan LJ, Maung AA, Lui FY, Davis KA (2014) The use of magnetic resonance imaging in the diagnosis of suspected appendicitis in pregnancy: shortened length of stay without increase in hospital charges. JAMA Surg 149:687-693
  45. Birchard KR, Brown MA, Hyslop WB, Firat Z, Semelka RC (2005) MRI of acute abdominal and pelvic pain in pregnant patients. AJR Am J Roentgenol 184:452-458
  46. Garcia-Bournissen F, Shrim A, Koren G (2006) Safety of gadolinium during pregnancy. Can Fam Physician 52:309-310
  47. Brown MA, Birchard KR, Semelka RC (2005) Magnetic resonance evaluation of pregnant patients with acute abdominal pain. Semin Ultrasound CT MR 26:206-211
  48. Patel SJ, Reede DL, Katz DS, Subramaniam R, Amorosa JK (2007) Imaging the pregnant patient for nonobstetric conditions: algorithms and radiation dose considerations. Radiographics 27:1705-1722
  49. De Wilde JP, Rivers AW, Price DL (2005) A review of the current use of magnetic resonance imaging in pregnancy and safety implications for the fetus. Prog Biophys Mol Biol 87:335-353
  50. Nagayama M, Watanabe Y, Okumura A, Amoh Y, Nakashita S, Dodo Y (2002) Fast MR imaging in obstetrics. Radiographics 22:563-580; discussion 580-562
  51. Leyendecker JR, Gorengaut V, Brown JJ (2004) MR imaging of maternal diseases of the abdomen and pelvis during pregnancy and the immediate postpartum period. Radiographics 24:1301-1316
  52. McKenna DA, Meehan CP, Alhajeri AN, Regan MC, O’Keeffe DP (2007) The use of MRI to demonstrate small bowel obstruction during pregnancy. The British journal of radiology 80:e11-14
  53. Expert Panel on MRS, Kanal E, Barkovich AJ, Bell C, Borgstede JP, Bradley WG, Jr., Froelich JW, Gimbel JR, Gosbee JW, Kuhni-Kaminski E, Larson PA, Lester JW, Jr., Nyenhuis J, Schaefer DJ, Sebek EA, Weinreb J, Wilkoff BL, Woods TO, Lucey L, Hernandez D (2013) ACR guidance document on MR safe practices: 2013. J Magn Reson Imaging 37:501-530
  54. Ditkofsky NG, Singh A (2015) Challenges in magnetic resonance imaging for suspected acute appendicitis in pregnant patients. Curr Probl Diagn Radiol 44:297-302
  55. Burke LM, Bashir MR, Miller FH, Siegelman ES, Brown M, Alobaidy M, Jaffe TA, Hussain SM, Palmer SL, Garon BL, Oto A, Reinhold C, Ascher SM, Demulder DK, Thomas S, Best S, Borer J, Zhao K, Pinel-Giroux F, De Oliveira I, Resende D, Semelka RC (2015) Magnetic resonance imaging of acute appendicitis in pregnancy: a 5-year multiinstitutional study. Am J Obstet Gynecol 213:693 e691-696
  56. Lubarsky M, Kalb B, Sharma P, Keim SM, Martin DR (2013) MR imaging for acute nontraumatic abdominopelvic pain: rationale and practical considerations. Radiographics 33:313-337
  57. Baron KT, Arleo EK, Robinson C, Sanelli PC (2012) Comparing the diagnostic performance of MRI versus CT in the evaluation of acute nontraumatic abdominal pain during pregnancy. Emerg Radiol 19:519-525
  58. Unal A, Sayharman SE, Ozel L, Unal E, Aka N, Titiz I, Kose G (2011) Acute abdomen in pregnancy requiring surgical management: a 20-case series. Eur J Obstet Gynecol Reprod Biol 159:87-90
  59. Adelstein SJ (1999) Administered radionuclides in pregnancy. Teratology 59:236-239
  60. Schaefer C, Meister R, Wentzeck R, Weber-Schoendorfer C (2009) Fetal outcome after technetium scintigraphy in early pregnancy. Reprod Toxicol 28:161-166
  61. Karthikesalingam A MS, Weerakkody R, Walsh SR, Carroll N, Praseedom RK (2009) Radiation exposure during laparoscopic cholecystectomy with routine intraoperatinve cholangiography. Surg Endosc 23:1845-1848
  62. Savas N (2014) Gastrointestinal endoscopy in pregnancy. World J Gastroenterol 20:15241-15252
  63. Akcakaya A, Koc B, Adas G, Kemik O (2014) The use of ERCP during pregnancy: is it safe and effective? Hepatogastroenterology 61:296-298
  64. Jorgensen JE, Rubenstein, J.H., Goodsitt, M.M., Elta, G.H. (2010) Raidation doses to ERCP patients are significantly lower with experienced endoscopists. Gastrointest Endosc 72:58-65.
