I. Introduction
Non-obstetrical surgical conditions complicate approximately 1 in every 500 pregnancies, necessitating careful consideration of both maternal and fetal well-being. Accurate and timely Surgical Diagnosis is paramount in these situations, as favorable outcomes for both mother and fetus hinge on prompt and appropriate intervention. Among the most frequent surgical emergencies during pregnancy are acute appendicitis and cholecystitis, but a spectrum of other conditions, including ovarian cysts, symptomatic gallstones, and complications from inflammatory bowel disease, may also require surgical management. This revised guideline, tailored for the English-speaking medical community, offers updated recommendations for the diagnostic and therapeutic approaches to surgical problems in pregnant patients, with a particular focus on leveraging laparoscopy and achieving precise surgical diagnosis. It is crucial for surgeons to be well-versed in the nuances of surgical techniques adapted for pregnant individuals to ensure optimal results, minimizing fetal risk while prioritizing maternal safety.
II. Diagnostic Workup in Pregnant Surgical Patients
Abdominal pain during pregnancy presents a complex diagnostic challenge. Clinicians must carefully weigh the benefits and risks of various diagnostic modalities to both the expectant mother and her fetus. A cornerstone principle in managing abdominal pain in pregnancy is that early and accurate surgical diagnosis significantly improves prognosis. Indeed, fetal outcomes are intrinsically linked to the mother’s health, underscoring the importance of precise and rapid diagnostic evaluations. Often, achieving an accurate surgical diagnosis necessitates employing diagnostic imaging techniques such as ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI). Prior to any diagnostic procedure, a thorough risk-benefit discussion with the patient is essential.
Ultrasound: The Primary Imaging Modality
Guideline 1: For pregnant patients presenting with acute abdominal pain, ultrasound imaging stands as a safe and highly effective initial diagnostic tool. It is strongly recommended as the primary imaging modality for identifying the underlying cause of acute abdominal pain in many pregnant individuals (+++; Strong).
In pregnant women experiencing abdominal pain, differentiating between gynecologic and non-gynecologic etiologies is crucial for effective surgical diagnosis. When imaging is clinically indicated, ultrasound is recognized for its safety and efficacy, making it the preferred initial radiographic investigation for numerous gynecologic causes of abdominal pain. These include adnexal masses, ovarian torsion, placental abruption, placenta previa, uterine rupture, and fetal demise. Notably, ultrasound exhibits a sensitivity of up to 80% and a specificity of 94% in diagnosing obstetric and gynecologic causes of abdominal pain, encompassing conditions like ectopic pregnancy and ovarian torsion.
Ultrasound also proves valuable in diagnosing various non-gynecologic causes of abdominal pain, such as symptomatic gallstones and appendicitis. It is the diagnostic modality of choice for evaluating biliary pathology in pregnant patients, boasting a diagnostic accuracy exceeding 90%. In pregnant patients with right lower quadrant abdominal pain, ultrasound can visualize the appendix in up to 60% of cases. However, inconclusive findings for appendicitis may occur in up to 90% of examinations. When clinical assessment, physical examination, and initial ultrasound results are inconclusive, further imaging is warranted to reach a definitive surgical diagnosis.
Ionizing Radiation Risks and Pregnancy
Guideline 2: Exposure to ionizing radiation during pregnancy elevates the risk of teratogenesis and childhood leukemia in the fetus. It is strongly recommended that cumulative radiation exposure be kept below 50-100 milligray (mGy) throughout pregnancy (+++; Strong).
Significant fetal exposure to ionizing radiation can induce chromosomal mutations, neurological abnormalities, and an increased risk of childhood leukemia. Cumulative radiation dose is the primary determinant of adverse fetal effects, although gestational age at the time of exposure also plays a critical role. Fetal mortality risk is highest when exposure occurs in the first week post-conception. Therefore, limiting cumulative radiation dose to the fetus to under 50-100 mGy during pregnancy is widely advised. For context, a single plain abdominal radiograph imparts an average fetal radiation dose of 1-3 mGy, while a pelvic CT scan averages less than 30 mGy.
