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Non-obstetric surgery in pregnancy (including bowel surgery and gallbladder surgery)
Journal Pre-proof Non-obstetric surgery in pregnancy (including bowel surgery and gallbladder surgery)
J. Arkenbosch, O. van Ruler, A.C. de Vries PII:
S1521-6918(20)30004-4
DOI:
https://doi.org/10.1016/j.bpg.2020.101669
Reference:
YBEGA 101669
To appear in:
Best Practice & Research Clinical Gastroenterology
Received Date:
03 February 2020
Accepted Date:
05 March 2020
Please cite this article as: J. Arkenbosch, O. van Ruler, A.C. de Vries, Non-obstetric surgery in pregnancy (including bowel surgery and gallbladder surgery), Best Practice & Research Clinical Gastroenterology (2020), https://doi.org/10.1016/j.bpg.2020.101669
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier.
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Best practice & Research Clinical Gastroenterology Volume 42C - Pregnancy in GI-disorders
Title: Non-obstetric surgery in pregnancy (including bowel surgery and gallbladder surgery)
Authors: Drs. J. Arkenbosch, PhD candidate, department of gastroenterology Erasmus Medical Center Address: Dr. Molewaterplein 40, room Na-618, 3015 GD Rotterdam E-mail: [email protected] Tel: +31 650033976
Dr. O. van Ruler (corresponding author), colorectal surgeon, department of surgery, IJsselland Hospital Address: Prins Constantijnweg 2, room M1-109, 2906 ZC Capelle aan den IJssel E-mail: [email protected] and [email protected]
Dr. A.C. de Vries, gastroenterologist, department of gastroenterology, Erasmus Medical Center Address: Dr. Molewaterplein 40, room NA-609, 3015 GD Rotterdam E-mail: [email protected]
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Abstract Abstract: Non-obstetric surgery during pregnancy is required in 0.75-2% of pregnancies. Physiologic changes during pregnancy, both hormonal and anatomic, can have interactions with surgery and anesthesia. Indication, timing as well as risks of anesthesia and surgery should be considered in surgical decision making. The health status of the mother should always be put first. A preoperative multidisciplinary approach, also including an obstetrician and neonatologist, is mandatory. Delay in diagnosis and treatment carry risks of complications in all septic visceral indications. Considerations should be individualized.
Introduction Surgery during pregnancy, not related to an obstetric indication, is required in 0.75 to 2% of pregnancies [1-3]. Approximately 42% of these operations are performed during the first trimester, 35% of operations during the second, and 23% during the third trimester [1]. Of all non-obstetric surgery performed during pregnancy, gastrointestinal procedures are most common, followed by trauma procedures, including bone fractures, and surgery for the indication of maternal malignancy. Appendectomy and cholecystectomy are the most common gastrointestinal procedures, which are performed in respectively 1 per 500-2000 and 1-8 per 10 000 pregnancies [4, 5]. Surgery during pregnancy requires specific considerations. Anesthetic and perioperative surgical care in pregnant women differs from non-pregnant women due to anatomical and physiological changes during pregnancy. Strict selection and timing should be taken into account when deciding on performing nonobstetric surgical procedures, considering the risks for both mother and child [6].
General principles in non-obstetric gastro-intestinal surgery Limited evidence is available to support specific guidelines in surgical management of pregnant women since (large-scale) randomized controlled trials are scarce [7, 8]. Nonetheless, pre-operative decision making is essential as maternal physiology and anatomy might have implications for both intraoperative maternal and fetal risks/ safety. Multidisciplinary consultation between obstetrics, surgeons, anesthesiologists and neonatologists, should precede non-obstetric surgery or other invasive procedures (e.g. colonoscopy) [7]. To ensure maternal and fetal safety, obstetricians and neonatologists should always be informed preoperatively and where necessary be involved once non-obstetric surgery is being performed in a pregnant patient.
Pre-operative patient selection and tailored surgery The decision whether and when a pregnant patient should undergo surgery, should be carefully weighed in each patient with assessment of the benefits and harms. Recent studies show that pregnant patients may undergo medically necessary (laparoscopic) procedures during any trimester with an acceptable increased maternal and/or fetal risk [9-11]; based on historic data a preference for the second trimester exists to avoid the risk of spontaneous abortion in the first trimester and preterm labor in the third trimester [12, 13]. Although elective surgery should be postponed until after gestation [9], postponing medically necessary surgery may increase the chance of maternal and fetal complications [11, 14]. As described more extensively further on, laparoscopic procedures have an advantage in outcome compared to open procedures.
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Physiological changes in pregnancy may impact surgery and anesthesia Physiologic changes during pregnancy occur due to hormonal and anatomic changes and can interact with surgery and anesthesia [15]. Signs and symptoms commonly present during pregnancy, such as tachypnea, dyspnea, heart murmurs and benign electro-cardiogram changes, might complicate anesthetic care of patients [15]. As modifications for anesthesia and surgery may be required during pregnancy, referral to a tertiary hospital might be considered. First of all, hemodynamic changes occur as cardiac output can increase up to twenty percent at the eighth week of gestation, and rise further up to 50 percent at week 32 after which it plateaus until the beginning of labor [16]. Cardiac output rises as a result of the following: an increase in preload due to a rise in blood volume; a decrease in afterload due to decreased vascular resistance; and an increase in maternal heart rate of 15 to 20 beats per minute [17]. Furthermore, cardiac output can decrease by 25 to 30 percent in supine position due to compression of the inferior vena cava by the gravid uterus resulting in a decreased venous return to the heart [16, 17]. Secondly, changes in the respiratory system occur which include a twenty percent increase in oxygen consumption [18, 19]. At twenty weeks of gestation, the elevated anatomical position of the diaphragm results in a twenty to thirty percent decrease in pulmonary functional residual capacity. Both contribute to decreased tolerance of apnea, e.g. during endotracheal intubation [20]. Presence of obesity or preeclampsia can magnify the risk of hypoxemia associated with the induction from general anesthesia [18]. However, progesterone stimulates and increases respiratory drive. In combination with increased tidal volume, this causes hyperventilation and a chronic respiratory alkalosis [18]. This state of respiratory alkalosis should be maintained during mechanical ventilation. Higher levels of maternal CO2 could potentially lead to acidosis and myocardial depression in the fetus; and severe alkalosis, caused by maternal hyperventilation, could reduce uterine blood flow and fetal oxygenation [21]. Airway changes can be present from the mid trimester onward and are most pronounced near the end of the pregnancy. These changes include swelling of oropharyngeal tissues and a decreased caliber of the glottic opening, which may lead to difficulty in ventilating and intubating the unconscious pregnant patient [15]. Even though a higher incidence of failed intubation during induction of anesthesia in pregnant women is debated, the encounter of difficult intubation and its consequences should be considered [15, 22]. The presence of other predisposing factors contributing to difficult intubation, such as weight gain and increased Mallampati airway score, should be taken into account [23, 24]. Furthermore, hematological changes can occur during pregnancy [25]. For instance, pregnant women can have a mild leukocytosis, in the absence of infection or inflammation, due to an excess in neutrophils [26]. Physiological leukocytosis during pregnancy can make accurate diagnosis of infection difficult. Also, hemodilution can occur due to an increase in plasma volume of up to 50 percent at week 32 and the total red blood cell count merely increases with 20 to 30 percent [27]. Normal gravid hemoglobin levels range from 6.5 to 6.8 mmol/L. An increase in circulating coagulation factors, reduced anticoagulant proteins, and reduced fibrinolysis activity result in a relatively hypercoagable state [28].
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Perioperative considerations To begin with, NSAIDS and opioids should be avoided as pain medication during pregnancy, whereas acetaminophen drugs are considered to be safe without teratogenic effects [29]. Other perioperative considerations, including thromboprophylaxis and fetal heart monitoring, are described below. Pregnancy and the puerperium are clear risk factors for venous thromboembolism (VTE), including deep venous thrombosis and pulmonary embolism [30]. VTE is one of the leading causes of maternal morbidity and mortality. Pregnant women are up to five times more likely to develop VTE compared to non-pregnant women [31]. The increased risk is caused by venous stasis of the lower extremities, endothelial damage and hypercoagulability [31, 32]. CO2 pneumoperitoneum, in combination with general anesthesia and muscle relaxation, can also contribute to the risk of VTE [33]. There is limited evidence on the use of thromboprophylaxis in pregnancies [30]. Recommendations on prophylactic treatment during surgery in pregnant patients are based on general principles for surgery [33]. The use of mechanical thromboprophylaxis (e.g. compression socks or sequential compression devices) is recommended intra- and postoperatively, as is early postoperative ambulation [33, 34]. Low molecular weight heparin is safe and efficacious as thromboprophylaxis in pregnant patients, administered in dosage following appropriate risk factor assessment [35]. All pregnant women with an indication for abdominal surgery should undergo risk assessment for VTE preoperatively, using a standardized risk assessment tool which includes assessment of both thrombosis and bleeding risks [36]. As described above, decreased cardiac output can result from the supine positioning of the pregnant patient during surgery, leading to maternal hypotension and fetal hypoperfusion during surgery [9, 37]. To reduce aortocaval compression, all patients over 18 to 20 weeks of gestation should be positioned in a 15 degree left lateral tilt in order to improve venous return and cardiac output. During the first trimester, the size of the uterus is still relatively small and does not likely reduce venous return [9]. Fetal heart monitoring is feasible from 18 to 22 weeks, and heart rate variability can be detected from 25 weeks [38]. The American College of Obstetrics and Gynecology Committee advices individualized, multidisciplinary decision-making on fetal heart monitoring for every patient based on factors such as gestational age, type of surgery, and available facilities [7]. Even though fetal acidosis has not been documented in human fetus, maternal CO2 monitoring is recommended due to potential harmful effects [33]. Several large studies have documented the safety and efficacy of end-tidal CO2 measurements in pregnant women making routine blood gas monitoring unnecessary [39].
Laparoscopic versus open procedures If abdominal surgery is indicated in a pregnant patient, the surgeon’s expertise, available staff and equipment determine the surgical approach used [9]. Historically, laparoscopy was considered hazardous and contraindicated in pregnant patients. However, more recent studies have shown that, as in non-pregnant patients, laparoscopy poses significant benefits over open procedures such as a decrease in postoperative pain, ileus, decreased length of hospital stay, and decreased risk of developing abdominal wall hernia [8, 39, 40].
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Laparoscopy during pregnancy is hampered due to alterations in the intra-abdominal anatomy during the second and third trimester [9]. In order to improve access safety and lower the risk of injury to the uterus or intra-abdominal organs, trocar placement should be adjusted to the increased size of the uterus [41]. The abdominal wall should be elevated during insertion [9]. Taking these considerations into account, both the open (or Hasson) technique and the Veress needle have been shown to be safe and effective opening techniques in pregnant patients [41]. Nonetheless, the Hasson technique is the preferred method of introduction as it is associated with less failed attempts and less complications [42]. Additional ultrasound guided trocar placement can attribute to a lower risk of uterine perforation [41]. In pregnant patients, laparoscopy leads to decreased maternal hypoventilation, a decreased risk of thromboembolic events, lower wound complication rates, and decreased occurrence of fetal respiratory depression subsequent to decreased narcotic needs [9]. Furthermore, laparoscopy offers a better visualization during surgery and lower uterine manipulation which might lower the risk of uterine irritability [43]. Therefore, despite anatomical changes which might complicate the procedure, laparoscopy is the preferred intended operative method in pregnant patients [8].
Conclusion Anesthetic and perioperative surgical care is different in pregnant women compared to non-pregnant women due to anatomical and physiological changes during pregnancy. Both the indication and urgency (timing) of surgery, as well as risks of anesthesia and surgery, should be taken into account when deciding on performing non-obstetric surgical procedures in pregnant women. In surgical decision making, the health status of the mother should always be put first. Preoperative multidisciplinary approach is mandatory.