  65. Andriulli A, Loperfido S, Napolitano G, Niro G, Valvano MR, Spirito F, Pilotto A, Forlano R (2007) Incidence Rates of Post-ERCP Complications: A Systematic Survey of Prospective Studies. Am J Gastroenterol
  66. Qureshi WA, Rajan E, Adler DG, Davila RE, Hirota WK, Jacobson BC, Leighton JA, Zuckerman MJ, Hambrick RD, Fanelli RD, Baron T, Faigel DO (2005) ASGE Guideline: Guidelines for endoscopy in pregnant and lactating women. Gastrointestinal endoscopy 61:357-362
  67. Quan WL, Chia CK, Yim HB (2006) Safety of endoscopical procedures during pregnancy. Singapore Med J 47:525-528
  68. Tang SJ, Mayo MJ, Rodriguez-Frias E, Armstrong L, Tang L, Sreenarasimhaiah J, Lara LF, Rockey DC (2009) Safety and utility of ERCP during pregnancy. Gastrointest Endosc 69:453-461
  69. Prachayakul V, Aswakul P (2016) Endoscopic ultrasound-guided interventions in special situations. World J Gastrointest Endosc 8:104-112
  70. Sethi S, Thosani N, Banerjee S (2015) Radiation-Free ERCP in Pregnancy: A “Sound” Approach to Leaving No Stone Unturned. Dig Dis Sci 60:2604-2607
  71. Wu W, Faigel DO, Sun G, Yang Y (2014) Non-radiation endoscopic retrograde cholangiopancreatography in the management of choledocholithiasis during pregnancy. Dig Endosc 26:691-700
  72. Bouyou J, Gaujoux S, Marcellin L, Leconte M, Goffinet F, Chapron C, Dousset B (2015) Abdominal emergencies during pregnancy. J Visc Surg 152:S105-115
  73. Aggenbach L, Zeeman GG, Cantineau AE, Gordijn SJ, Hofker HS (2015) Impact of appendicitis during pregnancy: no delay in accurate diagnosis and treatment. Int J Surg 15:84-89
  74. Cheng HT, Wang YC, Lo HC, Su LT, Soh KS, Tzeng CW, Wu SC, Sung FC, Hsieh CH (2015) Laparoscopic appendectomy versus open appendectomy in pregnancy: a population-based analysis of maternal outcome. Surg Endosc 29:1394-1399
  75. Andreoli M, Servakov M, Meyers P, Mann WJ, Jr. (1999) Laparoscopic surgery during pregnancy. J Am Assoc Gynecol Laparosc 6:229-233
  76. Shay DC, Bhavani-Shankar K, Datta S (2001) Laparoscopic surgery during pregnancy. Anesthesiol Clin North America 19:57-67
  77. Curet MJ, Allen D, Josloff RK, Pitcher DE, Curet LB, Miscall BG, Zucker KA (1996) Laparoscopy during pregnancy. Arch Surg 131:546-550; discussion 550-541
  78. Oelsner G, Stockheim D, Soriano D, Goldenberg M, Seidman DS, Cohen SB, Admon D, Novikov I, Maschiach S, Carp HJ, Anderman S, Ben-Ami M, Ben-Arie A, Hagay Z, Bustan M, Shalev E, Carp H, Gemer O, Golan A, Holzinger M, Beyth Y, Horowitz A, Hamani Y, Keis M, Lavie O, Luxman D, Oelsner G, Stockheim D, Rojansky N, Taichner G, Yafe C, Zohar S, Bilanca B (2003) Pregnancy outcome after laparoscopy or laparotomy in pregnancy. J Am Assoc Gynecol Laparosc 10:200-204
  79. Reedy MB, Galan HL, Richards WE, Preece CK, Wetter PA, Kuehl TJ (1997) Laparoscopy during pregnancy. A survey of laparoendoscopic surgeons. J Reprod Med 42:33-38
  80. Oelsner G, Stockheim D, Soriano D, Goldenberg M, Seidman DS, Cohen SB, Admon D, Novikov I, Maschiach S, Carp HJ, Anderman S, Ben-Ami M, Ben-Arie A, Hagay Z, Bustan M, Shalev E, Carp H, Gemer O, Golan A, Holzinger M, Beyth Y, Horowitz A, Hamani Y, Keis M, Lavie O, Luxman D, Rojansky N, Taichner G, Yafe C, Zohar S, Bilanca B (2003) Pregnancy outcome after laparoscopy or laparotomy in pregnancy. J Am Assoc Gynecol Laparosc 10:200-204
  81. Pucci RO, Seed RW (1991) Case report of laparoscopic cholecystectomy in the third trimester of pregnancy. Am J Obstet Gynecol 165:401-402
  82. Weber AM, Bloom GP, Allan TR, Curry SL (1991) Laparoscopic cholecystectomy during pregnancy. Obstet Gynecol 78:958-959
  83. Williams JK, Rosemurgy AS, Albrink MH, Parsons MT, Stock S (1995) Laparoscopic cholecystectomy in pregnancy. A case report. J Reprod Med 40:243-245
  84. Arvidsson D, Gerdin E (1991) Laparoscopic cholecystectomy during pregnancy. Surg Laparosc Endosc 1:193-194
  85. Costantino GN, Vincent GJ, Mukalian GG, Kliefoth WL, Jr. (1994) Laparoscopic cholecystectomy in pregnancy. J Laparoendosc Surg 4:161-164
  86. Soriano D, Yefet Y, Seidman DS, Goldenberg M, Mashiach S, Oelsner G (1999) Laparoscopy versus laparotomy in the management of adnexal masses during pregnancy. Fertil Steril 71:955-960
  87. McKellar DP, Anderson CT, Boynton CJ, Peoples JB (1992) Cholecystectomy during pregnancy without fetal loss. Surg Gynecol Obstet 174:465-468
  88. Fatum M, Rojansky N (2001) Laparoscopic surgery during pregnancy. Obstet Gynecol Surv 56:50-59
  89. Reedy MB, Kallen B, Kuehl TJ (1997) Laparoscopy during pregnancy: a study of five fetal outcome parameters with use of the Swedish Health Registry. Am J Obstet Gynecol 177:673-679