The period between 10 and 17 weeks of gestation is particularly sensitive for central nervous system teratogenesis, emphasizing the need to avoid routine radiographs during this time. In later stages of pregnancy, the primary concern shifts from teratogenesis to the increased risk of childhood hematologic malignancies. Background incidence of childhood cancer and leukemia is approximately 0.2-0.3%. Radiation exposure may incrementally increase this risk by 0.06% per 10 mGy delivered to the fetus.
Exposure of the conceptus to doses as low as 5 mGy elevates the risk of spontaneous abortion, major congenital malformations, and childhood malignancy, adding approximately one additional case per 6,000 live births above baseline risk. Crucially, over 99% of fetuses remain unaffected by radiation doses below 20 mGy. While the risk of teratogenesis is low at doses of 50 mGy or less, malformation risk significantly increases beyond 150 mGy. Consequently, no single diagnostic study during pregnancy should exceed a fetal radiation dose of 50 mGy.
Computed Tomography (CT) in Emergencies
Guideline 3: In emergency scenarios during pregnancy, abdominal CT scans are a valuable tool for rapid diagnostic information. However, CT scanning should not be the initial imaging modality of choice (++; Weak).
Computed tomography (CT) is a useful modality for evaluating abdominal pain in pregnant patients when rapid diagnostic information is critical and other imaging techniques are insufficient for achieving a timely surgical diagnosis. Fetal radiation exposure from pelvic CT scans can be as low as 20 mGy, but may reach 50 mGy with full abdomen and pelvis scans. This level of radiation exposure may pose risks of teratogenesis and increased childhood hematologic malignancies.
Except in emergencies like trauma or acute severe abdominal pain requiring urgent surgical diagnosis, CT scanning should not be the initial imaging modality for pregnant patients. Given the diagnostic utility and safety profile of ultrasound and MRI for abdominal pain in pregnancy, CT should be reserved for emergency cases or situations where MRI is unavailable. When ionizing radiation imaging is necessary, adherence to the ALARA (as low as reasonably achievable) principle, employing specific dose-reduction techniques, is crucial.
Magnetic Resonance Imaging (MRI): Preferred Advanced Imaging
Guideline 4: Magnetic resonance imaging (MRI), performed without intravenous Gadolinium contrast, is safe at any stage of pregnancy. MRI is favored over CT scanning for diagnosing non-obstetric abdominal pain in pregnant patients (++; Weak).
MRI offers superior soft tissue imaging without the use of ionizing radiation, making it a safe imaging option for pregnant women. Intravenous Gadolinium contrast agents can cross the placenta and potentially cause teratogenesis, limiting their use in pregnancy to essential cases only. While some concerns exist regarding potential detrimental effects of acoustic noise on the fetus during MRI, no specific adverse effects on fetal development related to MRI techniques have been reported.
Advances in MRI techniques have solidified its position as the preferred advanced imaging modality in pregnancy. Faster acquisition times and motion-insensitive sequences enhance MRI’s utility in pregnant patients. As experience with abdominal MRI grows, diagnostic accuracy for surgical diagnosis improves. In emergency settings, MRI demonstrates diagnostic accuracy equal to or exceeding CT scan or ultrasound for non-traumatic abdominal pathology. When available, MRI should be prioritized over CT scanning in the diagnostic workup of pregnant patients with abdominal pain, facilitating more accurate surgical diagnosis while minimizing radiation exposure.
Nuclear Medicine Considerations
Guideline 5: Administering radionuclides for diagnostic studies is generally safe for both mother and fetus (++; Weak).
When deemed necessary for urgent medical conditions, radiopharmaceuticals can generally be administered at doses ensuring whole fetal exposure remains below 5 mGy, well within established safe limits. Consultation with a nuclear medicine radiologist or technologist is recommended before proceeding with such studies.
Cholangiography and Radiation Minimization
Guideline 6: Intraoperative and endoscopic cholangiography involve minimal radiation exposure to both mother and fetus and can be selectively employed during pregnancy. Shielding the lower abdomen during cholangiography is essential to minimize fetal radiation exposure (++; Weak).