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Gastrointestinal surgery during pregnancy Appendicitis Acute appendicitis is the most common cause of non-obstetric surgery during pregnancy [44, 45]. Quick and correct diagnosis of appendicitis is needed in pregnant patients, as non-perforated appendicitis can rapidly progress and cause complications. Perforation with local or even generalized abdominal sepsis is associated with high rates of early labor, miscarriage and fetal loss [46]. Diagnosis of appendicitis in pregnant patients can be challenging due to the physiological and anatomical changes induced by pregnancy [47, 48]. A correct diagnosis of appendicitis is made more often in the first trimester than in the second and last trimester as anatomical changes are still limited. Clinical symptoms of gastrointestinal complaints, abdominal pain and malaise are common in normal pregnancy [49]. Increased inflammatory markers during gestation limit the value of routine laboratory examination in pregnant patients [50]. Limitations in diagnostic imaging techniques can also contribute to a delay in diagnosis, as discussed in chapter 8 ‘Imaging in pregnancy (including fetal and maternal risks)’ [51]. Retrospective studies have shown laparoscopy for appendicitis in pregnancy to be safe and effective as preterm delivery rates are very low and fetal loss is rare [52]. Preferably, appendectomy is performed within 20 to 36 hours following onset of symptoms to reduce the risk of complications [53]. Early surgery for appendicitis reduces these risks, possibly at the cost of a small number of unnecessary operations [54, 55]. A negative appendectomy appears more harmful than previously assumed. One study found premature delivery and fetal loss up to 26% and 3-7.3% respectively, after negative laparoscopy for presumed acute appendicitis [46]. Antibiotic treatment can be an alternative treatment strategy in selected, non-pregnant patients [56]. However, antibiotic treatment poses an increased risk of maternal morbidity and fetal loss when progression to (perforated) appendicitis occurs, and has been associated with significantly higher rates of sepsis, septic shock, venous thromboembolism and peritonitis compared to appendectomy [9, 53]. On the other hand, a recent prospective observational study showed that antibiotics may be a meaningful treatment option for selected pregnant patients with uncomplicated appendicitis [57]. In this study maternal and fetal complications appeared to be limited and the need for surgery could be obviated in 75% of the patients [58]. However, more and larger studies are needed to change therapy recommendations. For now, appendectomy is the preferred treatment for pregnant patients with acute appendicitis based on the lower incidence of adverse events [13].
Cholelithiasis and cholecystitis Cholecystectomy for complications of cholelithiasis is the second most common operative procedure during pregnancy [59]. The incidence of cholecystectomy during pregnancy has been described to be up to 0.8% [60]. Pregnant women are at increased risk of cholelithiasis, which is probably multifactorial. The increased levels of estrogen and progesterone during gestation may cause biliary stasis [61]. Furthermore, elevated levels of progesterone cause smooth muscle relaxation of the gallbladder, which leads to reduced gallbladder emptying. Estrogen contributes to increased cholesterol secretion and bile saturation. Biliary stasis, in combination with decreased gallbladder motility, can increase gallstone formation [62]. Most patients with cholelithiasis will remain asymptomatic during pregnancy and
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gallstones can be found incidentally during routine ultrasound examinations. A proportion of pregnant patients will develop gallstone related complications [33]. Symptomatic cholelithiasis affects 0.2-2% of pregnant women, with an increase in occurrence in women with pre-pregnancy obesity or increased parity [33]. Patient with uncomplicated, symptomatic cholelithiasis were previously treated with conservative management including intravenous hydration, electrolyte correction and bowel rest [63]. However, non-surgical management of symptomatic cholelithiasis poses a high risk of recurrence of symptoms. If biliary disease remains uncomplicated, rates of preterm labor and spontaneous abortion do not differ between non-operative and operative management [13]. Also, laparoscopic cholecystectomy is found to have low maternal and fetal risks and is the optimal treatment for symptomatic gallbladder disease, regardless of the trimester [33]. Therefore, to date early surgical management is advised as recurrence of symptoms can lead to more hospitalizations in 50% of patients with unrelenting recurrent gallbladder symptoms but also to progression to complicated biliary disease compared to patients who undergo cholecystectomy [64, 65]. Complications associated with choledocholithiasis include acute cholecystitis, cholangitis, and gallstone pancreatitis [66]. Although they are relatively uncommon during pregnancy (incidence of 0.05-0.8%), these complications pose a significant risk of morbidity and mortality if not adequately treated [9]. Complications can result in preterm labor in up to 20% of cases and fetal loss. Cholangitis in particular poses a 10 percent risk of spontaneous abortion. Treatment strategies including surgical procedures and conservative treatment have their own risks and restrictions in pregnancy [67]. Endoscopic retrograde cholangiopancreatography (ERCP) is safe and effective for choledocholithiasis and indications include complicated choledocholithiasis. [33]. Fetal radiation exposure during ERCP should be minimized by applying techniques such as lead shielding and minimization of radiation dosage [13]. Taking into account that patient selection should be tailored, choledocholithiasis can be treated by preoperative ERCP with sphincterotomy followed by laparoscopic cholecystectomy or in only a selected subpopulation with laparoscopic common bile duct exploration [68]. Due to the possibilities of performing ERCP and cholecystectomy during pregnancy, maternal mortality rates have dropped to less than 1%. Laparoscopic cholecystectomy after ERCP with sphincterotomy is safe in pregnant woman [9]. Both laparoscopic cholecystectomy and ERCP decrease the incidence of postpartum biliary symptoms compared to conservative management in patients with complicated gallstone disease [69]. Cholangitis is associated with higher rates fetal risks, including preterm labor and spontaneous abortion. Cholangitis is initially treated by non-surgical interventions including hospitalization, intravenous fluids, analgesia and bowel rest [65]. Overall, pregnant patients with cholangitis are treated similar to nonpregnant patients [67]. Stone extraction for cholangitis can be achieved safely by ERCP with fetal shielding [70]. Intraoperative common bile duct exploration is an uncommon procedure requiring specialized surgical skills, and has been reported only in few cases but with good fetal and maternal outcomes [68]. Acute biliary pancreatitis is associated with increased morbidity and mortality as well as higher rates of fetal loss [71]. Patients with biliary pancreatitis are initially treated conservatively, and according to general guidelines. ERCP with sphincterotomy and stone extraction is indicated in cases
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with concomitant cholangitis. After recovery of acute biliary pancreatitis, early cholecystectomy (during the same hospital admission) should be considered [72]. Pancreatitis during pregnancy can be successfully managed with conservative treatment as it usually has a mild to moderate clinical course [73]. Supportive treatment includes hospitalization, bowel rest, intravenous fluid administration, analgesia and later enteral nutrition. In case of very severe pancreatitis, surgical intervention could be indicated as this carries high mortality risk for both mother and child [74].
Conclusion Laparoscopic appendectomy is the preferred treatment for acute appendicitis, as is laparoscopic cholecystectomy for acute cholecystitis. Both delay in diagnosis and treatment possess the risk of complications in both appendicitis and cholecystitis. Complications such as cholangitis and pancreatitis are aimed to be treated non-surgically.
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Surgery in Inflammatory bowel disease (IBD) Introduction Crohn’s Disease (CD) and ulcerative colitis (UC) are often diagnosed during reproductive years. Female patients are advised to conceive at a time of IBD remission, as active disease during pregnancy is associated with increased risks of preterm birth and low birth weight [75]. In general, maintenance treatment is continued in patients who wish to conceive, in order to reduce the risk of flares during pregnancy. Most medical options for IBD are considered to be of low risk during pregnancy with regard to fetal outcome. Surgery may be considered for severe therapy refractory cases or complications of IBD during pregnancy [76].
Fertility after IBD surgery Subfertility is probably increased after pouch surgery amongst women with IBD. Adhesions after surgery could possibly lead to subfertility. The rates of postoperative adhesions have improved due to a rise in laparoscopic procedures compared to open surgery; even more so in pouch surgery [77]. However, available guidelines do not recommend subtotal colectomy with rectal stump and ileostomy during the childbearing years followed by pouch surgery later in life to help reduce infertility as there is no data to support this treatment strategy. Relative rare ileostomy complications such as obstruction or stomarelated problems, could arise during pregnancy [75]. Male IBD patients may experience retrograde ejaculation and erectile dysfunction after pouch surgery due to nerve damage. However, a direct association between pouch surgery and subfertility has not been reported in male patients [75].
Mode of delivery Decisions on mode of delivery should be based on obstetric indications taking postpartum pelvic floor impairment with respect to present and future bowel function into account [78]. Vaginal delivery has been proven to be safe for most IBD patients with mild or quiescent disease [79, 80]. International guidelines identify active perianal disease or active disease with rectal involvement as indications for cesarean section [78, 81]. Ileal pouch-anal anastomosis is considered a relative indication for cesarean section [82].
Surgery for IBD during pregnancy The literature on IBD surgery during pregnancy is rather scarce. The indications for surgery may be evident in pregnant patients with severe complications of IBD, such as perforation or ileus. However, in cases of therapy refractory disease the decision to perform an intestinal resection during pregnancy are less straight forward. Also, in IBD surgery the combination of anatomical, physiological and immunological changes during pregnancy are important drawbacks [83]. Studies published before 1980 showed an increased risk of miscarriage in the first trimester. Also, high fetal mortality in UC patients with septic complications undergoing colectomy, has been described in these studies [84]. However, due to advances in medical IBD, perioperative and neonatal care as well as preconception counseling have probably led to a reduction of current maternal and fetal outcome, in which a close collaboration of involved disciplines seems of paramount importance [83]. Hospitalization for resuscitation and fetal monitoring is required in (acute) severe UC and therapy refractory cases, as the risk of complications is high in these cases [85]. In therapy refractory UC during 9
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pregnancy, surgery should be considered timely to avoid complications such as transfusion-dependent anemia, perforation with intra-abdominal sepsis and toxic colitis [86]. These complications pose a high risk of fetal and maternal morbidity and even mortality urging immediate surgical intervention [87, 88]. An obstetrician and surgeon experienced with IBD surgery should be consulted [89]. Consultation by a stoma therapist prior to surgery is advised. The optimal location for a stoma is usually higher on the abdominal wall in pregnant women, as the stoma will descend to a lower position after delivery [89]. Subtotal colectomy with end-ileostomy, is recommended for all severely ill pregnant UC patients with an indication for surgery [83]. Prevention of dehiscence of a closed stump due to dilatation of the rectal stump as a result of compression of the enlarged uterus is essential. Strategies to prevent this “blowout” include insertion of a rectal drain, daily digital rectal examination (during first days postoperatively), and double stapling and oversewing of the stump [83, 89]. Proctocolectomy is contraindicated during pregnancy, as this complex operation requires pelvic dissection. Pelvic dissection is difficult because of uterine enlargement and dilated pelvic vessels. Reported cases have described premature delivery in all cases after colectomy in the third trimester as manipulation of the late gravid uterus can precipitate premature delivery. A synchronous cesarean section and colectomy may be considered in these cases [90, 91].
Ostomy and pregnancy Ileostomy has been described as the most prevalent type of ostomy in pregnant patients [92, 93]. IBD patients with an ostomy, without disease activity, are expected to encounter a normal pregnancy and delivery [93]. Complications of an ostomy in pregnant patients include stoma pouching problems, alterations in stoma size and abdominal contours, bleeding, retraction, prolapse, stenosis, laceration and bowel obstruction [92, 94]. Ileostomy/small bowel obstruction is a rare complication and leads to increased maternal and fetal morbidity and mortality if not timely and adequately treated. Maternal complications include bowel perforation, hypovolemic shock and sepsis, while perinatal complications include prematurity, low gestational weight, stillbirths and perinatal death due to fetal hypoxia [95, 96]. MRI could distinguish between obstruction caused by abdominal adhesions, CD activity or compression by enlargement of the gravid uterus [97]. Treatment strategies include conservative treatment, mostly when the obstruction is caused by the gravid uterus, and laparotomy; exclusive enteral nutrition (EEN) is recommended in case of active CD disease and stenosis [97]. Cesarean section in patients with ostomy is only indicated in case of obstetrical indications [92, 93].