  90. Glasgow RE, Visser BC, Harris HW, Patti MG, Kilpatrick SJ, Mulvihill SJ (1998) Changing management of gallstone disease during pregnancy. Surg Endosc 12:241-246
  91. Affleck DG, Handrahan DL, Egger MJ, Price RR (1999) The laparoscopic management of appendicitis and cholelithiasis during pregnancy. Am J Surg 178:523-529
  92. Barone JE, Bears S, Chen S, Tsai J, Russell JC (1999) Outcome study of cholecystectomy during pregnancy. Am J Surg 177:232-236
  93. Rollins MD, Chan KJ, Price RR (2003) Laparoscopy for appendicitis and cholelithiasis during pregnancy: a new standard of care. Surg Endosc
  94. Weiner E, Mizrachi Y, Keidar R, Kerner R, Golan A, Sagiv R (2015) Laparoscopic surgery performed in advanced pregnancy compared to early pregnancy. Arch Gynecol Obstet 292:1063-1068
  95. Geisler JP, Rose SL, Mernitz CS, Warner JL, Hiett AK (1998) Non-gynecologic laparoscopy in second and third trimester pregnancy: obstetric implications. JSLS 2:235-238
  96. Davis A, Katz VL, Cox R (1995) Gallbladder disease in pregnancy. J Reprod Med 40:759-762
  97. Muench J, Albrink M, Serafini F, Rosemurgy A, Carey L, Murr MM (2001) Delay in treatment of biliary disease during pregnancy increases morbidity and can be avoided with safe laparoscopic cholecystectomy. Am Surg 67:539-542; discussion 542-533
  98. Visser BC, Glasgow RE, Mulvihill KK, Mulvihill SJ (2001) Safety and timing of nonobstetric abdominal surgery in pregnancy. Dig Surg 18:409-417
  99. Elkayam U GN (1982) Cardiovascular physiology of pregnancy, Alan R Liss, New York
  100. Clark SL, Cotton DB, Pivarnik JM, Lee W, Hankins GD, Benedetti TJ, Phelan JP (1991) Position change and central hemodynamic profile during normal third-trimester pregnancy and post partum. Am J Obstet Gynecol 164:883-887
  101. Gordon MC (2002) Maternal Physiology in Pregnancy. In: Gabbe SG, J.R. Niebyl, J.L. Simpson (ed) Obstetrics: Normal and Problem Pregnancies, Churchill Livingstone, Philadelphia, pp 63-91
  102. Friedman JD, Ramsey PS, Ramin KD, Berry C (2002) Pneumoamnion and pregnancy loss after second-trimester laparoscopic surgery. Obstet Gynecol 99:512-513
  103. Halpern NB (1998) Laparoscopic cholecystectomy in pregnancy: a review of published experiences and clinical considerations. Semin Laparosc Surg 5:129-134
  104. Canis M, Rabischong B, Houlle C, Botchorishvili R, Jardon K, Safi A, Wattiez A, Mage G, Pouly JL, Bruhat MA (2002) Laparoscopic management of adnexal masses: a gold standard? Curr Opin Obstet Gynecol 14:423-428
  105. Malangoni MA (2003) Gastrointestinal surgery and pregnancy. Gastroenterol Clin North Am 32:181-200
  106. Huang KG, Chua AA, Lee CL (2014) Surgical trocar insertion among pregnant patients. Int J Gynecol Cancer 24:965-966
  107. Lemaire BM, van Erp WF (1997) Laparoscopic surgery during pregnancy. Surg Endosc 11:15-18
  108. Wang CJ, Yen CF, Lee CL, Soong YK (2002) Minilaparoscopic cystectomy and appendectomy in late second trimester. JSLS 6:373-375
  109. Hume RF, Killiam AP (1990) Maternal Physiology. In: Scott JR, J. KiSaia, D.B. Hammon (ed) Obstetrics and Gynecology, JB Lippincott, Philadelphia, pp 93-100
  110. (1998) Guidelines for laparoscopic surgery during pregnancy. Society of American Gastrointestinal Endoscopic Surgeons (SAGES). Surg Endosc 12:189-190
  111. Hunter JG, Swanstrom L, Thornburg K (1995) Carbon dioxide pneumoperitoneum induces fetal acidosis in a pregnant ewe model. Surg Endosc 9:272-277; discussion 277-279
  112. Reedy MB, Galan HL, Bean-Lijewski JD, Carnes A, Knight AB, Kuehl TJ (1995) Maternal and fetal effects of laparoscopic insufflation in the gravid baboon. J Am Assoc Gynecol Laparosc 2:399-406
  113. Curet MJ, Vogt DA, Schob O, Qualls C, Izquierdo LA, Zucker KA (1996) Effects of CO2 pneumoperitoneum in pregnant ewes. J Surg Res 63:339-344
  114. Barnard JM, Chaffin D, Droste S, Tierney A, Phernetton T (1995) Fetal response to carbon dioxide pneumoperitoneum in the pregnant ewe. Obstet Gynecol 85:669-674
  115. Cruz AM, Southerland LC, Duke T, Townsend HG, Ferguson JG, Crone LA (1996) Intraabdominal carbon dioxide insufflation in the pregnant ewe. Uterine blood flow, intraamniotic pressure, and cardiopulmonary effects. Anesthesiology 85:1395-1402
  116. Soper NJ, Hunter JG, Petrie RH (1992) Laparoscopic cholecystectomy during pregnancy. Surg Endosc 6:115-117
  117. Comitalo JB, Lynch D (1994) Laparoscopic cholecystectomy in the pregnant patient. Surg Laparosc Endosc 4:268-271