Radiation exposure during cholangiography is estimated to be 20-50 mGy. Fluoroscopy typically delivers radiation doses up to 200 mGy/minute, varying based on equipment, patient positioning, and size. During cholangiography, fetal shielding using protective devices between the radiation source and the patient is critical to minimize radiation exposure without compromising necessary imaging field of view. No adverse effects specifically from cholangiography have been reported in pregnant patients or their fetuses.
Endoscopic retrograde cholangiopancreatography (ERCP) averages 20-120 mGy of radiation exposure, but can be significantly higher in prolonged procedures. ERCP also carries additional risks beyond radiation, such as bleeding and pancreatitis. In non-pregnant patients, bleeding risk is around 1.3%, and pancreatitis risk ranges from 3.5% to 11%. These risks necessitate a careful risk-benefit assessment and patient discussion, similar to other operative and procedural interventions.
Alternatives to fluoroscopy for biliary tree imaging include endoscopic ultrasound and choledochoscopy. These are acceptable alternatives provided the surgeon possesses the necessary equipment and expertise for accurate procedure performance.
Diagnostic Laparoscopy: A Selective Tool
Guideline 7: When imaging modalities are unavailable or inconclusive, diagnostic laparoscopy can be selectively employed in the diagnostic workup and treatment of acute abdominal processes during pregnancy (++, weak).
While imaging is generally preferred for diagnosing abdominal conditions in pregnancy, diagnostic laparoscopy can be considered when imaging is inaccessible or yields inconclusive results for surgical diagnosis. However, laparoscopy should be used judiciously due to potential increased risks of preterm labor and fetal demise following negative laparoscopy for presumed appendicitis. Risks and benefits of diagnostic laparoscopy for other conditions in pregnancy require further investigation.
Establishing a timely and accurate surgical diagnosis of abdominal conditions in pregnancy is crucial for optimizing maternal and fetal outcomes. When resources limit prompt diagnostic imaging, or imaging results are inconclusive, diagnostic laparoscopy may be considered. The risks of delayed diagnosis should be carefully weighed against the potential risks of negative laparoscopy. Surgeons must be prepared to manage conditions diagnosed during laparoscopy.
III. Patient Selection for Laparoscopic Surgery
Pre-operative Decision Making for Laparoscopy
Guideline 8: Laparoscopic treatment for acute abdominal disease offers comparable benefits to pregnant and non-pregnant patients when compared to laparotomy (+++; Strong).
Once surgery is deemed necessary, the surgical approach – laparotomy versus laparoscopy – should be determined by the surgeon’s expertise and the availability of appropriate staff and equipment. Laparoscopy in pregnancy offers benefits mirroring those in non-pregnant patients, including reduced postoperative pain, decreased postoperative ileus, shorter hospital stays, and quicker return to daily activities. Additional advantages for pregnant patients include reduced fetal respiratory depression due to lower postoperative narcotic requirements, lower risk of wound complications, diminished postoperative maternal hypoventilation, and decreased thromboembolic event risk. Enhanced visualization during laparoscopy may also lessen uterine irritability by minimizing uterine manipulation.
Laparoscopy and Pregnancy Trimester
Guideline 9: Laparoscopy can be safely performed during any trimester of pregnancy when surgical intervention is indicated (+++; Strong).
Traditional recommendations advised against non-emergent surgeries during the first and third trimesters to minimize risks of spontaneous abortion and preterm labor, respectively. This led to suggestions of delaying surgery until the second trimester, or limiting laparoscopic surgery to gestational ages under 26-28 weeks. However, current evidence does not support these restrictions. Recent literature demonstrates that laparoscopic surgery can be safely performed in pregnant patients during any trimester without increased maternal or fetal risk.
Both laparoscopic cholecystectomy and appendectomy have been successfully performed late in the third trimester without increasing preterm labor or fetal demise. Importantly, delaying necessary surgery until after delivery has been shown to increase complication rates for both mother and fetus in certain cases.
IV. Surgical Treatment Modalities
Patient Positioning for Laparoscopy
Guideline 10: Pregnant patients beyond the first trimester should be positioned in the left lateral decubitus or partial left lateral decubitus position to minimize vena cava compression (++; Strong).