Conclusion IBD patients are advised to conceive during quiescent disease. If medical therapy fails during pregnancy, timing and indication for surgery can be challenging. A proctectomy should be avoided during pregnancy. Ostomy during pregnancy can give complications such as alterations in stoma size and abdominal contours, bleeding, retraction, prolapse, stenosis, laceration and bowel obstruction, but does not influence gestation and delivery. In patients with mild or quiescent IBD, vaginal delivery has been proven to be safe for. Active perianal disease, active disease with rectal involvement (and ileal pouch-anal anastomosis) are considered (relative) indications for cesarean section. 10
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Summary Surgery during pregnancy, not related to an obstetric indication, is required in 0.75 to 2% of pregnancies. Gastrointestinal procedures are most common, of which appendectomy and cholecystectomy are the most prevalent procedures performed. Physiologic changes during pregnancy occur due to hormonal and anatomic changes and can interact with surgery and anesthesia in important ways. Both the indication and timing of surgery, as well as risks of anesthesia and surgery on fetus and mother, should be considered when deciding on performing non-obstetric surgical procedures in pregnant women. In surgical decision making, the health status of the mother should always be put first. A preoperative multidisciplinary approach, also including an obstetrician and pediatrician, is mandatory. Considering whether surgery is necessary and feasible should be discussed for every individual patient. Laparoscopic appendectomy is the preferred treatment for acute appendicitis, as is laparoscopic cholecystectomy for cholelithiasis related complications. Delay in diagnosis and treatment carry risks of septic complications in both appendicitis and cholelithiasis related complications leading to increased risks for mother and child. Stone extraction for cholangitis can be achieved safely by ERCP, followed by cholecystectomy. During ERCP, measurements to minimize fetal radiation dosage should be taken, including fetal shielding and reduction of used dosage. After resolution of acute biliary pancreatitis with conservative treatment with fluid resuscitation and pain medication, a cholecystectomy is indicated during the same hospital admission. Patients with IBD are advised to conceive during quiescent disease. If medical therapy fails during pregnancy, timing and indication for surgery can be challenging. Several surgical interventions have been described in pregnant IBD patients, but decision making should be tailored to patient specific characteristics. Proctectomy should be avoided. Ostomy during pregnancy can cause a range of complications, but does not influence gestation and delivery.
Abstract Non-obstetric surgery during pregnancy is required in 0.75-2% of pregnancies. Physiologic changes during pregnancy, both hormonal and anatomic, can have interactions with surgery and anesthesia. Indication, timing as well as risks of anesthesia and surgery should be considered in surgical decision making. The health status of the mother should always be put first. A preoperative multidisciplinary approach, also including an obstetrician and neonatologist, is mandatory. Delay in diagnosis and treatment carry risks of complications in all septic visceral indications. Considerations should be individualized.
Key words Non-obstetric, gastrointestinal, surgery, pregnancy, appendectomy, cholecystectomy, IBD, laparoscopy, laparotomy
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Recommendations for surgery in pregnancy General remarks -
In surgical decision making, the health status of the mother should always be put first. Preoperative multidisciplinary approach is mandatory as anesthesia, surgery but also the decision to postpone surgery might have implications for both maternal and fetal risks / safety.
Anesthetic and perioperative surgical care -
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Indication and timing of surgery, as well as risks of anesthesia and surgery, should be taken into account when deciding on performing non-obstetric surgical procedures in pregnant women. Laparoscopy is the preferred intended operative method in all pregnant patients, despite anatomical changes, which might complicate the procedure; based on the lower incidence of adverse events. Perioperative considerations for the pregnant patient include correct positioning, nonteratogenic analgesics, risk assessment for venous thromboembolism and fetal monitoring.
Appendectomy -
Diagnosis of appendicitis in pregnant patients can be challenging due to the physiological and anatomical changes induced by pregnancy. Perforation with generalized or even local abdominal sepsis is associated with high rates of early labor, miscarriage and fetal loss. Preferably, appendectomy is performed within 20 to 36 hours following onset of symptoms to reduce the risk of complications.
Cholecystectomy -
Pregnant women are at increased risk of cholelithiasis, of which the etiology is multifactorial. Early surgical management is advised as recurrence of symptoms can lead to more hospitalizations and progression to complicated biliary disease. Complications such as cholangitis and pancreatitis are aimed to be treated non-surgically.
Inflammatory bowel disease -
IBD patients are advised to conceive during quiescent disease. Proctectomy should be avoided during pregnancy. Ostomy during pregnancy can give mechanical complications but does not influence gestation or delivery. In patients with mild or quiescent IBD, vaginal delivery has been proven to be safe for. Active perianal disease, active disease with rectal involvement (and ileal pouch-anal anastomosis) are considered (relative) indications for cesarean section.
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Practice points
In surgical decision making, the health status of the mother should always be put first.
Physiologic changes during pregnancy can interact with surgery and anesthesia in important ways. Indication and timing of surgery, as well as risks of anesthesia and surgery, should be considered when deciding on performing non-obstetric surgical procedures in pregnant women.
Preoperative multidisciplinary approach, also including an obstetrician, is mandatory.
Laparoscopic appendectomy is the preferred treatment for acute appendicitis, as is laparoscopic cholecystectomy for acute cholecystitis. Delay in both diagnosis and treatment of appendicitis and cholecystitis possesses the risk of complications for both mother and child.
Patients with IBD are advised to conceive during quiescent disease.
Decisions on surgical treatment in refractory IBD during pregnancy should be tailor-made.
Research agenda
Given the paucity of on current management (including timing) and outcome of surgery during pregnancy, data registration of surgery during pregnancy may provide important clues to improve management
Acknowledgements Role of funding source: none. Conflict of interest: none.
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Literature 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22.
Mazze, R.I. and B. Kallen, Reproductive outcome after anesthesia and operation during pregnancy: a registry study of 5405 cases. Am J Obstet Gynecol, 1989. 161(5): p. 1178-85. Ni Mhuireachtaigh, R. and D.A. O'Gorman, Anesthesia in pregnant patients for nonobstetric surgery. J Clin Anesth, 2006. 18(1): p. 60-6. Goodman, S., Anesthesia for nonobstetric surgery in the pregnant patient. Semin Perinatol, 2002. 26(2): p. 136-145. Augustin, G. and M. Majerovic, Non-obstetrical acute abdomen during pregnancy. Eur J Obstet Gynecol Reprod Biol, 2007. 131(1): p. 4-12. El-Messidi, A., et al., Evaluation of management and surgical outcomes in pregnancies complicated by acute cholecystitis. J Perinat Med, 2018. 46(9): p. 998-1003. Kwon, H., et al., Laparoscopic management is feasible for nonobstetric surgical disease in all trimesters of pregnancy. Surg Endosc, 2018. 32(6): p. 2643-2649. ACOG Committee Opinion No. 775 Summary: Nonobstetric Surgery During Pregnancy. Obstet Gynecol, 2019. 133(4): p. 844-845. Ball, E., et al., Evidence-Based Guideline on Laparoscopy in Pregnancy: Commissioned by the British Society for Gynaecological Endoscopy (BSGE) Endorsed by the Royal College of Obstetricians & Gynaecologists (RCOG). Facts Views Vis Obgyn, 2019. 11(1): p. 5-25. Jonathan P Pearl, R.R.P., Allison E Tonkin, William S Richardson, Dimitrios Stefanidis, SAGES Guidelines for the Use of Laparoscopy during Pregnancy. 2017. Glasgow, R.E., et al., Changing management of gallstone disease during pregnancy. Surg Endosc, 1998. 12(3): p. 241-246. Muench, J., et al., Delay in treatment of biliary disease during pregnancy increases morbidity and can be avoided with safe laparoscopic cholecystectomy. Am Surg, 2001. 67(6): p. 539-542; discussion 542-543. Saunders, P. and P.J.D. Milton, Laparotomy during pregnancy: an assessment of diagnostic accuracy and fetal wastage. Br Med J, 1973. Pearl, J.P., et al., SAGES guidelines for the use of laparoscopy during pregnancy. 2017. 31(10): p. 3767-3782. Visser, B.C., et al., Safety and timing of nonobstetric abdominal surgery in pregnancy. Dig Surg, 2001. 18(5): p. 409-417. Cheek, T.G. and E. Baird, Anesthesia for nonobstetric surgery: maternal and fetal considerations. Clin Obstet Gynecol, 2009. 52(4): p. 535-45. Meah, V.L., et al., Cardiac output and related haemodynamics during pregnancy: a series of meta-analyses. Heart, 2016. 102(7): p. 518-26. Chapman, A.B., et al., Temporal relationships between hormonal and hemodynamic changes in early human pregnancy. Kidney Int, 1998. 54(6): p. 2056-63. Hegewald, M.J. and R.O. Crapo, Respiratory physiology in pregnancy. Clin Chest Med, 2011. 32(1): p. 1-13. LoMauro, A. and A. Aliverti, Respiratory physiology of pregnancy: Physiology masterclass. Breathe (Sheff), 2015. 11(4): p. 297-301. McAuliffe, F., et al., Respiratory function in singleton and twin pregnancy. BJOG, 2002. 109(7): p. 765-9. Levinson, G., et al., Effects of maternal hyperventilation on uterine blood flow and fetal oxygenation and acid-base status. Anesthesiology, 1974. 40(4): p. 340-7. Matthew Rucklidge, C.H., Difficult and failed intubation in obstetrics. Continuing Education in Anaesthesia Critical Care & Pain, 2012. 12(4): p. 218. 14
Journal Pre-proof
23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44.
Pilkington, S., et al., Increase in Mallampati score during pregnancy. Br J Anaesth, 1995. 74(6): p. 638-42. Ahuja, P., et al., Airway changes following labor and delivery in preeclamptic parturients: a prospective case control study. Int J Obstet Anesth, 2018. 33: p. 17-22. de Haas, S., et al., Physiological adaptation of maternal plasma volume during pregnancy: a systematic review and meta-analysis. Ultrasound Obstet Gynecol, 2017. 49(2): p. 177-187. Kuvin, S.F. and G. Brecher, Differential neutrophil counts in pregnancy. N Engl J Med, 1962. 266: p. 877-8. Bernstein, I.M., W. Ziegler, and G.J. Badger, Plasma volume expansion in early pregnancy. Obstet Gynecol, 2001. 97(5 Pt 1): p. 669-72. Nijkeuter, M., J.S. Ginsberg, and M.V. Huisman, Diagnosis of deep vein thrombosis and pulmonary embolism in pregnancy: a systematic review. J Thromb Haemost, 2006. 4(3): p. 496500. Li, D.K., et al., Use of nonsteroidal antiinflammatory drugs during pregnancy and the risk of miscarriage. Am J Obstet Gynecol, 2018. 219(3): p. 275 e1-275 e8. Marik, P.E. and L.A. Plante, Venous thromboembolic disease and pregnancy. N Engl J Med, 2008. 359(19): p. 2025-33. James, A.H., et al., Venous thromboembolism during pregnancy and the postpartum period: incidence, risk factors, and mortality. Am J Obstet Gynecol, 2006. 194(5): p. 1311-5. Sobolewski, A.P., et al., Venous hemodynamic changes during laparoscopic cholecystectomy. J Laparoendosc Surg, 1995. 5(6): p. 363-9. Soper, N.J., SAGES' guidelines for diagnosis, treatment, and use of laparoscopy for surgical problems during pregnancy. Surg Endosc, 2011. 25(11): p. 3477-8. Guimicheva, B., J. Czuprynska, and R. Arya, The prevention of pregnancy-related venous thromboembolism. Br J Haematol, 2015. 168(2): p. 163-74. Crowley, M.P., et al., A Multicentre Study of Thromboprophylaxis in Pregnancy. Ir Med J, 2017. 110(5): p. 567. RCOG Green-top Guideline No. 37b. Thromboembolic Disease in Pregnancy and the Puerperium: Acute Management. Royal College of Obstetricians and Gynaecologists 2015. Clark, S.L., et al., Position change and central hemodynamic profile during normal third-trimester pregnancy and post partum. Am J Obstet Gynecol, 1991. 164(3): p. 883-7. Reitman, E. and P. Flood, Anaesthetic considerations for non-obstetric surgery during pregnancy. Br J Anaesth, 2011. 107 Suppl 1: p. i72-8. Reedy, M.B., B. Kallen, and T.J. Kuehl, Laparoscopy during pregnancy: a study of five fetal outcome parameters with use of the Swedish Health Registry. Am J Obstet Gynecol, 1997. 177(3): p. 673-9. Oelsner, G., et al., Pregnancy outcome after laparoscopy or laparotomy in pregnancy. J Am Assoc Gynecol Laparosc, 2003. 10(2): p. 200-4. Huang, K.G., A.A. Chua, and C.L. Lee, Surgical trocar insertion among pregnant patients. Int J Gynecol Cancer, 2014. 24(6): p. 965-6. Cornette, B. and F. Berrevoet, Trocar Injuries in Laparoscopy: Techniques, Tools, and Means for Prevention. A Systematic Review of the Literature. World J Surg, 2016. 40(10): p. 2331-41. Soriano, D., et al., Laparoscopy versus laparotomy in the management of adnexal masses during pregnancy. Fertil Steril, 1999. 71(5): p. 955-60. Prodromidou, A., et al., Outcomes after open and laparoscopic appendectomy during pregnancy: A meta-analysis. Eur J Obstet Gynecol Reprod Biol, 2018. 225: p. 40-50.