  118. Bhavani-Shankar K, Steinbrook RA, Brooks DC, Datta S (2000) Arterial to end-tidal carbon dioxide pressure difference during laparoscopic surgery in pregnancy. Anesthesiology 93:370-373
  119. Melnick DM, Wahl WL, Dalton VK (2004) Management of general surgical problems in the pregnant patient. Am J Surg 187:170-180
  120. Jorgensen JO, Lalak NJ, North L, Hanel K, Hunt DR, Morris DL (1994) Venous stasis during laparoscopic cholecystectomy. Surg Laparosc Endosc 4:128-133
  121. (1992) Risk of and prophylaxis for venous thromboembolism in hospital patients. Thromboembolic Risk Factors (THRIFT) Consensus Group. Bmj 305:567-574
  122. Casele HL (2006) The use of unfractionated heparin and low molecular weight heparins in pregnancy. Clinical obstetrics and gynecology 49:895-905
  123. Hiatt JR, Hiatt JC, Williams RA, Klein SR (1986) Biliary disease in pregnancy: strategy for surgical management. Am J Surg 151:263-265
  124. Ghumman E, Barry M, Grace PA (1997) Management of gallstones in pregnancy. Br J Surg 84:1646-1650
  125. Chamogeorgakis T, Lo Menzo E, Smink RD, Jr., Feuerstein B, Fantazzio M, Kaufman J, Brennan EJ, Russell R (1999) Laparoscopic cholecystectomy during pregnancy: three case reports. JSLS 3:67-69
  126. Jelin EB, Smink DS, Vernon AH, Brooks DC (2008) Management of biliary tract disease during pregnancy: a decision analysis. Surg Endosc 22:54-60
  127. Graham G, Baxi L, Tharakan T (1998) Laparoscopic cholecystectomy during pregnancy: a case series and review of the literature. Obstet Gynecol Surv 53:566-574
  128. Steinbrook RA, Brooks DC, Datta S (1996) Laparoscopic cholecystectomy during pregnancy. Review of anesthetic management, surgical considerations. Surg Endosc 10:511-515
  129. Date RS, Kaushal M, Ramesh A (2008) A review of the management of gallstone disease and its complications in pregnancy. Am J Surg 196:599-608
  130. Jorge AM, Keswani RN, Veerappan A, Soper NJ, Gawron AJ (2015) Non-operative management of symptomatic cholelithiasis in pregnancy is associated with frequent hospitalizations. J Gastrointest Surg 19:598-603
  131. Ko CW (2006) Risk factors for gallstone-related hospitalization during pregnancy and the postpartum. Am J Gastroenterol 101:2263-2268
  132. Scott LD (1992) Gallstone disease and pancreatitis in pregnancy. Gastroenterol Clin North Am 21:803-815
  133. Printen KJ, Ott RA (1978) Cholecystectomy during pregnancy. Am Surg 44:432-434
  134. Othman MO, Stone E, Hashimi M, Parasher G (2012) Conservative management of cholelithiasis and its complications in pregnancy is associated with recurrent symptoms and more emergency department visits. Gastrointest Endosc 76:564-569
  135. Veerappan A, Gawron AJ, Soper NJ, Keswani RN (2013) Delaying cholecystectomy for complicated gallstone disease in pregnancy is associated with recurrent postpartum symptoms. J Gastrointest Surg 17:1953-1959
  136. Zhou Y, Zhang X, Zhang X, Guo Y, Lu W, Li J, Li Z (2013) ERCP in acute cholangitis during third trimester of pregnancy. Hepatogastroenterology 60:981-984
  137. Park ET (2015) Endoscopic Retrograde Cholangiopancreatography during Pregnancy: Really Guarantee to Safety? Gut Liver 9:569-570
  138. DeVore GR (1980) Acute abdominal pain in the pregnant patient due to pancreatitis, acute appendicitis, cholecystitis, or peptic ulcer disease. Clin Perinatol 7:349-369
  139. Borum ML (1998) Hepatobiliary diseases in women. Med Clin North Am 82:51-75
  140. Kimura Y, Takada T, Kawarada Y, Nimura Y, Hirata K, Sekimoto M, Yoshida M, Mayumi T, Wada K, Miura F, Yasuda H, Yamashita Y, Nagino M, Hirota M, Tanaka A, Tsuyuguchi T, Strasberg SM, Gadacz TR (2007) Definitions, pathophysiology, and epidemiology of acute cholangitis and cholecystitis: Tokyo Guidelines. J Hepatobiliary Pancreat Surg 14:15-26
  141. Tuech JJ, Binelli C, Aube C, Pessaux P, Fauvet R, Descamps P, Arnaud JP (2000) Management of choledocholithiasis during pregnancy by magnetic resonance cholangiography and laparoscopic common bile duct stone extraction. Surg Laparosc Endosc Percutan Tech 10:323-325
  142. Baillie J, Cairns SR, Putman WS, Cotton PB (1990) Endoscopic management of choledocholithiasis during pregnancy. Surg Gynecol Obstet 171:1-4
  143. Sungler P, Heinerman PM, Steiner H, Waclawiczek HW, Holzinger J, Mayer F, Heuberger A, Boeckl O (2000) Laparoscopic cholecystectomy and interventional endoscopy for gallstone complications during pregnancy. Surg Endosc 14:267-271
  144. Cosenza CA, Saffari B, Jabbour N, Stain SC, Garry D, Parekh D, Selby RR (1999) Surgical management of biliary gallstone disease during pregnancy. Am J Surg 178:545-548