In the supine position, the gravid uterus compresses the inferior vena cava, reducing venous return to the heart. This can lead to maternal hypotension and decreased placental perfusion during surgery. Left lateral decubitus positioning shifts the uterus off the vena cava, improving venous return and cardiac output. If abdominal access is compromised in the full decubitus position, a partial left lateral decubitus position is acceptable. Positioning adjustments are generally not needed for first-trimester patients due to the smaller uterine size.
Initial Port Placement Techniques
Guideline 11: Initial abdominal access for laparoscopy can be safely achieved using open (Hasson), Veress needle, or optical trocar techniques by experienced surgeons, adjusting the insertion location based on fundal height (++; weak).
Safe laparoscopic abdominal access can be achieved with open or closed techniques when performed correctly by experienced surgeons. Concerns regarding closed access techniques (Veress needle or optical entry) primarily relate to potential uterine or intra-abdominal organ injury. During the second and third trimesters, altered intra-abdominal anatomy necessitates adjusting trocar placement from standard configurations to accommodate uterine enlargement. Adjusting the initial access site based on fundal height and elevating the abdominal wall during insertion allows for safe and effective use of both the Hassan technique and Veress needle. A subcostal approach for initial access, using either open or closed techniques, is recommended to avoid uterine injury. Ultrasound-guided trocar placement can provide an additional safety measure.
Insufflation Pressure Management
Guideline 12: CO2 insufflation pressures of 10-15 mmHg are considered safe for laparoscopy in pregnant patients. Insufflation pressure levels should be tailored to the patient’s individual physiology (++; weak).
The gravid uterus elevates the diaphragm, reducing residual lung volume and functional residual capacity in pregnant patients. Pneumoperitoneum-induced diaphragmatic elevation is more concerning in pregnant patients with pre-existing restrictive pulmonary physiology. Some recommend maintaining intra-abdominal insufflation pressures below 12 mmHg to avoid worsening pulmonary physiology in pregnant women. However, others argue that pressures below 12 mmHg may compromise intra-abdominal visualization. Pressures up to 15 mmHg have been used safely in pregnant patients without increasing adverse maternal or fetal outcomes.
Concerns exist regarding potential fetal effects from CO2 pneumoperitoneum due to CO2 exchange. Animal studies have shown fetal acidosis with tachycardia, hypertension, and hypercapnia during CO2 pneumoperitoneum, while other studies contradict these findings. However, no data demonstrate detrimental effects on human fetuses from CO2 pneumoperitoneum.
Intra-operative CO2 Monitoring
Guideline 13: Intraoperative CO2 monitoring via capnography is strongly recommended during laparoscopy in pregnant patients (+++; Strong).
While animal studies have documented fetal acidosis and instability with CO2 pneumoperitoneum, long-term effects remain unidentified. Fetal acidosis from insufflation hasn’t been documented in human fetuses, but concerns about potential acidosis effects have led to recommendations for maternal CO2 monitoring. Initially, debate existed regarding arterial carbon dioxide (PaCO2) versus end-tidal carbon dioxide (ETCO2) monitoring. However, less invasive capnography has been shown to adequately reflect maternal acid-base status in humans. Large studies have confirmed the safety and efficacy of ETCO2 measurements in pregnant women, rendering routine blood gas monitoring unnecessary.
Venous Thromboembolic (VTE) Prophylaxis
Guideline 14: Intraoperative and postoperative pneumatic compression devices, along with early postoperative ambulation, are recommended for deep venous thrombosis prophylaxis in pregnant patients (++; weak).
Pregnancy is a hypercoagulable state, with a 0.1-0.2% incidence of deep venous thrombosis. CO2 pneumoperitoneum may further increase DVT risk due to venous stasis. Insufflation at 12 mmHg significantly reduces blood flow, which may not be fully reversed by intermittent pneumatic compression devices.
While limited research exists on DVT prophylaxis in pregnant patients undergoing laparoscopy, general principles for laparoscopic surgery apply. Given the elevated thrombosis risk, pneumatic compression devices both intraoperatively and postoperatively, along with early ambulation, are recommended. Data on unfractionated or low molecular weight heparin prophylaxis in pregnant laparoscopic patients are lacking, although use has been suggested for extended major operations. Unfractionated heparin is considered safe and the preferred agent for anticoagulation during pregnancy when needed.