15
Journal Pre-proof
45. 46. 47. 48. 49. 50. 51. 52. 53. 54. 55. 56. 57. 58. 59. 60. 61. 62. 63. 64. 65. 66. 67.
Wilasrusmee, C., et al., Systematic review and meta-analysis of safety of laparoscopic versus open appendicectomy for suspected appendicitis in pregnancy. Br J Surg, 2012. 99(11): p. 14701478. Aggenbach, L., et al., Impact of appendicitis during pregnancy: no delay in accurate diagnosis and treatment. Int J Surg, 2015. 15: p. 84-9. Theilen, L.H., et al., Acute Appendicitis in Pregnancy: Predictive Clinical Factors and Pregnancy Outcomes. Am J Perinatol, 2017. 34(6): p. 523-528. Drake, F.T., et al., Single institution and statewide performance of ultrasound in diagnosing appendicitis in pregnancy. J Matern Fetal Neonatal Med, 2015. 28(6): p. 727-33. Kosai, N.R., et al., Pregnant and severe acute abdominal pain: A surgical diagnostic dilemma. Clin Ter, 2015. 166(3): p. 110-113. Yazar, F.M., et al., Predictive role of neutrophil-to-lymphocyte and platelet-to-lymphocyte ratios for diagnosis of acute appendicitis during pregnancy. Kaohsiung J Med Sci, 2015. 31(11): p. 591596. Kulvatunyou, N., et al., Risk Factors for Perforated Appendicitis in the Acute Care Surgery EraMinimizing the Patient's Delayed Presentation Factor. J Surg Res, 2019. 238: p. 113-118. Cheng, H.T., et al., Laparoscopic appendectomy versus open appendectomy in pregnancy: a population-based analysis of maternal outcome. Surg Endosc, 2015. 29(6): p. 1394-9. Lemieux, P., et al., Laparoscopic appendectomy in pregnant patients: a review of 45 cases. Surg Endosc, 2009. 23(8): p. 1701-5. Yilmaz, H.G., et al., Acute appendicitis in pregnancy--risk factors associated with principal outcomes: a case control study. Int J Surg, 2007. 5(3): p. 192-7. Ito, K., et al., Appendectomy in pregnancy: Evaluation of the risks of a negative appendectomy. Am J Surg, 2012. 203(2): p. 145-150. Salminen, P., et al., Five-Year Follow-up of Antibiotic Therapy for Uncomplicated Acute Appendicitis in the APPAC Randomized Clinical Trial. JAMA, 2018. 320(12): p. 1259-1265. Yefet, E., et al., Successful treatment of acute uncomplicated appendicitis in pregnancy with intravenous antibiotics. Eur J Obstet Gynecol Reprod Biol, 2013. 169(1): p. 121-122. Joo, J.I., et al., Outcomes of Antibiotic Therapy for Uncomplicated Appendicitis in Pregnancy. Am J Med, 2017. 130(12): p. 1467-1469. Ghumman, E., M. Barry, and P.A. Grace, Management of gallstones in pregnancy. BR J SURG, 1997. 84(12): p. 1646-1650. Kuy, S., et al., Outcomes following cholecystectomy in pregnant and nonpregnant women. Surgery, 2009. 146(2): p. 358-66. Al-Akeely, M.H., Management of complicated gallstone disease during pregnancy. Saudi J Gastroenterol, 2003. 9(3): p. 135-8. Nakeeb, A., et al., Gallstones: genetics versus environment. Ann Surg, 2002. 235(6): p. 842-9. Ibiebele, I., et al., Outcomes of Gallstone Disease during Pregnancy: a Population-based Data Linkage Study. Paediatr Perinat Epidemiol, 2017. 31(6): p. 522-530. Gilbert, A., V. Patenaude, and H.A. Abenhaim, Acute pancreatitis in pregnancy: A comparison of associated conditions, treatments and complications. J Perinat Med, 2014. 42(5): p. 565-570. Jorge, A.M., et al., Non-operative management of symptomatic cholelithiasis in pregnancy is associated with frequent hospitalizations. J Gastrointest Surg, 2015. 19(4): p. 598-603. Ko, C.W., Risk factors for gallstone-related hospitalization during pregnancy and the postpartum. Am J Gastroenterol, 2006. 101(10): p. 2263-2268. İlhan, M., et al., The course and outcomes of complicated gallstone disease in pregnancy: Experience of a tertiary center. Turk Jinekoloji Obstet Dernegi Derg, 2016. 13(4): p. 178-182. 16
Journal Pre-proof
68. 69. 70. 71. 72. 73. 74. 75. 76. 77. 78. 79. 80. 81. 82. 83. 84. 85. 86. 87.
Tuech, J.J., et al., Management of choledocholithiasis during pregnancy by magnetic resonance cholangiography and laparoscopic common bile duct stone extraction. Surg Laparosc Endosc Percutan Tech, 2000. 10(5): p. 323-5. Veerappan, A., et al., Delaying Cholecystectomy for Complicated Gallstone Disease in Pregnancy is Associated with Recurrent Postpartum Symptoms. J Gastrointest Surg, 2013. 17(11): p. 19531959. Magno-Pereira, V., P. Moutinho-Ribeiro, and G. Macedo, Demystifying endoscopic retrograde cholangiopancreatography (ERCP) during pregnancy. Eur J Obstet Gynecol Reprod Biol, 2017. 219: p. 35-39. Othman, M.O., et al., Conservative management of cholelithiasis and its complications in pregnancy is associated with recurrent symptoms and more emergency department visits. Gastrointest Endosc, 2012. 76(3): p. 564-569. Juo, Y.Y., et al., Cumulative financial burden of readmissions for biliary pancreatitis in pregnant women. Obstet Gynecol, 2018. 132(2): p. 415-422. Hot, S., et al., Acute biliary pancreatitis during pregnancy and in the post-delivery period. Ulusal Travma Acil Cerrahi Derg, 2019. 25(3): p. 253-258. Mali, P., Pancreatitis in pregnancy: etiology, diagnosis, treatment, and outcomes. Hepatobiliary Pancreatic Dis Int, 2016. 15(4): p. 434-438. De Lima-Karagiannis, A., Z. Zelinkova-Detkova, and C.J. Van Der Woude, The Effects of Active IBD During Pregnancy in the Era of Novel IBD Therapies. Am J Gastroenterol, 2016. 111(9): p. 13051312. van der Woude, C.J., et al., European evidenced-based consensus on reproduction in inflammatory bowel disease. J Crohn's Colitis, 2010. 4(5): p. 493-510. Hull, T.L., et al., Adhesions after laparoscopic and open ileal pouch-anal anastomosis surgery for ulcerative colitis. Br J Surg, 2012. 99(2): p. 270-5. van der Woude, C.J., et al., The second European evidenced-based consensus on reproduction and pregnancy in inflammatory bowel disease. J Crohns Colitis, 2015. 9(2): p. 107-24. Nguyen, G.C., et al., Outcomes of obstetric hospitalizations among women with inflammatory bowel disease in the United States. Clin Gastroenterol Hepatol, 2009. 7(3): p. 329-34. Ananthakrishnan, A.N., et al., Mode of childbirth and long-term outcomes in women with inflammatory bowel diseases. Dig Dis Sci, 2015. 60(2): p. 471-477. Nguyen, G.C., et al., The Toronto Consensus Statements for the Management of Inflammatory Bowel Disease in Pregnancy. Gastroenterology, 2016. 150(3): p. 734-757 e1. Hahnloser, D., et al., Pregnancy and delivery before and after ileal pouch-anal anastomosis for inflammatory bowel disease: Immediate and long-term consequences and outcomes. Dis Colon Rectum, 2004. 47(7): p. 1127-1135. Killeen, S., J. Gunn, and J. Hartley, Surgical management of complicated and medically refractory inflammatory bowel disease during pregnancy. Colorectal Dis, 2017. 19(2): p. 123-138. Flatmark, A.L., A. Nordöy, and E. Gjone, Radical surgery for ulcerative colitis during pregnancy. Scand J Gastroenterol, 1971. 6(1): p. 45-47. Selinger, C.P., R.W. Leong, and S. Lal, Pregnancy related issues in inflammatory bowel disease: evidence base and patients' perspective. World J Gastroenterol, 2012. 18(21): p. 2600-8. Mogadam, M., et al., The course of inflammatory bowel disease during pregnancy and postpartum. Am J Gastroenterol, 1981. 75(4): p. 265-9. Anderson, J.B., G.M. Turner, and R.C.N. Williamson, Fulminant ulcerative colitis in late pregnancy and the puerperium. J R SOC MED, 1987. 80(8): p. 492-494.
17
Journal Pre-proof
88. 89. 90. 91. 92. 93. 94. 95. 96. 97.
Kashkooli, S.B., et al., Inflammatory bowel disease-specific pregnancy knowledge of gastroenterologists against general practitioners and obstetricians. United European Gastroenterol J, 2015. 3(5): p. 462-70. Dozois, E.J., et al., Maternal and fetal outcome after colectomy for fulminant ulcerative colitis during pregnancy: case series and literature review. Dis Colon Rectum, 2006. 49(1): p. 64-73. Toiyama, Y., et al., Fulminant ulcerative colitis during pregnancy successfully treated by threestage operation. J Gastroenterol, 2004. 39(3): p. 300-1. Parker, A.R., N. Baker, and D. Maxwell, A modification of the surgical indications for the treatment of ulcerative colitis during pregnancy. Am Surg, 2011. 77(12): p. E281-3. Sredl, D. and V. Aukamp, Evidence-based nursing care management for the pregnant woman with an ostomy. J Wound Ostomy Continence Nurs, 2006. 33(1): p. 42-9; quiz 50-1. Ojerskog, B., et al., Pregnancy and delivery in patients with a continent ileostomy. SURG GYNECOL OBSTET, 1988. 167(1): p. 61-64. Spring, A., et al., Ileostomy obstruction in the third trimester of pregnancy. Colorectal Dis, 2012. 14(9): p. e631-2. Rauff, S., S.K. Chang, and E.K. Tan, Intestinal obstruction in pregnancy: a case report. Case Rep Obstet Gynecol, 2013. 2013: p. 564838. Sagi, Y., et al., Small Bowel Obstruction in Pregnancy: A Systematic Review [32F]. Obstetrics & Gynecology, 2018. 131: p. 72S. Porter, H. and S. Seeho, Obstructed ileostomy in the third trimester of pregnancy due to compression from the gravid uterus: diagnosis and management. BMJ Case Rep, 2014. 2014.
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Recommendations for surgery in pregnancy General remarks -
In surgical decision making, the health status of the mother should always be put first. Preoperative multidisciplinary approach is mandatory as anesthesia, surgery but also the decision to postpone surgery might have implications for both maternal and fetal risks / safety.
Anesthetic and perioperative surgical care -
-
Indication and timing of surgery, as well as risks of anesthesia and surgery, should be taken into account when deciding on performing non-obstetric surgical procedures in pregnant women. Laparoscopy is the preferred intended operative method in all pregnant patients, despite anatomical changes, which might complicate the procedure; based on the lower incidence of adverse events. Perioperative considerations for the pregnant patient include correct positioning, nonteratogenic analgesics, risk assessment for venous thromboembolism and fetal monitoring.
Appendectomy -
Diagnosis of appendicitis in pregnant patients can be challenging due to the physiological and anatomical changes induced by pregnancy. Perforation with generalized or even local abdominal sepsis is associated with high rates of early labor, miscarriage and fetal loss. Preferably, appendectomy is performed within 20 to 36 hours following onset of symptoms to reduce the risk of complications.
Cholecystectomy -
Pregnant women are at increased risk of cholelithiasis, of which the etiology is multifactorial. Early surgical management is advised as recurrence of symptoms can lead to more hospitalizations and progression to complicated biliary disease. Complications such as cholangitis and pancreatitis are aimed to be treated non-surgically.