  145. Barthel JS, Chowdhury T, Miedema BW (1998) Endoscopic sphincterotomy for the treatment of gallstone pancreatitis during pregnancy. Surg Endosc 12:394-399
  146. Scapa E (1995) To do or not to do an endoscopic retrograde cholangiopancreatography in acute biliary pancreatitis? Surg Laparosc Endosc 5:453-454
  147. Andreoli M, Sayegh SK, Hoefer R, Matthews G, Mann WJ (1996) Laparoscopic cholecystectomy for recurrent gallstone pancreatitis during pregnancy. South Med J 89:1114-1115
  148. Fine S, Beirne J, Delgi-Esposti S, Habr F (2014) Continued evidence for safety of endoscopic retrograde cholangiopancreatography during pregnancy. World J Gastrointest Endosc 6:352-358
  149. Agcaoglu O, Ozcinar B, Gok AF, Yanar F, Yanar H, Ertekin C, Gunay K (2013) ERCP without radiation during pregnancy in the minimal invasive world. Arch Gynecol Obstet 288:1275-1278
  150. Committee ASoP, Maple JT, Ikenberry SO, Anderson MA, Appalaneni V, Decker GA, Early D, Evans JA, Fanelli RD, Fisher D, Fisher L, Fukami N, Hwang JH, Jain R, Jue T, Khan K, Krinsky ML, Malpas P, Ben-Menachem T, Sharaf RN, Dominitz JA (2011) The role of endoscopy in the management of choledocholithiasis. Gastrointest Endosc 74:731-744
  151. Korndorffer JR Jr FE, Reed W (2010) SAGES guideline for laparoscopic appendectomy. Surg Endosc 24:757-761
  152. Cox TC, Huntington CR, Blair LJ, Prasad T, Lincourt AE, Augenstein VA, Heniford BT (2015) Laparoscopic appendectomy and cholecystectomy versus open: a study in 1999 pregnant patients. Surg Endosc
  153. Schwartzberg BS, Conyers JA, Moore JA (1997) First trimester of pregnancy laparoscopic procedures. Surg Endosc 11:1216-1217
  154. Thomas SJ, Brisson P (1998) Laparoscopic appendectomy and cholecystectomy during pregnancy: six case reports. JSLS 2:41-46
  155. Barnes SL, Shane MD, Schoemann MB, Bernard AC, Boulanger BR (2004) Laparoscopic appendectomy after 30 weeks pregnancy: report of two cases and description of technique. Am Surg 70:733-736
  156. de Perrot M, Jenny A, Morales M, Kohlik M, Morel P (2000) Laparoscopic appendectomy during pregnancy. Surg Laparosc Endosc Percutan Tech 10:368-371
  157. Schreiber JH (1990) Laparoscopic appendectomy in pregnancy. Surg Endosc 4:100-102
  158. Sadot E, Telem DA, Arora M, Butala P, Nguyen SQ, Divino CM Laparoscopy: a safe approach to appendicitis during pregnancy. Surg Endosc 24:383-389
  159. Lemieux P, Rheaume P, Levesque I, Bujold E, Brochu G (2009) Laparoscopic appendectomy in pregnant patients: a review of 45 cases. Surg Endosc 23:1701-1705
  160. Abbasi N, Patenaude V, Abenhaim HA (2014) Management and outcomes of acute appendicitis in pregnancy-population-based study of over 7000 cases. BJOG 121:1509-1514
  161. Rapp EJ, Naim F, Kadivar K, Davarpanah A, Cornfeld D (2013) Integrating MR imaging into the clinical workup of pregnant patients suspected of having appendicitis is associated with a lower negative laparotomy rate: single-institution study. Radiology 267:137-144
  162. Shalhav AL, Landman J, Afane J, Levi R, Clayman RV (2000) Laparoscopic adrenalectomy for primary hyperaldosteronism during pregnancy. J Laparoendosc Adv Surg Tech A 10:169-171
  163. Finkenstedt G, Gasser RW, Hofle G, Lhotta K, Kolle D, Gschwendtner A, Janetschek G (1999) Pheochromocytoma and sub-clinical Cushing’s syndrome during pregnancy: diagnosis, medical pre-treatment and cure by laparoscopic unilateral adrenalectomy. J Endocrinol Invest 22:551-557
  164. Aishima M, Tanaka M, Haraoka M, Naito S (2000) Retroperitoneal laparoscopic adrenalectomy in a pregnant woman with Cushing’s syndrome. J Urol 164:770-771
  165. Lo CY, Lo CM, Lam KY (2002) Cushing’s syndrome secondary to adrenal adenoma during pregnancy. Surg Endosc 16:219-220
  166. Aslzare M, Alipour M, Taghavi M, Ghoreifi A (2014) Bilateral laparoscopic adrenalectomy in a pregnant woman with Cushing’s syndrome. Urol J 11:1911-1913
  167. Janetschek G, Finkenstedt G, Gasser R, Waibel UG, Peschel R, Bartsch G, Neumann HP (1998) Laparoscopic surgery for pheochromocytoma: adrenalectomy, partial resection, excision of paragangliomas. J Urol 160:330-334
  168. Demeure MJ, Carlsen B, Traul D, Budney C, Lalande B, Lipinski A, Cruikshank D, Kotchen T, Wilson S (1998) Laparoscopic removal of a right adrenal pheochromocytoma in a pregnant woman. J Laparoendosc Adv Surg Tech A 8:315-319
  169. Pace DE, Chiasson PM, Schlachta CM, Mamazza J, Cadeddu MO, Poulin EC (2002) Minimally invasive adrenalectomy for pheochromocytoma during pregnancy. Surg Laparosc Endosc Percutan Tech 12:122-125