Management of Gallbladder Disease
Guideline 15: Laparoscopic cholecystectomy is the preferred treatment for symptomatic gallbladder disease in pregnant patients, regardless of trimester (++; weak).
Historically, non-operative management was often recommended for symptomatic cholelithiasis in pregnancy. However, early surgical management, specifically laparoscopic cholecystectomy, is now the treatment of choice. Compared to open cholecystectomy, laparoscopic cholecystectomy during pregnancy is associated with shorter hospital stays, shorter operative times, and fewer complications. No fetal demise cases have been reported for laparoscopic cholecystectomy during the first and second trimesters. Furthermore, lower rates of spontaneous abortion and preterm labor have been observed after laparoscopic cholecystectomy compared to laparotomy.
Recurrent gallbladder symptoms develop in 92% of patients managed non-operatively who present in the first trimester, 64% in the second trimester, and 44% in the third trimester. While preterm labor and spontaneous abortion rates are similar for operative and non-operative management in uncomplicated biliary disease, approximately 50% of patients with recurrent symptoms require hospitalization, and up to 23% develop acute cholecystitis, cholangitis, or gallstone pancreatitis. Complicated gallstone disease can lead to preterm labor in up to 20% of cases and fetal loss in 10% to 60%, depending on severity.
Delaying cholecystectomy until after delivery results in high rates of recurrent symptoms, emergency department visits, and hospitalizations. Given the low risk of laparoscopic cholecystectomy to pregnant women and fetuses, it should be considered for all pregnant women with symptomatic gallstones.
Choledocholithiasis Management
Guideline 16: Choledocholithiasis during pregnancy can be safely managed with preoperative endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy followed by laparoscopic cholecystectomy, laparoscopic common bile duct exploration during cholecystectomy, or postoperative ERCP. Comparative studies are needed (++; weak).
ERCP for choledocholithiasis during pregnancy is safe and effective. Complications like preterm labor and spontaneous abortion associated with choledocholithiasis are uncommon during pregnancy. No trials have directly compared common bile duct exploration during 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.
Intraoperative common bile duct exploration has shown good outcomes, but reported cases are limited. Multiple studies demonstrate safe and effective management of common bile duct stones using preoperative ERCP followed by laparoscopic cholecystectomy. Although radiation exposure during ERCP is low, radiation-free endoscopic stone extraction using endoscopic ultrasound and choledochoscopy is possible. Endoscopic stenting without stone extraction, using minimal radiation, is another option.
Depending on local expertise, the least invasive procedure for common duct stone extraction should be performed. Both ERCP and laparoscopic common duct exploration are safe in pregnant women.
Laparoscopic Appendectomy for Appendicitis
Guideline 17: Laparoscopic appendectomy is the preferred treatment for pregnant patients with acute appendicitis (++; Weak).
Laparoscopic appendectomy is the preferred approach for pregnant patients with acute appendicitis, supported by numerous studies demonstrating its safety and efficacy. Retrospective series show very low preterm delivery rates and, in most, no fetal demise reports. Non-operative management of uncomplicated acute appendicitis in pregnant women is contraindicated due to higher rates of peritonitis, fetal demise, shock, and venous thromboembolism compared to operative management. Recent evidence supporting antibiotics alone for acute appendicitis does not extend to pregnant patients.
Limited data suggest increased maternal morbidity, preterm labor, and fetal loss in negative laparoscopy for presumed appendicitis compared to laparoscopic appendectomy for uncomplicated appendicitis. The cause of increased morbidity in negative laparoscopy is unclear and requires further prospective study.
This highlights the importance of accurate and timely surgical diagnosis of appendicitis in pregnant patients. When diagnosis remains uncertain after clinical findings and ultrasound, MRI is the preferred adjunct for accurate diagnosis. MRI reduces negative exploration rates by 50% in pregnant patients with suspected appendicitis. CT scan can be used if MRI is unavailable, but radiation exposure risks must be considered.