Inflammatory bowel disease -
IBD patients are advised to conceive during quiescent disease. Proctectomy should be avoided during pregnancy. Ostomy during pregnancy can give mechanical complications but does not influence gestation or delivery. In patients with mild or quiescent IBD, vaginal delivery has been proven to be safe for. Active perianal disease, active disease with rectal involvement (and ileal pouch-anal anastomosis) are considered (relative) indications for cesarean section.
J. Arkenbosch, O. van Ruler, A.C. de Vries PII:
S1521-6918(20)30004-4
DOI:
https://doi.org/10.1016/j.bpg.2020.101669
Reference:
YBEGA 101669
To appear in:
Best Practice & Research Clinical Gastroenterology
Received Date:
03 February 2020
Accepted Date:
05 March 2020
Please cite this article as: J. Arkenbosch, O. van Ruler, A.C. de Vries, Non-obstetric surgery in pregnancy (including bowel surgery and gallbladder surgery), Best Practice & Research Clinical Gastroenterology (2020), https://doi.org/10.1016/j.bpg.2020.101669
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier.
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Best practice & Research Clinical Gastroenterology Volume 42C - Pregnancy in GI-disorders
Title: Non-obstetric surgery in pregnancy (including bowel surgery and gallbladder surgery)
Authors: Drs. J. Arkenbosch, PhD candidate, department of gastroenterology Erasmus Medical Center Address: Dr. Molewaterplein 40, room Na-618, 3015 GD Rotterdam E-mail: [email protected] Tel: +31 650033976
Dr. O. van Ruler (corresponding author), colorectal surgeon, department of surgery, IJsselland Hospital Address: Prins Constantijnweg 2, room M1-109, 2906 ZC Capelle aan den IJssel E-mail: [email protected] and [email protected]
Dr. A.C. de Vries, gastroenterologist, department of gastroenterology, Erasmus Medical Center Address: Dr. Molewaterplein 40, room NA-609, 3015 GD Rotterdam E-mail: [email protected]
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Abstract Abstract: Non-obstetric surgery during pregnancy is required in 0.75-2% of pregnancies. Physiologic changes during pregnancy, both hormonal and anatomic, can have interactions with surgery and anesthesia. Indication, timing as well as risks of anesthesia and surgery should be considered in surgical decision making. The health status of the mother should always be put first. A preoperative multidisciplinary approach, also including an obstetrician and neonatologist, is mandatory. Delay in diagnosis and treatment carry risks of complications in all septic visceral indications. Considerations should be individualized.
Introduction Surgery during pregnancy, not related to an obstetric indication, is required in 0.75 to 2% of pregnancies [1-3]. Approximately 42% of these operations are performed during the first trimester, 35% of operations during the second, and 23% during the third trimester [1]. Of all non-obstetric surgery performed during pregnancy, gastrointestinal procedures are most common, followed by trauma procedures, including bone fractures, and surgery for the indication of maternal malignancy. Appendectomy and cholecystectomy are the most common gastrointestinal procedures, which are performed in respectively 1 per 500-2000 and 1-8 per 10 000 pregnancies [4, 5]. Surgery during pregnancy requires specific considerations. Anesthetic and perioperative surgical care in pregnant women differs from non-pregnant women due to anatomical and physiological changes during pregnancy. Strict selection and timing should be taken into account when deciding on performing nonobstetric surgical procedures, considering the risks for both mother and child [6].
General principles in non-obstetric gastro-intestinal surgery Limited evidence is available to support specific guidelines in surgical management of pregnant women since (large-scale) randomized controlled trials are scarce [7, 8]. Nonetheless, pre-operative decision making is essential as maternal physiology and anatomy might have implications for both intraoperative maternal and fetal risks/ safety. Multidisciplinary consultation between obstetrics, surgeons, anesthesiologists and neonatologists, should precede non-obstetric surgery or other invasive procedures (e.g. colonoscopy) [7]. To ensure maternal and fetal safety, obstetricians and neonatologists should always be informed preoperatively and where necessary be involved once non-obstetric surgery is being performed in a pregnant patient.
Pre-operative patient selection and tailored surgery The decision whether and when a pregnant patient should undergo surgery, should be carefully weighed in each patient with assessment of the benefits and harms. Recent studies show that pregnant patients may undergo medically necessary (laparoscopic) procedures during any trimester with an acceptable increased maternal and/or fetal risk [9-11]; based on historic data a preference for the second trimester exists to avoid the risk of spontaneous abortion in the first trimester and preterm labor in the third trimester [12, 13]. Although elective surgery should be postponed until after gestation [9], postponing medically necessary surgery may increase the chance of maternal and fetal complications [11, 14]. As described more extensively further on, laparoscopic procedures have an advantage in outcome compared to open procedures.
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Physiological changes in pregnancy may impact surgery and anesthesia Physiologic changes during pregnancy occur due to hormonal and anatomic changes and can interact with surgery and anesthesia [15]. Signs and symptoms commonly present during pregnancy, such as tachypnea, dyspnea, heart murmurs and benign electro-cardiogram changes, might complicate anesthetic care of patients [15]. As modifications for anesthesia and surgery may be required during pregnancy, referral to a tertiary hospital might be considered. First of all, hemodynamic changes occur as cardiac output can increase up to twenty percent at the eighth week of gestation, and rise further up to 50 percent at week 32 after which it plateaus until the beginning of labor [16]. Cardiac output rises as a result of the following: an increase in preload due to a rise in blood volume; a decrease in afterload due to decreased vascular resistance; and an increase in maternal heart rate of 15 to 20 beats per minute [17]. Furthermore, cardiac output can decrease by 25 to 30 percent in supine position due to compression of the inferior vena cava by the gravid uterus resulting in a decreased venous return to the heart [16, 17]. Secondly, changes in the respiratory system occur which include a twenty percent increase in oxygen consumption [18, 19]. At twenty weeks of gestation, the elevated anatomical position of the diaphragm results in a twenty to thirty percent decrease in pulmonary functional residual capacity. Both contribute to decreased tolerance of apnea, e.g. during endotracheal intubation [20]. Presence of obesity or preeclampsia can magnify the risk of hypoxemia associated with the induction from general anesthesia [18]. However, progesterone stimulates and increases respiratory drive. In combination with increased tidal volume, this causes hyperventilation and a chronic respiratory alkalosis [18]. This state of respiratory alkalosis should be maintained during mechanical ventilation. Higher levels of maternal CO2 could potentially lead to acidosis and myocardial depression in the fetus; and severe alkalosis, caused by maternal hyperventilation, could reduce uterine blood flow and fetal oxygenation [21]. Airway changes can be present from the mid trimester onward and are most pronounced near the end of the pregnancy. These changes include swelling of oropharyngeal tissues and a decreased caliber of the glottic opening, which may lead to difficulty in ventilating and intubating the unconscious pregnant patient [15]. Even though a higher incidence of failed intubation during induction of anesthesia in pregnant women is debated, the encounter of difficult intubation and its consequences should be considered [15, 22]. The presence of other predisposing factors contributing to difficult intubation, such as weight gain and increased Mallampati airway score, should be taken into account [23, 24]. Furthermore, hematological changes can occur during pregnancy [25]. For instance, pregnant women can have a mild leukocytosis, in the absence of infection or inflammation, due to an excess in neutrophils [26]. Physiological leukocytosis during pregnancy can make accurate diagnosis of infection difficult. Also, hemodilution can occur due to an increase in plasma volume of up to 50 percent at week 32 and the total red blood cell count merely increases with 20 to 30 percent [27]. Normal gravid hemoglobin levels range from 6.5 to 6.8 mmol/L. An increase in circulating coagulation factors, reduced anticoagulant proteins, and reduced fibrinolysis activity result in a relatively hypercoagable state [28].
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Perioperative considerations To begin with, NSAIDS and opioids should be avoided as pain medication during pregnancy, whereas acetaminophen drugs are considered to be safe without teratogenic effects [29]. Other perioperative considerations, including thromboprophylaxis and fetal heart monitoring, are described below. Pregnancy and the puerperium are clear risk factors for venous thromboembolism (VTE), including deep venous thrombosis and pulmonary embolism [30]. VTE is one of the leading causes of maternal morbidity and mortality. Pregnant women are up to five times more likely to develop VTE compared to non-pregnant women [31]. The increased risk is caused by venous stasis of the lower extremities, endothelial damage and hypercoagulability [31, 32]. CO2 pneumoperitoneum, in combination with general anesthesia and muscle relaxation, can also contribute to the risk of VTE [33]. There is limited evidence on the use of thromboprophylaxis in pregnancies [30]. Recommendations on prophylactic treatment during surgery in pregnant patients are based on general principles for surgery [33]. The use of mechanical thromboprophylaxis (e.g. compression socks or sequential compression devices) is recommended intra- and postoperatively, as is early postoperative ambulation [33, 34]. Low molecular weight heparin is safe and efficacious as thromboprophylaxis in pregnant patients, administered in dosage following appropriate risk factor assessment [35]. All pregnant women with an indication for abdominal surgery should undergo risk assessment for VTE preoperatively, using a standardized risk assessment tool which includes assessment of both thrombosis and bleeding risks [36]. As described above, decreased cardiac output can result from the supine positioning of the pregnant patient during surgery, leading to maternal hypotension and fetal hypoperfusion during surgery [9, 37]. To reduce aortocaval compression, all patients over 18 to 20 weeks of gestation should be positioned in a 15 degree left lateral tilt in order to improve venous return and cardiac output. During the first trimester, the size of the uterus is still relatively small and does not likely reduce venous return [9]. Fetal heart monitoring is feasible from 18 to 22 weeks, and heart rate variability can be detected from 25 weeks [38]. The American College of Obstetrics and Gynecology Committee advices individualized, multidisciplinary decision-making on fetal heart monitoring for every patient based on factors such as gestational age, type of surgery, and available facilities [7]. Even though fetal acidosis has not been documented in human fetus, maternal CO2 monitoring is recommended due to potential harmful effects [33]. Several large studies have documented the safety and efficacy of end-tidal CO2 measurements in pregnant women making routine blood gas monitoring unnecessary [39].
Laparoscopic versus open procedures If abdominal surgery is indicated in a pregnant patient, the surgeon’s expertise, available staff and equipment determine the surgical approach used [9]. Historically, laparoscopy was considered hazardous and contraindicated in pregnant patients. However, more recent studies have shown that, as in non-pregnant patients, laparoscopy poses significant benefits over open procedures such as a decrease in postoperative pain, ileus, decreased length of hospital stay, and decreased risk of developing abdominal wall hernia [8, 39, 40].
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Laparoscopy during pregnancy is hampered due to alterations in the intra-abdominal anatomy during the second and third trimester [9]. In order to improve access safety and lower the risk of injury to the uterus or intra-abdominal organs, trocar placement should be adjusted to the increased size of the uterus [41]. The abdominal wall should be elevated during insertion [9]. Taking these considerations into account, both the open (or Hasson) technique and the Veress needle have been shown to be safe and effective opening techniques in pregnant patients [41]. Nonetheless, the Hasson technique is the preferred method of introduction as it is associated with less failed attempts and less complications [42]. Additional ultrasound guided trocar placement can attribute to a lower risk of uterine perforation [41]. In pregnant patients, laparoscopy leads to decreased maternal hypoventilation, a decreased risk of thromboembolic events, lower wound complication rates, and decreased occurrence of fetal respiratory depression subsequent to decreased narcotic needs [9]. Furthermore, laparoscopy offers a better visualization during surgery and lower uterine manipulation which might lower the risk of uterine irritability [43]. Therefore, despite anatomical changes which might complicate the procedure, laparoscopy is the preferred intended operative method in pregnant patients [8].
Conclusion Anesthetic and perioperative surgical care is different in pregnant women compared to non-pregnant women due to anatomical and physiological changes during pregnancy. Both the indication and urgency (timing) of surgery, as well as risks of anesthesia and surgery, should be taken into account when deciding on performing non-obstetric surgical procedures in pregnant women. In surgical decision making, the health status of the mother should always be put first. Preoperative multidisciplinary approach is mandatory.
