Can i have laparoscopy while pregnant

Radiation may increase that incidence by 0. Exposure of the conceptus to 5 mGy increases the risk of spontaneous abortion, major malformations, and childhood malignancy to one additional case per 6, live births above baseline risk [21, 27]. The risk of aberrant teratogenesis is low at 50 mGy or less and that the risk of malformation is significantly increased at doses above mGy. No single diagnostic study should exceed 50 mGy [13, 20, 22, ].

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

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, ].

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]. Guideline 4: MR Imaging without the use of intravenous Gadolinium can be performed at any stage of pregnancy. MRI provides excellent soft tissue imaging without ionizing radiation and is safe to use in pregnant patients [8, 9, ].

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. 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, ].

Improvements in technique have made MRI the preferred advanced imaging modality in the pregnant patient [42, 43, ]. 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]. 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. Guideline 6: Intraoperative and endoscopic cholangiography exposes the mother and fetus to minimal radiation and may be used selectively during pregnancy. Radiation exposure during cholangiography is estimated to be mGy [61].

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 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. These additional risks warrant the same careful risk-benefit analysis and discussion with the patient as other operative and procedural interventions [12, 32, ].

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

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 []. Other advantages of laparoscopy in the pregnant patient include decreased fetal respiratory depression due to diminished postoperative narcotic requirements [77, ] , 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]. 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, ]. 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].

Choice of anesthesia should be guided by maternal indications and the site and nature of the surgery. Standard maternal monitoring should be used. Fetal monitoring has not been shown to change outcome, but may help the anesthesiologist assess adequacy of uteroplacental perfusion. If the surgical site precludes continuous intraoperative fetal monitoring, monitoring should occur preoperatively and postoperatively to document fetal viability.

Use sequential compression devices on her legs. If ionizing radiation is needed for diagnostic studies, shield the fetus as much as possible. Benefits: Drug exposure is minimized unless heavy sedation is used, reducing concerns about teratogenicity in the first trimester and reducing anesthetic effects on fetal monitoring later in pregnancy. Regional techniques often provide the best postoperative pain control, allowing for early mobilization to reduce risk of thromboembolism.

Airway control is maintained, perhaps lessening risk of aspiration. If the mother is awake, it can be reassuring to her to hear the fetal heart rate on the monitor. The literature has shown a reduced or even absent risk of transient neurologic symptoms TNS in pregnancy associated with lidocaine spinal anesthesia, so this technique may be appropriate for short procedures.

The surgical procedure may not be appropriate for neuraxial blocks e. Issues: Aggressive prevention and treatment of hypotension is crucial. Maintain uterine displacement at all times. Use fluids to maintain normal preload and pressors to maintain normal blood pressure.

Ephedrine or phenylephrine should be chosen based on maternal heart rate. Benefits: Drug exposure is minimized, reducing concerns about teratogenicity in the first trimester and reducing anesthetic effects on fetal monitoring later in pregnancy, unless heavy sedation is used.

These techniques often provide the best postoperative pain control, allowing for early mobilization to reduce risk of thromboembolism. Peripheral blocks will not impact ambulation and urination to the same extent as neuraxial techniques. If the mother is awake during her surgery, it can be reassuring to her to hear the fetal heart rate on the monitor.

The surgical procedure may not be appropriate for peripheral nerve blocks. Benefits: The surgical procedure may require general anesthesia e. There is a small study showing that patients who received general anesthesia with volatile agents for abdominal surgery during pregnancy had a lower risk of preterm labor than those patients receiving regional anesthetics, although the rates in both anesthetic groups were still higher than the non-surgical group. The patient may prefer to be completely asleep during her procedure.

Drawbacks: Organogenesis occurs during first trimester, and that is when we are most concerned about exposure to potential teratogens. No anesthetics have been shown to be teratogenic, but the patient may be concerned and wish to avoid as much exposure as possible. While the implications are uncertain, fetal or newborn exposure to anesthetic agents both NMDA blockers and GABA agonists in animal studies results in widespread apoptotic neurodegeneration and persistent memory and learning impairments.