  170. Gagner M, Breton G, Pharand D, Pomp A (1996) Is laparoscopic adrenalectomy indicated for pheochromocytomas? Surgery 120:1076-1079; discussion 1079-1080
  171. Wolf A, Goretzki PE, Rohrborn A, Feldkamp J, Simon D, Scherbaum WA, Roher HD (2004) Pheochromocytoma during pregnancy: laparoscopic and conventional surgical treatment of two cases. Exp Clin Endocrinol Diabetes 112:98-101
  172. Kim PT, Kreisman SH, Vaughn R, Panton ON (2006) Laparoscopic adrenalectomy for pheochromocytoma in pregnancy. Can J Surg 49:62-63
  173. Zuluaga-Gomez A, Arrabal-Polo MA, Arrabal-Martin M, Lahoz-Garcia C, Escobar-Jimenez F, Torres-Vela E, Saz T (2012) Management of pheochromocytoma during pregnancy: laparoscopic adrenalectomy. Am Surg 78:E156-158
  174. Griffiths J, Sia W, Shapiro AM, Tataryn I, Turner AR (2005) Laparoscopic splenectomy for the treatment of refractory immune thrombocytopenia in pregnancy. J Obstet Gynaecol Can 27:771-774
  175. Majesky I, Daniel I, Stefanikova Z, Skultety J, Koudelka P, Hutan M (2013) Laparoscopic splenectomy in pregnancy – from contraindication to golden standard. Bratisl Lek Listy 114:484-487
  176. Samame J, Kaul A, Garza U, Echeverria A, Galvani C (2013) Laparoscopic aneurysm resection and splenectomy for splenic artery aneurysm in the third trimester of pregnancy. Surg Endosc 27:2988-2991
  177. Hardwick RH, Slade RR, Smith PA, Thompson MH (1999) Laparoscopic splenectomy in pregnancy. J Laparoendosc Adv Surg Tech A 9:439-440
  178. Allran CF, Jr., Weiss CA, 3rd, Park AE (2002) Urgent laparoscopic splenectomy in a morbidly obese pregnant woman: case report and literature review. J Laparoendosc Adv Surg Tech A 12:445-447
  179. Iwase K, Higaki J, Yoon HE, Mikata S, Tanaka Y, Takahashi T, Hatanaka K, Tamaki T, Hori S, Mitsuda N, Kamiike W (2001) Hand-assisted laparoscopic splenectomy for idiopathic thrombocytopenic purpura during pregnancy. Surg Laparosc Endosc Percutan Tech 11:53-56
  180. Anglin BV, Rutherford C, Ramus R, Lieser M, Jones DB (2001) Immune thrombocytopenic purpura during pregnancy: laparoscopic treatment. JSLS 5:63-67
  181. O’Connor JP, Biyani CS, Taylor J, Agarwal V, Curley PJ, Browning AJ (2004) Laparoscopic nephrectomy for renal-cell carcinoma during pregnancy. J Endourol 18:871-874
  182. Sainsbury DC, Dorkin TJ, MacPhail S, Soomro NA (2004) Laparoscopic radical nephrectomy in first-trimester pregnancy. Urology 64:1231 e1237-1238
  183. Akin Y, Ciftci H, Karahan MA, Incebiyik A (2015) Laparoscopic retroperitoneal radical nephrectomy in a pregnant woman with retrocaval artery. Int Urol Nephrol 47:469-471
  184. Domjan Z, Holman E, Bordas N, Dakay AS, Bahrehmand K, Buzogany I (2014) Hand-assisted laparoscopic radical nephrectomy in pregnancy. Int Urol Nephrol 46:1757-1760
  185. Yin L, Zhang D, Teng J, Xu D (2013) Retroperitoneal laparoscopic radical nephrectomy for renal cell carcinoma during pregnancy. Urol Int 90:487-489
  186. Arvind NK, Singh O, Gupta SS, Sahay S, Ali K, Dharaskar A (2011) Laparoscopic nephrectomy for pyonephrosis during pregnancy: case report and review of the literature. Rev Urol 13:98-103
  187. Bozzo M, Buscaglia M, Ferrazzi E (1997) The management of persistent adnexal masses in pregnancy. Am J Obstet Gynecol 177:981-982
  188. Webb KE, Sakhel K, Chauhan SP, Abuhamad AZ (2015) Adnexal mass during pregnancy: a review. Am J Perinatol 32:1010-1016
  189. Sisodia RM, Del Carmen MG, Boruta DM (2015) Role of minimally invasive surgery in the management of adnexal masses. Clin Obstet Gynecol 58:66-75
  190. Naqvi M, Kaimal A (2015) Adnexal masses in pregnancy. Clin Obstet Gynecol 58:93-101
  191. Grimes WH, Jr., Bartholomew RA, Colvin ED, Fish JS, Lester WM (1954) Ovarian cyst complicating pregnancy. Am J Obstet Gynecol 68:594-605
  192. Sherard GB, 3rd, Hodson CA, Williams HJ, Semer DA, Hadi HA, Tait DL (2003) Adnexal masses and pregnancy: a 12-year experience. Am J Obstet Gynecol 189:358-362; discussion 362-353
  193. Hess LW, Peaceman A, O’Brien WF, Winkel CA, Cruikshank DP, Morrison JC (1988) Adnexal mass occurring with intrauterine pregnancy: report of fifty-four patients requiring laparotomy for definitive management. Am J Obstet Gynecol 158:1029-1034
  194. Schmeler KM, Mayo-Smith WW, Peipert JF, Weitzen S, Manuel MD, Gordinier ME (2005) Adnexal masses in pregnancy: surgery compared with observation. Obstetrics and gynecology 105:1098-1103
  195. Zanetta G, Mariani E, Lissoni A, Ceruti P, Trio D, Strobelt N, Mariani S (2003) A prospective study of the role of ultrasound in the management of adnexal masses in pregnancy. Bjog 110:578-583