Solid Organ Resection in Pregnancy
Guideline 18: Laparoscopic adrenalectomy, nephrectomy, and splenectomy are safe procedures in appropriately selected pregnant patients (+; Weak).
Laparoscopic adrenalectomy during pregnancy has proven effective for managing primary hyperaldosteronism, Cushing’s syndrome, and pheochromocytoma. Laparoscopic splenectomy is increasingly accepted in pregnancy, with good outcomes for mother and fetus in cases of antiphospholipid syndrome, hereditary spherocytosis, and autoimmune thrombocytopenia purpura. Several cases of laparoscopic nephrectomy during pregnancy have been reported without complications.
Given limited data on laparoscopic solid organ exploration in pregnant patients, each case should be individualized. If solid organ surgery can be safely postponed until after delivery, it should be. However, pathologic surgical conditions of the adrenal gland, kidney, and spleen endangering the mother or fetus should be approached laparoscopically.
Adnexal Masses in Pregnancy
Guideline 19: Laparoscopy is a safe and effective treatment for symptomatic ovarian cystic masses in pregnant patients. Observation is acceptable for other cystic lesions if ultrasound is not concerning for malignancy and tumor markers are normal. Initial observation is generally warranted for most cystic lesions.
Adnexal masses occur in approximately 2% of pregnancies. Most adnexal masses found in the first trimester are functional cysts that resolve spontaneously by the second trimester. 80% to 95% of adnexal masses are benign.
Persistent masses are often functional cysts or mature cystic teratomas with low malignancy rates (2% to 6%). Historically, concerns over malignant potential and emergency surgery risks led to elective removal of masses persisting after 16 weeks and larger than 6 cm. Recent literature supports close observation when ultrasound findings are reassuring, tumor markers are normal, and patients are asymptomatic. If surgery is indicated, case reports support laparoscopic management of adnexal masses in all trimesters.
Adnexal Torsion Management
Guideline 20: Laparoscopy is recommended for both diagnosis and treatment of adnexal torsion (++; Strong).
10% to 15% of adnexal masses undergo torsion. Laparoscopy is the preferred method for both surgical diagnosis and treatment of adnexal torsion in pregnant patients. Multiple case reports confirm the safety and efficacy of laparoscopy for adnexal torsion during pregnancy. If diagnosed before tissue necrosis, adnexal torsion can be managed by simple laparoscopic detorsion. However, delayed surgical diagnosis and treatment of torsion can lead to adnexal infarction, potentially resulting in peritonitis, spontaneous abortion, preterm delivery, and death. Gangrenous adnexa should be resected, and progesterone therapy initiated after corpus luteum removal if gestation is less than 12 weeks. Laparotomy may be necessary based on clinical condition and operative findings.
V. Perioperative Care Considerations
Fetal Heart Rate Monitoring
Guideline 21: Fetal heart monitoring should be conducted preoperatively and postoperatively for viable fetuses undergoing urgent abdominal surgery during pregnancy (++; Weak).
While intraoperative fetal heart rate monitoring was previously considered the most accurate method to detect fetal distress during laparoscopy, no intraoperative fetal heart rate abnormalities have been reported in the literature. Preoperative and postoperative fetal heart rate monitoring for viable fetuses is the current standard, with no reported increase in fetal morbidity. Current lower limit of fetal viability is between 22 and 24 weeks.
Tocolytic Agent Use
Guideline 22: Prophylactic tocolytics are not recommended for pregnant women undergoing surgery. Tocolytics should be considered perioperatively when signs of preterm labor are present (++++; Strong).
Threatened preterm labor can be effectively managed with tocolytic therapy. The specific agent and indications for tocolytic use should be individualized and guided by obstetrician recommendations. No evidence supports prophylactic tocolytic use.
Limitations of Current Literature
As laparoscopy becomes more common during pregnancy, data are accumulating. However, most data derive from case series and retrospective reviews, limiting definitive recommendations. Prospective comparative studies evaluating common abdominal conditions during pregnancy, such as cholelithiasis and appendicitis, are lacking. Further controlled clinical studies are needed to refine these guidelines, and revisions may be necessary as new data emerge.
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
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).