The relevance to human exposure is unclear, but the equivalent period in humans is from the third trimester of pregnancy to about 3 years of age. Other issues: If fetal monitoring is being used, loss of beat-to-beat variability is normal during general anesthesia or sedation.

Maintain blood pressure at near-baseline levels to prevent decreases in uterine perfusion. End-tidal CO2 should reflect an arterial CO2 that is normal for pregnancy — roughly 10 torr lower than non-pregnant patients. Hyperventilation should be avoided to prevent decreases in cardiac output and alkalosis that could shift the oxy-hemoglobin dissociation curve to the left, decreasing the release of oxygen at the placenta.

Airway concerns: Functional residual capacity is decreased during pregnancy, so full preoxygenation and denitrogenation should be used to prolong time to desaturation during laryngoscopy and intubation. Full stomach precautions and rapid sequence induction with cricoid pressure should reduce aspiration risk from a full stomach. Smaller endotracheal tubes should be available in case the airway is edematous. The risk of failed intubation is much higher in pregnancy, so have tools available for an unanticipated difficulty airway.

Drawbacks: Sedatives will reduce fetal heart rate variability if monitoring is being used. Avoid deep sedation because of full stomach concerns and risk of aspiration. Other Issues: Any sedative preferred by the anesthesiologist can be used: midazolam, propofol, ketamine, dexmedetomidine, or opioids.

The safest anesthetic that you would use for a non-pregnant patient having the same or similar procedure should be chosen, with modifications for the physiologic changes of pregnancy such as full stomach precautions and uterine displacement. The goals are maintaining maternal oxygenation and avoiding hypotension or decreases in cardiac output that would compromise uteroplacental perfusion.

No outcome data has shown regional or general anesthesia to be preferable. If the procedure could be done using either a regional or general anesthetic, I prefer to discuss those options with the patient and let her choose the technique she is most comfortable with, based on questions about exposure to medications, being awake during the procedure, postoperative pain management, ability to observe the fetal monitor, or other concerns.

She can be reassured that both techniques are routinely used for cesarean delivery and are safe for the fetus. What prophylactic antibiotics should be administered? The antibiotic will be chosen based on the type of surgery being performed, but all antibiotics are acceptable during pregnancy.

What do I need to know about the surgical technique to optimize my anesthetic care? Pelvic and intra-abdominal procedures will preclude the use of intraoperative fetal monitoring.

Uterine displacement should be maintained at all times in pregnancies in the second and third trimester. For laparoscopic techniques, open trocar placement may be preferred to avoid injury to the uterus, and the lowest possible insufflation pressure should be used.

What can I do intraoperatively to assist the surgeon and optimize patient care? This will depend on the specific surgical procedure. Prioritize them by urgency. The surgeon should be notified if there are decelerations on the fetal heart rate monitor, and the obstetric team should be consulted.

Maneuvers other than delivery that may improve uteroplacental perfusion and fetal oxygenation should be initiated. They may include increasing maternal FIO2, increasing maternal blood pressure, increasing left uterine displacement or trying displacement to the right, moving retractors away from the uterus, having the surgeons temporarily stop intra-abdominal manipulations, and administering a tocolytic such as nitroglycerin mcg or terbutaline 0.

Cardiac complications: Pregnant patients are at high risk for thromboembolic complications, and prophylaxis should include compression stockings at a minimum, with consideration of pharmacologic prophylaxis if the patient cannot be mobilized soon after surgery.

Bibliography ACOG. Commentaries Expert commentary This study provides reassuring information for women who need to undergo non-obstetric surgery during pregnancy. Essential surgery should not be postponed on the basis of these results. Categories Alerts Collections Themed Reviews. Follow us. Recent searches No recent searches found. Categories Glossary.