  196. Condous G, Khalid A, Okaro E, Bourne T (2004) Should we be examining the ovaries in pregnancy? Prevalence and natural history of adnexal pathology detected at first-trimester sonography. Ultrasound Obstet Gynecol 24:62-66
  197. (2007) ACOG Practice Bulletin. Management of adnexal masses. Obstetrics and gynecology 110:201-214
  198. Goh W, Bohrer J, Zalud I (2014) Management of the adnexal mass in pregnancy. Curr Opin Obstet Gynecol 26:49-53
  199. Parker J, Watkins W, Robinson H, Byrne D (1995) Laparoscopic adnexal surgery during pregnancy: a case of heterotopic tubal pregnancy treated by laparoscopic salpingectomy. Aust N Z J Obstet Gynaecol 35:208-210
  200. Moore RD, Smith WG (1999) Laparoscopic management of adnexal masses in pregnant women. J Reprod Med 44:97-100
  201. Lin YH, Hwang JL, Huang LW, Seow KM (2003) Successful laparoscopic management of a huge ovarian tumor in the 27th week of pregnancy. A case report. J Reprod Med 48:834-836
  202. Mathevet P, Nessah K, Dargent D, Mellier G (2003) Laparoscopic management of adnexal masses in pregnancy: a case series. Eur J Obstet Gynecol Reprod Biol 108:217-222
  203. Scheib SA, Jones HH, Boruta DM, Simpson K, Bedaiwy M, Grumbine FC, Fader AN (2013) Laparoendoscopic single-site surgery for management of adnexal masses in pregnancy: case series. J Minim Invasive Gynecol 20:701-707
  204. Lee JH, Lee JR, Jee BC, Suh CS, Kim SH (2013) Safety and feasibility of a single-port laparoscopic adnexal surgery during pregnancy. J Minim Invasive Gynecol 20:864-870
  205. Dursun P, Gulumser C, Caglar M, Araz C, Zeyneloglu H, Haberal A (2013) Laparoendoscopic single-site surgery for acute adnexal pathology during pregnancy: preliminary experience. J Matern Fetal Neonatal Med 26:1282-1286
  206. De Santis M, Licameli A, Spagnuolo T, Scambia G (2013) Laparoscopic management of a large, twisted, ovarian dermoid cyst during pregnancy: a case report. J Reprod Med 58:271-276
  207. Struyk AP, Treffers PE (1984) Ovarian tumors in pregnancy. Acta Obstet Gynecol Scand 63:421-424
  208. Nichols DH, Julian PJ (1985) Torsion of the adnexa. Clin Obstet Gynecol 28:375-380
  209. Takeda A, Hayashi S, Imoto S, Sugiyama C, Nakamura H (2014) Pregnancy outcomes after emergent laparoscopic surgery for acute adnexal disorders at less than 10 weeks of gestation. J Obstet Gynaecol Res 40:1281-1287
  210. Mage G, Canis M, Manhes H, Pouly JL, Bruhat MA (1989) Laparoscopic management of adnexal torsion. A review of 35 cases. J Reprod Med 34:520-524
  211. Garzarelli S, Mazzuca N (1994) One laparoscopic puncture for treatment of ovarian cysts with adnexal torsion in early pregnancy. A report of two cases. J Reprod Med 39:985-986
  212. Morice P, Louis-Sylvestre C, Chapron C, Dubuisson JB (1997) Laparoscopy for adnexal torsion in pregnant women. J Reprod Med 42:435-439
  213. Abu-Musa A, Nassar A, Usta I, Khalil A, Hussein M (2001) Laparoscopic unwinding and cystectomy of twisted dermoid cyst during second trimester of pregnancy. J Am Assoc Gynecol Laparosc 8:456-460
  214. Bassil S, Steinhart U, Donnez J (1999) Successful laparoscopic management of adnexal torsion during week 25 of a twin pregnancy. Hum Reprod 14:855-857
  215. Argenta PA, Yeagley TJ, Ott G, Sondheimer SJ (2000) Torsion of the uterine adnexa. Pathologic correlations and current management trends. J Reprod Med 45:831-836
  216. Tarraza HM, Moore RD (1997) Gynecologic causes of the acute abdomen and the acute abdomen in pregnancy. Surg Clin North Am 77:1371-1394
  217. Oelsner G, Bider D, Goldenberg M, Admon D, Mashiach S (1993) Long-term follow-up of the twisted ischemic adnexa managed by detorsion. Fertil Steril 60:976-979
  218. Cappell MS, Friedel D (2003) Abdominal pain during pregnancy. Gastroenterol Clin North Am 32:1-58
  219. Practice ACoO (2011) ACOG Committee Opinion No. 474: nonobstetric surgery during pregnancy. Obstet Gynecol 117:420-421
  220. Morgan MA, Goldenberg RL, Schulkin J (2008) Obstetrician-gynecologists’ practices regarding preterm birth at the limit of viability. J Matern Fetal Neonatal Med 21:115-121
  221. Weissmann-Brenner A, Haiman S, Ayala MM, Gindes L, Achiron R, Sivan E, Barzilay E (2015) Maternal medical compromise during pregnancy and pregnancy outcomes. J Matern Fetal Neonatal Med 28:1202-1207
  222. Katz VL, Farmer RM (1999) Controversies in tocolytic therapy. Clin Obstet Gynecol 42:802-819