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Gastrointestinal surgery during pregnancy Appendicitis Acute appendicitis is the most common cause of non-obstetric surgery during pregnancy [44, 45]. Quick and correct diagnosis of appendicitis is needed in pregnant patients, as non-perforated appendicitis can rapidly progress and cause complications. Perforation with local or even generalized abdominal sepsis is associated with high rates of early labor, miscarriage and fetal loss [46]. Diagnosis of appendicitis in pregnant patients can be challenging due to the physiological and anatomical changes induced by pregnancy [47, 48]. A correct diagnosis of appendicitis is made more often in the first trimester than in the second and last trimester as anatomical changes are still limited. Clinical symptoms of gastrointestinal complaints, abdominal pain and malaise are common in normal pregnancy [49]. Increased inflammatory markers during gestation limit the value of routine laboratory examination in pregnant patients [50]. Limitations in diagnostic imaging techniques can also contribute to a delay in diagnosis, as discussed in chapter 8 ‘Imaging in pregnancy (including fetal and maternal risks)’ [51]. Retrospective studies have shown laparoscopy for appendicitis in pregnancy to be safe and effective as preterm delivery rates are very low and fetal loss is rare [52]. Preferably, appendectomy is performed within 20 to 36 hours following onset of symptoms to reduce the risk of complications [53]. Early surgery for appendicitis reduces these risks, possibly at the cost of a small number of unnecessary operations [54, 55]. A negative appendectomy appears more harmful than previously assumed. One study found premature delivery and fetal loss up to 26% and 3-7.3% respectively, after negative laparoscopy for presumed acute appendicitis [46]. Antibiotic treatment can be an alternative treatment strategy in selected, non-pregnant patients [56]. However, antibiotic treatment poses an increased risk of maternal morbidity and fetal loss when progression to (perforated) appendicitis occurs, and has been associated with significantly higher rates of sepsis, septic shock, venous thromboembolism and peritonitis compared to appendectomy [9, 53]. On the other hand, a recent prospective observational study showed that antibiotics may be a meaningful treatment option for selected pregnant patients with uncomplicated appendicitis [57]. In this study maternal and fetal complications appeared to be limited and the need for surgery could be obviated in 75% of the patients [58]. However, more and larger studies are needed to change therapy recommendations. For now, appendectomy is the preferred treatment for pregnant patients with acute appendicitis based on the lower incidence of adverse events [13].
Cholelithiasis and cholecystitis Cholecystectomy for complications of cholelithiasis is the second most common operative procedure during pregnancy [59]. The incidence of cholecystectomy during pregnancy has been described to be up to 0.8% [60]. Pregnant women are at increased risk of cholelithiasis, which is probably multifactorial. The increased levels of estrogen and progesterone during gestation may cause biliary stasis [61]. Furthermore, elevated levels of progesterone cause smooth muscle relaxation of the gallbladder, which leads to reduced gallbladder emptying. Estrogen contributes to increased cholesterol secretion and bile saturation. Biliary stasis, in combination with decreased gallbladder motility, can increase gallstone formation [62]. Most patients with cholelithiasis will remain asymptomatic during pregnancy and
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gallstones can be found incidentally during routine ultrasound examinations. A proportion of pregnant patients will develop gallstone related complications [33]. Symptomatic cholelithiasis affects 0.2-2% of pregnant women, with an increase in occurrence in women with pre-pregnancy obesity or increased parity [33]. Patient with uncomplicated, symptomatic cholelithiasis were previously treated with conservative management including intravenous hydration, electrolyte correction and bowel rest [63]. However, non-surgical management of symptomatic cholelithiasis poses a high risk of recurrence of symptoms. If biliary disease remains uncomplicated, rates of preterm labor and spontaneous abortion do not differ between non-operative and operative management [13]. Also, laparoscopic cholecystectomy is found to have low maternal and fetal risks and is the optimal treatment for symptomatic gallbladder disease, regardless of the trimester [33]. Therefore, to date early surgical management is advised as recurrence of symptoms can lead to more hospitalizations in 50% of patients with unrelenting recurrent gallbladder symptoms but also to progression to complicated biliary disease compared to patients who undergo cholecystectomy [64, 65]. Complications associated with choledocholithiasis include acute cholecystitis, cholangitis, and gallstone pancreatitis [66]. Although they are relatively uncommon during pregnancy (incidence of 0.05-0.8%), these complications pose a significant risk of morbidity and mortality if not adequately treated [9]. Complications can result in preterm labor in up to 20% of cases and fetal loss. Cholangitis in particular poses a 10 percent risk of spontaneous abortion. Treatment strategies including surgical procedures and conservative treatment have their own risks and restrictions in pregnancy [67]. Endoscopic retrograde cholangiopancreatography (ERCP) is safe and effective for choledocholithiasis and indications include complicated choledocholithiasis. [33]. Fetal radiation exposure during ERCP should be minimized by applying techniques such as lead shielding and minimization of radiation dosage [13]. Taking into account that patient selection should be tailored, choledocholithiasis can be treated by preoperative ERCP with sphincterotomy followed by laparoscopic cholecystectomy or in only a selected subpopulation with laparoscopic common bile duct exploration [68]. Due to the possibilities of performing ERCP and cholecystectomy during pregnancy, maternal mortality rates have dropped to less than 1%. Laparoscopic cholecystectomy after ERCP with sphincterotomy is safe in pregnant woman [9]. Both laparoscopic cholecystectomy and ERCP decrease the incidence of postpartum biliary symptoms compared to conservative management in patients with complicated gallstone disease [69]. Cholangitis is associated with higher rates fetal risks, including preterm labor and spontaneous abortion. Cholangitis is initially treated by non-surgical interventions including hospitalization, intravenous fluids, analgesia and bowel rest [65]. Overall, pregnant patients with cholangitis are treated similar to nonpregnant patients [67]. Stone extraction for cholangitis can be achieved safely by ERCP with fetal shielding [70]. Intraoperative common bile duct exploration is an uncommon procedure requiring specialized surgical skills, and has been reported only in few cases but with good fetal and maternal outcomes [68]. Acute biliary pancreatitis is associated with increased morbidity and mortality as well as higher rates of fetal loss [71]. Patients with biliary pancreatitis are initially treated conservatively, and according to general guidelines. ERCP with sphincterotomy and stone extraction is indicated in cases
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with concomitant cholangitis. After recovery of acute biliary pancreatitis, early cholecystectomy (during the same hospital admission) should be considered [72]. Pancreatitis during pregnancy can be successfully managed with conservative treatment as it usually has a mild to moderate clinical course [73]. Supportive treatment includes hospitalization, bowel rest, intravenous fluid administration, analgesia and later enteral nutrition. In case of very severe pancreatitis, surgical intervention could be indicated as this carries high mortality risk for both mother and child [74].
Conclusion Laparoscopic appendectomy is the preferred treatment for acute appendicitis, as is laparoscopic cholecystectomy for acute cholecystitis. Both delay in diagnosis and treatment possess the risk of complications in both appendicitis and cholecystitis. Complications such as cholangitis and pancreatitis are aimed to be treated non-surgically.
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Surgery in Inflammatory bowel disease (IBD) Introduction Crohn’s Disease (CD) and ulcerative colitis (UC) are often diagnosed during reproductive years. Female patients are advised to conceive at a time of IBD remission, as active disease during pregnancy is associated with increased risks of preterm birth and low birth weight [75]. In general, maintenance treatment is continued in patients who wish to conceive, in order to reduce the risk of flares during pregnancy. Most medical options for IBD are considered to be of low risk during pregnancy with regard to fetal outcome. Surgery may be considered for severe therapy refractory cases or complications of IBD during pregnancy [76].
Fertility after IBD surgery Subfertility is probably increased after pouch surgery amongst women with IBD. Adhesions after surgery could possibly lead to subfertility. The rates of postoperative adhesions have improved due to a rise in laparoscopic procedures compared to open surgery; even more so in pouch surgery [77]. However, available guidelines do not recommend subtotal colectomy with rectal stump and ileostomy during the childbearing years followed by pouch surgery later in life to help reduce infertility as there is no data to support this treatment strategy. Relative rare ileostomy complications such as obstruction or stomarelated problems, could arise during pregnancy [75]. Male IBD patients may experience retrograde ejaculation and erectile dysfunction after pouch surgery due to nerve damage. However, a direct association between pouch surgery and subfertility has not been reported in male patients [75].
Mode of delivery Decisions on mode of delivery should be based on obstetric indications taking postpartum pelvic floor impairment with respect to present and future bowel function into account [78]. Vaginal delivery has been proven to be safe for most IBD patients with mild or quiescent disease [79, 80]. International guidelines identify active perianal disease or active disease with rectal involvement as indications for cesarean section [78, 81]. Ileal pouch-anal anastomosis is considered a relative indication for cesarean section [82].
Surgery for IBD during pregnancy The literature on IBD surgery during pregnancy is rather scarce. The indications for surgery may be evident in pregnant patients with severe complications of IBD, such as perforation or ileus. However, in cases of therapy refractory disease the decision to perform an intestinal resection during pregnancy are less straight forward. Also, in IBD surgery the combination of anatomical, physiological and immunological changes during pregnancy are important drawbacks [83]. Studies published before 1980 showed an increased risk of miscarriage in the first trimester. Also, high fetal mortality in UC patients with septic complications undergoing colectomy, has been described in these studies [84]. However, due to advances in medical IBD, perioperative and neonatal care as well as preconception counseling have probably led to a reduction of current maternal and fetal outcome, in which a close collaboration of involved disciplines seems of paramount importance [83]. Hospitalization for resuscitation and fetal monitoring is required in (acute) severe UC and therapy refractory cases, as the risk of complications is high in these cases [85]. In therapy refractory UC during 9
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pregnancy, surgery should be considered timely to avoid complications such as transfusion-dependent anemia, perforation with intra-abdominal sepsis and toxic colitis [86]. These complications pose a high risk of fetal and maternal morbidity and even mortality urging immediate surgical intervention [87, 88]. An obstetrician and surgeon experienced with IBD surgery should be consulted [89]. Consultation by a stoma therapist prior to surgery is advised. The optimal location for a stoma is usually higher on the abdominal wall in pregnant women, as the stoma will descend to a lower position after delivery [89]. Subtotal colectomy with end-ileostomy, is recommended for all severely ill pregnant UC patients with an indication for surgery [83]. Prevention of dehiscence of a closed stump due to dilatation of the rectal stump as a result of compression of the enlarged uterus is essential. Strategies to prevent this “blowout” include insertion of a rectal drain, daily digital rectal examination (during first days postoperatively), and double stapling and oversewing of the stump [83, 89]. Proctocolectomy is contraindicated during pregnancy, as this complex operation requires pelvic dissection. Pelvic dissection is difficult because of uterine enlargement and dilated pelvic vessels. Reported cases have described premature delivery in all cases after colectomy in the third trimester as manipulation of the late gravid uterus can precipitate premature delivery. A synchronous cesarean section and colectomy may be considered in these cases [90, 91].
Ostomy and pregnancy Ileostomy has been described as the most prevalent type of ostomy in pregnant patients [92, 93]. IBD patients with an ostomy, without disease activity, are expected to encounter a normal pregnancy and delivery [93]. Complications of an ostomy in pregnant patients include stoma pouching problems, alterations in stoma size and abdominal contours, bleeding, retraction, prolapse, stenosis, laceration and bowel obstruction [92, 94]. Ileostomy/small bowel obstruction is a rare complication and leads to increased maternal and fetal morbidity and mortality if not timely and adequately treated. Maternal complications include bowel perforation, hypovolemic shock and sepsis, while perinatal complications include prematurity, low gestational weight, stillbirths and perinatal death due to fetal hypoxia [95, 96]. MRI could distinguish between obstruction caused by abdominal adhesions, CD activity or compression by enlargement of the gravid uterus [97]. Treatment strategies include conservative treatment, mostly when the obstruction is caused by the gravid uterus, and laparotomy; exclusive enteral nutrition (EEN) is recommended in case of active CD disease and stenosis [97]. Cesarean section in patients with ostomy is only indicated in case of obstetrical indications [92, 93].