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These cookies do not store any personal information. All of these changes could result in fetal hypoxia [ 10 , 14 , 15 ]. The acidosis experienced in patients undergoing a carbon dioxide pneumoperitoneum could be potentiated in the fetus, leading to respiratory acidosis in the mother of the fetus [ 15 , 17 — 19 ]. Inadvertent uterine and fetal injury by Veress needle and primary trocar entry is another area of concern which renders the procedure risky, particularly in the third trimester.

The fetal and maternal risk factors are governed by the stage of the pregnancy. Risk of miscarriage is possibly due to disturbance to the corpusluteum as the developing pregnancy is hormonally dependent on it in the first trimester. Laparoscopic surgery in the third trimester carries increase risk of preterm labour and poses unique technical difficulties and maternal risks due to the extent of the space occupied by the gravid uterus.

Detail discussion of safety and technical aspects of operative laparoscopy in the third trimester is, however, beyond the scope of this article. Conversely, in the second trimester, the risk of miscarriage, teratogenesis and preterm labour are minimal and the gravid uterus does not create an obstruction [ 1 , 6 , 8 ]. For these reasons, the second trimester is considered the safest and most pragmatic time period for surgery in pregnant patients [ 5 , 13 , 16 , 22 ].

However, the absolute safety of laparoscopic surgery during pregnancy in humans is yet to be established as no controlled studies have been reported yet. In a retrospective case control study, Curet et al. There was no difference between laparotomy and laparoscopy outcomes.

Gouldman et al. Reedy et al. There was no difference in laparoscopy and laparotomy in the rate of malformation and cumulative infant survival rate. Mazze and Kallen [ 17 ] published the largest study involving 5, pregnant patients and found no increased incidence of still births or congenital anomalies in each trimester. Some suggested precautions to be taken during performing laparoscopy in pregnancy include close intra-operative fetal monitoring by transvaginal ultrasound, positioning the patient in the left lateral decubitus position to prevent aorto-caval compression and meticulous attention on air way management to circumvent the increased risk of aspiration due to raised intra-abdominal pressure.

A Hasson open laparoscopic technique seems prudent in order to prevent inadvertent puncture of the uterus especially in advanced gestations. The technique involves the introduction of primary trocar through a 2—3-cm long superficial incision after dissection of fascia and incision of the peritoneum and finally the pneumoperitoneum is secured with a purse string suture.

However, intraumbilical Veress technique to create pneumoperitoneum is feasible with sufficient care and the expertise as in our case Fig. It may be prudent to avoid intra-abdominal pressure rising beyond 15 mmHg which would pose technical difficulty in ventilating.

Maternal end tidal volume CO 2 should be monitored and kept within the normal range. Tocolytic agents need not be used prophylactically, but can be administered if the uterus starts contracting.

Should elective surgery be embarked upon, the second trimester seems the ideal time for the successful completion of laparoscopic surgery with the least risk of maternal and fetal adverse effects. Moreover, an experienced theatre team and appropriate equipment are a prerequisite to the safety and success of operative laparoscopy in pregnancy [ 1 , 2 , 3 , 7 — 9 , 13 , 22 ]. The second trimester is traditionally considered to be the optimal time for laparoscopic procedures.

The success and risk profile of laparoscopic surgery in pregnancy are skill-dependent. Proper precautions should be embarked on to obviate the maternal and fetal risks arising from the anaesthesia and surgical procedure. The evidence so far available, based on retrospective cohort studies and case reports, suggest that it is safe and beneficial for the mother and the fetus.

Nonetheless, absolute safety of laparoscopic surgery during pregnancy and the long-term effects have yet to be fully ascertained. Although randomised controlled studies are imperative to yield the answer to many of these clinical uncertainties, the feasibility is critically limited due to ethical reasons.

Arvidsson D, Gerdin E Laparoscopic cholecystectomy during pregnancy. Surg Lapafosc Endosc CAS Google Scholar. Obstet Gynecol Surg Laparosc Endosc