  223. Berkman ND, Thorp JM, Jr., Lohr KN, Carey TS, Hartmann KE, Gavin NI, Hasselblad V, Idicula AE (2003) Tocolytic treatment for the management of preterm labor: a review of the evidence. American journal of obstetrics and gynecology 188:1648-1659
  224. Tan TC, Devendra K, Tan LK, Tan HK (2006) Tocolytic treatment for the management of preterm labour: a systematic review. Singapore medical journal 47:361-366
  225. Romero R, Sibai BM, Sanchez-Ramos L, Valenzuela GJ, Veille JC, Tabor B, Perry KG, Varner M, Goodwin TM, Lane R, Smith J, Shangold G, Creasy GW (2000) An oxytocin receptor antagonist (atosiban) in the treatment of preterm labor: a randomized, double-blind, placebo-controlled trial with tocolytic rescue. American journal of obstetrics and gynecology 182:1173-1183
  226. Illanes SE, Perez-Sepulveda A, Rice GE, Mitchell MD (2014) Preterm labour: association between labour physiology, tocolysis and prevention. Expert Opin Investig Drugs 23:759-771
  227. Ehsanipoor RM, Shrivastava VK, Lee RM, Chan K, Galyean AM, Garite TJ, Rumney PJ, Wing DA (2011) A randomized, double-masked trial of prophylactic indomethacin tocolysis versus placebo in women with premature rupture of membranes. Am J Perinatol 28:473-478
Table 1: GRADE system for rating the quality of evidence for SAGES guidelines.
Quality of EvidenceDefinitionSymbol Used
High qualityFurther research is very unlikely to alter confidence in the estimate of impact++++
Moderate qualityFurther research is likely to alter confidence in the estimate of impact and may change the estimate+++
Low qualityFurther research is very likely to alter confidence in the estimate of impact and is likely to change the estimate++
Very low qualityAny estimate of impact is uncertain+
Adapted from Guyatt et al.

 

Table 2: GRADE system for recommendations based on the quality of evidence for SAGES guidelines.
StrongIt is very certain that benefit exceeds risk for the option considered
WeakRisk and benefit well balanced, patients in differing clinical situations would make different choices, or benefits available but not certain

Adapted from Guyatt et al.

Guyatt GH, Oxman AD, Vist GE, et al; GRADE Working Group. GRADE: An emerging consensus on rating quality of evidence and strength of recommendations. BMJ 2008;336:924-6.

 

Table 3. Radiation Exposure to Conceptus in Common Radiologic Studies[24, 61, 64]
StudyRadiation Exposure (mGy)
Abdominal Radiograph1-3
Intraoperative Cholangiography2
Lumbar Spine Radiograph6
Intravenous Pyelogram6
Barium Enema7
CT of Pelvis10-50
ERCP (without pelvic shielding)20-125

This document was prepared and revised by Jonathan P Pearl, Raymond R Price, Allison E Tonkin, William S Richardson, Dimitrios Stefanidis and the SAGES Guidelines Committee

This statement was reviewed and approved by the Board of Governors of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) on May 2017.

This is a revision of SAGES publication #23 printed Sep 2007, revised Jan 2011 and May 2017.

For more information please contact:

SOCIETY OF AMERICAN GASTROINTESTINAL ENDOSCOPIC SURGEONS (SAGES)
11300 West Olympic Blvd., Suite 600
Los Angeles, CA 90064
Tel:
(310) 437-0544
Fax:
(310) 437-0585
Email:
publications@sages.org

Guidelines for clinical practice are intended to indicate preferable approaches to medical problems as established by experts in the field. These recommendations will be based on existing data or a consensus of expert opinion when little or no data are available. Guidelines are applicable to all physicians who address the clinical problem(s) without regard to specialty training or interests, and are intended to indicate the preferable, but not necessarily the only acceptable approaches due to the complexity of the healthcare environment. Guidelines are intended to be flexible. Given the wide range of specifics in any health care problem, the surgeon must always choose the course best suited to the individual patient and the variables in existence at the moment of decision.

Guidelines are developed under the auspices of the Society of American Gastrointestinal and Endoscopic Surgeons and its various committees, and approved by the Board of Governors. Each clinical practice guideline has been systematically researched, reviewed and revised by the guidelines committee, and reviewed by an appropriate multidisciplinary team. The recommendations are therefore considered valid at the time of its production based on the data available. Each guideline is scheduled for periodic review to allow incorporation of pertinent new developments in medical research knowledge, and practice.