Conclusion IBD patients are advised to conceive during quiescent disease. If medical therapy fails during pregnancy, timing and indication for surgery can be challenging. A proctectomy should be avoided during pregnancy. Ostomy during pregnancy can give complications such as alterations in stoma size and abdominal contours, bleeding, retraction, prolapse, stenosis, laceration and bowel obstruction, but does not influence gestation and delivery. In patients with mild or quiescent IBD, vaginal delivery has been proven to be safe for. Active perianal disease, active disease with rectal involvement (and ileal pouch-anal anastomosis) are considered (relative) indications for cesarean section. 10
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Summary Surgery during pregnancy, not related to an obstetric indication, is required in 0.75 to 2% of pregnancies. Gastrointestinal procedures are most common, of which appendectomy and cholecystectomy are the most prevalent procedures performed. Physiologic changes during pregnancy occur due to hormonal and anatomic changes and can interact with surgery and anesthesia in important ways. Both the indication and timing of surgery, as well as risks of anesthesia and surgery on fetus and mother, should be considered when deciding on performing non-obstetric surgical procedures in pregnant women. In surgical decision making, the health status of the mother should always be put first. A preoperative multidisciplinary approach, also including an obstetrician and pediatrician, is mandatory. Considering whether surgery is necessary and feasible should be discussed for every individual patient. Laparoscopic appendectomy is the preferred treatment for acute appendicitis, as is laparoscopic cholecystectomy for cholelithiasis related complications. Delay in diagnosis and treatment carry risks of septic complications in both appendicitis and cholelithiasis related complications leading to increased risks for mother and child. Stone extraction for cholangitis can be achieved safely by ERCP, followed by cholecystectomy. During ERCP, measurements to minimize fetal radiation dosage should be taken, including fetal shielding and reduction of used dosage. After resolution of acute biliary pancreatitis with conservative treatment with fluid resuscitation and pain medication, a cholecystectomy is indicated during the same hospital admission. Patients with IBD are advised to conceive during quiescent disease. If medical therapy fails during pregnancy, timing and indication for surgery can be challenging. Several surgical interventions have been described in pregnant IBD patients, but decision making should be tailored to patient specific characteristics. Proctectomy should be avoided. Ostomy during pregnancy can cause a range of complications, but does not influence gestation and delivery.
Abstract Non-obstetric surgery during pregnancy is required in 0.75-2% of pregnancies. Physiologic changes during pregnancy, both hormonal and anatomic, can have interactions with surgery and anesthesia. Indication, timing as well as risks of anesthesia and surgery should be considered in surgical decision making. The health status of the mother should always be put first. A preoperative multidisciplinary approach, also including an obstetrician and neonatologist, is mandatory. Delay in diagnosis and treatment carry risks of complications in all septic visceral indications. Considerations should be individualized.
Key words Non-obstetric, gastrointestinal, surgery, pregnancy, appendectomy, cholecystectomy, IBD, laparoscopy, laparotomy
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Recommendations for surgery in pregnancy General remarks -
In surgical decision making, the health status of the mother should always be put first. Preoperative multidisciplinary approach is mandatory as anesthesia, surgery but also the decision to postpone surgery might have implications for both maternal and fetal risks / safety.
Anesthetic and perioperative surgical care -
-
Indication and timing of surgery, as well as risks of anesthesia and surgery, should be taken into account when deciding on performing non-obstetric surgical procedures in pregnant women. Laparoscopy is the preferred intended operative method in all pregnant patients, despite anatomical changes, which might complicate the procedure; based on the lower incidence of adverse events. Perioperative considerations for the pregnant patient include correct positioning, nonteratogenic analgesics, risk assessment for venous thromboembolism and fetal monitoring.
Appendectomy -
Diagnosis of appendicitis in pregnant patients can be challenging due to the physiological and anatomical changes induced by pregnancy. Perforation with generalized or even local abdominal sepsis is associated with high rates of early labor, miscarriage and fetal loss. Preferably, appendectomy is performed within 20 to 36 hours following onset of symptoms to reduce the risk of complications.
Cholecystectomy -
Pregnant women are at increased risk of cholelithiasis, of which the etiology is multifactorial. Early surgical management is advised as recurrence of symptoms can lead to more hospitalizations and progression to complicated biliary disease. Complications such as cholangitis and pancreatitis are aimed to be treated non-surgically.
Inflammatory bowel disease -
IBD patients are advised to conceive during quiescent disease. Proctectomy should be avoided during pregnancy. Ostomy during pregnancy can give mechanical complications but does not influence gestation or delivery. In patients with mild or quiescent IBD, vaginal delivery has been proven to be safe for. Active perianal disease, active disease with rectal involvement (and ileal pouch-anal anastomosis) are considered (relative) indications for cesarean section.
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Practice points
In surgical decision making, the health status of the mother should always be put first.
Physiologic changes during pregnancy can interact with surgery and anesthesia in important ways. Indication and timing of surgery, as well as risks of anesthesia and surgery, should be considered when deciding on performing non-obstetric surgical procedures in pregnant women.
Preoperative multidisciplinary approach, also including an obstetrician, is mandatory.
Laparoscopic appendectomy is the preferred treatment for acute appendicitis, as is laparoscopic cholecystectomy for acute cholecystitis. Delay in both diagnosis and treatment of appendicitis and cholecystitis possesses the risk of complications for both mother and child.
Patients with IBD are advised to conceive during quiescent disease.
Decisions on surgical treatment in refractory IBD during pregnancy should be tailor-made.
Research agenda
Given the paucity of on current management (including timing) and outcome of surgery during pregnancy, data registration of surgery during pregnancy may provide important clues to improve management
Acknowledgements Role of funding source: none. Conflict of interest: none.
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Literature 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22.
Mazze, R.I. and B. Kallen, Reproductive outcome after anesthesia and operation during pregnancy: a registry study of 5405 cases. Am J Obstet Gynecol, 1989. 161(5): p. 1178-85. Ni Mhuireachtaigh, R. and D.A. O'Gorman, Anesthesia in pregnant patients for nonobstetric surgery. J Clin Anesth, 2006. 18(1): p. 60-6. Goodman, S., Anesthesia for nonobstetric surgery in the pregnant patient. Semin Perinatol, 2002. 26(2): p. 136-145. Augustin, G. and M. Majerovic, Non-obstetrical acute abdomen during pregnancy. Eur J Obstet Gynecol Reprod Biol, 2007. 131(1): p. 4-12. El-Messidi, A., et al., Evaluation of management and surgical outcomes in pregnancies complicated by acute cholecystitis. J Perinat Med, 2018. 46(9): p. 998-1003. Kwon, H., et al., Laparoscopic management is feasible for nonobstetric surgical disease in all trimesters of pregnancy. Surg Endosc, 2018. 32(6): p. 2643-2649. ACOG Committee Opinion No. 775 Summary: Nonobstetric Surgery During Pregnancy. Obstet Gynecol, 2019. 133(4): p. 844-845. Ball, E., et al., Evidence-Based Guideline on Laparoscopy in Pregnancy: Commissioned by the British Society for Gynaecological Endoscopy (BSGE) Endorsed by the Royal College of Obstetricians & Gynaecologists (RCOG). Facts Views Vis Obgyn, 2019. 11(1): p. 5-25. Jonathan P Pearl, R.R.P., Allison E Tonkin, William S Richardson, Dimitrios Stefanidis, SAGES Guidelines for the Use of Laparoscopy during Pregnancy. 2017. Glasgow, R.E., et al., Changing management of gallstone disease during pregnancy. Surg Endosc, 1998. 12(3): p. 241-246. Muench, J., et al., Delay in treatment of biliary disease during pregnancy increases morbidity and can be avoided with safe laparoscopic cholecystectomy. Am Surg, 2001. 67(6): p. 539-542; discussion 542-543. Saunders, P. and P.J.D. Milton, Laparotomy during pregnancy: an assessment of diagnostic accuracy and fetal wastage. Br Med J, 1973. Pearl, J.P., et al., SAGES guidelines for the use of laparoscopy during pregnancy. 2017. 31(10): p. 3767-3782. Visser, B.C., et al., Safety and timing of nonobstetric abdominal surgery in pregnancy. Dig Surg, 2001. 18(5): p. 409-417. Cheek, T.G. and E. Baird, Anesthesia for nonobstetric surgery: maternal and fetal considerations. Clin Obstet Gynecol, 2009. 52(4): p. 535-45. Meah, V.L., et al., Cardiac output and related haemodynamics during pregnancy: a series of meta-analyses. Heart, 2016. 102(7): p. 518-26. Chapman, A.B., et al., Temporal relationships between hormonal and hemodynamic changes in early human pregnancy. Kidney Int, 1998. 54(6): p. 2056-63. Hegewald, M.J. and R.O. Crapo, Respiratory physiology in pregnancy. Clin Chest Med, 2011. 32(1): p. 1-13. LoMauro, A. and A. Aliverti, Respiratory physiology of pregnancy: Physiology masterclass. Breathe (Sheff), 2015. 11(4): p. 297-301. McAuliffe, F., et al., Respiratory function in singleton and twin pregnancy. BJOG, 2002. 109(7): p. 765-9. Levinson, G., et al., Effects of maternal hyperventilation on uterine blood flow and fetal oxygenation and acid-base status. Anesthesiology, 1974. 40(4): p. 340-7. Matthew Rucklidge, C.H., Difficult and failed intubation in obstetrics. Continuing Education in Anaesthesia Critical Care & Pain, 2012. 12(4): p. 218. 14
Journal Pre-proof
23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44.
Pilkington, S., et al., Increase in Mallampati score during pregnancy. Br J Anaesth, 1995. 74(6): p. 638-42. Ahuja, P., et al., Airway changes following labor and delivery in preeclamptic parturients: a prospective case control study. Int J Obstet Anesth, 2018. 33: p. 17-22. de Haas, S., et al., Physiological adaptation of maternal plasma volume during pregnancy: a systematic review and meta-analysis. Ultrasound Obstet Gynecol, 2017. 49(2): p. 177-187. Kuvin, S.F. and G. Brecher, Differential neutrophil counts in pregnancy. N Engl J Med, 1962. 266: p. 877-8. Bernstein, I.M., W. Ziegler, and G.J. Badger, Plasma volume expansion in early pregnancy. Obstet Gynecol, 2001. 97(5 Pt 1): p. 669-72. Nijkeuter, M., J.S. Ginsberg, and M.V. Huisman, Diagnosis of deep vein thrombosis and pulmonary embolism in pregnancy: a systematic review. J Thromb Haemost, 2006. 4(3): p. 496500. Li, D.K., et al., Use of nonsteroidal antiinflammatory drugs during pregnancy and the risk of miscarriage. Am J Obstet Gynecol, 2018. 219(3): p. 275 e1-275 e8. Marik, P.E. and L.A. Plante, Venous thromboembolic disease and pregnancy. N Engl J Med, 2008. 359(19): p. 2025-33. James, A.H., et al., Venous thromboembolism during pregnancy and the postpartum period: incidence, risk factors, and mortality. Am J Obstet Gynecol, 2006. 194(5): p. 1311-5. Sobolewski, A.P., et al., Venous hemodynamic changes during laparoscopic cholecystectomy. J Laparoendosc Surg, 1995. 5(6): p. 363-9. Soper, N.J., SAGES' guidelines for diagnosis, treatment, and use of laparoscopy for surgical problems during pregnancy. Surg Endosc, 2011. 25(11): p. 3477-8. Guimicheva, B., J. Czuprynska, and R. Arya, The prevention of pregnancy-related venous thromboembolism. Br J Haematol, 2015. 168(2): p. 163-74. Crowley, M.P., et al., A Multicentre Study of Thromboprophylaxis in Pregnancy. Ir Med J, 2017. 110(5): p. 567. RCOG Green-top Guideline No. 37b. Thromboembolic Disease in Pregnancy and the Puerperium: Acute Management. Royal College of Obstetricians and Gynaecologists 2015. Clark, S.L., et al., Position change and central hemodynamic profile during normal third-trimester pregnancy and post partum. Am J Obstet Gynecol, 1991. 164(3): p. 883-7. Reitman, E. and P. Flood, Anaesthetic considerations for non-obstetric surgery during pregnancy. Br J Anaesth, 2011. 107 Suppl 1: p. i72-8. Reedy, M.B., B. Kallen, and T.J. Kuehl, Laparoscopy during pregnancy: a study of five fetal outcome parameters with use of the Swedish Health Registry. Am J Obstet Gynecol, 1997. 177(3): p. 673-9. Oelsner, G., et al., Pregnancy outcome after laparoscopy or laparotomy in pregnancy. J Am Assoc Gynecol Laparosc, 2003. 10(2): p. 200-4. Huang, K.G., A.A. Chua, and C.L. Lee, Surgical trocar insertion among pregnant patients. Int J Gynecol Cancer, 2014. 24(6): p. 965-6. Cornette, B. and F. Berrevoet, Trocar Injuries in Laparoscopy: Techniques, Tools, and Means for Prevention. A Systematic Review of the Literature. World J Surg, 2016. 40(10): p. 2331-41. Soriano, D., et al., Laparoscopy versus laparotomy in the management of adnexal masses during pregnancy. Fertil Steril, 1999. 71(5): p. 955-60. Prodromidou, A., et al., Outcomes after open and laparoscopic appendectomy during pregnancy: A meta-analysis. Eur J Obstet Gynecol Reprod Biol, 2018. 225: p. 40-50.
15
Journal Pre-proof
45. 46. 47. 48. 49. 50. 51. 52. 53. 54. 55. 56. 57. 58. 59. 60. 61. 62. 63. 64. 65. 66. 67.
Wilasrusmee, C., et al., Systematic review and meta-analysis of safety of laparoscopic versus open appendicectomy for suspected appendicitis in pregnancy. Br J Surg, 2012. 99(11): p. 14701478. Aggenbach, L., et al., Impact of appendicitis during pregnancy: no delay in accurate diagnosis and treatment. Int J Surg, 2015. 15: p. 84-9. Theilen, L.H., et al., Acute Appendicitis in Pregnancy: Predictive Clinical Factors and Pregnancy Outcomes. Am J Perinatol, 2017. 34(6): p. 523-528. Drake, F.T., et al., Single institution and statewide performance of ultrasound in diagnosing appendicitis in pregnancy. J Matern Fetal Neonatal Med, 2015. 28(6): p. 727-33. Kosai, N.R., et al., Pregnant and severe acute abdominal pain: A surgical diagnostic dilemma. Clin Ter, 2015. 166(3): p. 110-113. Yazar, F.M., et al., Predictive role of neutrophil-to-lymphocyte and platelet-to-lymphocyte ratios for diagnosis of acute appendicitis during pregnancy. Kaohsiung J Med Sci, 2015. 31(11): p. 591596. Kulvatunyou, N., et al., Risk Factors for Perforated Appendicitis in the Acute Care Surgery EraMinimizing the Patient's Delayed Presentation Factor. J Surg Res, 2019. 238: p. 113-118. Cheng, H.T., et al., Laparoscopic appendectomy versus open appendectomy in pregnancy: a population-based analysis of maternal outcome. Surg Endosc, 2015. 29(6): p. 1394-9. Lemieux, P., et al., Laparoscopic appendectomy in pregnant patients: a review of 45 cases. Surg Endosc, 2009. 23(8): p. 1701-5. Yilmaz, H.G., et al., Acute appendicitis in pregnancy--risk factors associated with principal outcomes: a case control study. Int J Surg, 2007. 5(3): p. 192-7. Ito, K., et al., Appendectomy in pregnancy: Evaluation of the risks of a negative appendectomy. Am J Surg, 2012. 203(2): p. 145-150. Salminen, P., et al., Five-Year Follow-up of Antibiotic Therapy for Uncomplicated Acute Appendicitis in the APPAC Randomized Clinical Trial. JAMA, 2018. 320(12): p. 1259-1265. Yefet, E., et al., Successful treatment of acute uncomplicated appendicitis in pregnancy with intravenous antibiotics. Eur J Obstet Gynecol Reprod Biol, 2013. 169(1): p. 121-122. Joo, J.I., et al., Outcomes of Antibiotic Therapy for Uncomplicated Appendicitis in Pregnancy. Am J Med, 2017. 130(12): p. 1467-1469. Ghumman, E., M. Barry, and P.A. Grace, Management of gallstones in pregnancy. BR J SURG, 1997. 84(12): p. 1646-1650. Kuy, S., et al., Outcomes following cholecystectomy in pregnant and nonpregnant women. Surgery, 2009. 146(2): p. 358-66. Al-Akeely, M.H., Management of complicated gallstone disease during pregnancy. Saudi J Gastroenterol, 2003. 9(3): p. 135-8. Nakeeb, A., et al., Gallstones: genetics versus environment. Ann Surg, 2002. 235(6): p. 842-9. Ibiebele, I., et al., Outcomes of Gallstone Disease during Pregnancy: a Population-based Data Linkage Study. Paediatr Perinat Epidemiol, 2017. 31(6): p. 522-530. Gilbert, A., V. Patenaude, and H.A. Abenhaim, Acute pancreatitis in pregnancy: A comparison of associated conditions, treatments and complications. J Perinat Med, 2014. 42(5): p. 565-570. Jorge, A.M., et al., Non-operative management of symptomatic cholelithiasis in pregnancy is associated with frequent hospitalizations. J Gastrointest Surg, 2015. 19(4): p. 598-603. Ko, C.W., Risk factors for gallstone-related hospitalization during pregnancy and the postpartum. Am J Gastroenterol, 2006. 101(10): p. 2263-2268. İlhan, M., et al., The course and outcomes of complicated gallstone disease in pregnancy: Experience of a tertiary center. Turk Jinekoloji Obstet Dernegi Derg, 2016. 13(4): p. 178-182. 16
Journal Pre-proof
68. 69. 70. 71. 72. 73. 74. 75. 76. 77. 78. 79. 80. 81. 82. 83. 84. 85. 86. 87.
Tuech, J.J., et al., Management of choledocholithiasis during pregnancy by magnetic resonance cholangiography and laparoscopic common bile duct stone extraction. Surg Laparosc Endosc Percutan Tech, 2000. 10(5): p. 323-5. Veerappan, A., et al., Delaying Cholecystectomy for Complicated Gallstone Disease in Pregnancy is Associated with Recurrent Postpartum Symptoms. J Gastrointest Surg, 2013. 17(11): p. 19531959. Magno-Pereira, V., P. Moutinho-Ribeiro, and G. Macedo, Demystifying endoscopic retrograde cholangiopancreatography (ERCP) during pregnancy. Eur J Obstet Gynecol Reprod Biol, 2017. 219: p. 35-39. Othman, M.O., et al., Conservative management of cholelithiasis and its complications in pregnancy is associated with recurrent symptoms and more emergency department visits. Gastrointest Endosc, 2012. 76(3): p. 564-569. Juo, Y.Y., et al., Cumulative financial burden of readmissions for biliary pancreatitis in pregnant women. Obstet Gynecol, 2018. 132(2): p. 415-422. Hot, S., et al., Acute biliary pancreatitis during pregnancy and in the post-delivery period. Ulusal Travma Acil Cerrahi Derg, 2019. 25(3): p. 253-258. Mali, P., Pancreatitis in pregnancy: etiology, diagnosis, treatment, and outcomes. Hepatobiliary Pancreatic Dis Int, 2016. 15(4): p. 434-438. De Lima-Karagiannis, A., Z. Zelinkova-Detkova, and C.J. Van Der Woude, The Effects of Active IBD During Pregnancy in the Era of Novel IBD Therapies. Am J Gastroenterol, 2016. 111(9): p. 13051312. van der Woude, C.J., et al., European evidenced-based consensus on reproduction in inflammatory bowel disease. J Crohn's Colitis, 2010. 4(5): p. 493-510. Hull, T.L., et al., Adhesions after laparoscopic and open ileal pouch-anal anastomosis surgery for ulcerative colitis. Br J Surg, 2012. 99(2): p. 270-5. van der Woude, C.J., et al., The second European evidenced-based consensus on reproduction and pregnancy in inflammatory bowel disease. J Crohns Colitis, 2015. 9(2): p. 107-24. Nguyen, G.C., et al., Outcomes of obstetric hospitalizations among women with inflammatory bowel disease in the United States. Clin Gastroenterol Hepatol, 2009. 7(3): p. 329-34. Ananthakrishnan, A.N., et al., Mode of childbirth and long-term outcomes in women with inflammatory bowel diseases. Dig Dis Sci, 2015. 60(2): p. 471-477. Nguyen, G.C., et al., The Toronto Consensus Statements for the Management of Inflammatory Bowel Disease in Pregnancy. Gastroenterology, 2016. 150(3): p. 734-757 e1. Hahnloser, D., et al., Pregnancy and delivery before and after ileal pouch-anal anastomosis for inflammatory bowel disease: Immediate and long-term consequences and outcomes. Dis Colon Rectum, 2004. 47(7): p. 1127-1135. Killeen, S., J. Gunn, and J. Hartley, Surgical management of complicated and medically refractory inflammatory bowel disease during pregnancy. Colorectal Dis, 2017. 19(2): p. 123-138. Flatmark, A.L., A. Nordöy, and E. Gjone, Radical surgery for ulcerative colitis during pregnancy. Scand J Gastroenterol, 1971. 6(1): p. 45-47. Selinger, C.P., R.W. Leong, and S. Lal, Pregnancy related issues in inflammatory bowel disease: evidence base and patients' perspective. World J Gastroenterol, 2012. 18(21): p. 2600-8. Mogadam, M., et al., The course of inflammatory bowel disease during pregnancy and postpartum. Am J Gastroenterol, 1981. 75(4): p. 265-9. Anderson, J.B., G.M. Turner, and R.C.N. Williamson, Fulminant ulcerative colitis in late pregnancy and the puerperium. J R SOC MED, 1987. 80(8): p. 492-494.
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Journal Pre-proof
88. 89. 90. 91. 92. 93. 94. 95. 96. 97.
Kashkooli, S.B., et al., Inflammatory bowel disease-specific pregnancy knowledge of gastroenterologists against general practitioners and obstetricians. United European Gastroenterol J, 2015. 3(5): p. 462-70. Dozois, E.J., et al., Maternal and fetal outcome after colectomy for fulminant ulcerative colitis during pregnancy: case series and literature review. Dis Colon Rectum, 2006. 49(1): p. 64-73. Toiyama, Y., et al., Fulminant ulcerative colitis during pregnancy successfully treated by threestage operation. J Gastroenterol, 2004. 39(3): p. 300-1. Parker, A.R., N. Baker, and D. Maxwell, A modification of the surgical indications for the treatment of ulcerative colitis during pregnancy. Am Surg, 2011. 77(12): p. E281-3. Sredl, D. and V. Aukamp, Evidence-based nursing care management for the pregnant woman with an ostomy. J Wound Ostomy Continence Nurs, 2006. 33(1): p. 42-9; quiz 50-1. Ojerskog, B., et al., Pregnancy and delivery in patients with a continent ileostomy. SURG GYNECOL OBSTET, 1988. 167(1): p. 61-64. Spring, A., et al., Ileostomy obstruction in the third trimester of pregnancy. Colorectal Dis, 2012. 14(9): p. e631-2. Rauff, S., S.K. Chang, and E.K. Tan, Intestinal obstruction in pregnancy: a case report. Case Rep Obstet Gynecol, 2013. 2013: p. 564838. Sagi, Y., et al., Small Bowel Obstruction in Pregnancy: A Systematic Review [32F]. Obstetrics & Gynecology, 2018. 131: p. 72S. Porter, H. and S. Seeho, Obstructed ileostomy in the third trimester of pregnancy due to compression from the gravid uterus: diagnosis and management. BMJ Case Rep, 2014. 2014.
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Recommendations for surgery in pregnancy General remarks -
In surgical decision making, the health status of the mother should always be put first. Preoperative multidisciplinary approach is mandatory as anesthesia, surgery but also the decision to postpone surgery might have implications for both maternal and fetal risks / safety.
Anesthetic and perioperative surgical care -
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Indication and timing of surgery, as well as risks of anesthesia and surgery, should be taken into account when deciding on performing non-obstetric surgical procedures in pregnant women. Laparoscopy is the preferred intended operative method in all pregnant patients, despite anatomical changes, which might complicate the procedure; based on the lower incidence of adverse events. Perioperative considerations for the pregnant patient include correct positioning, nonteratogenic analgesics, risk assessment for venous thromboembolism and fetal monitoring.
Appendectomy -
Diagnosis of appendicitis in pregnant patients can be challenging due to the physiological and anatomical changes induced by pregnancy. Perforation with generalized or even local abdominal sepsis is associated with high rates of early labor, miscarriage and fetal loss. Preferably, appendectomy is performed within 20 to 36 hours following onset of symptoms to reduce the risk of complications.
Cholecystectomy -
Pregnant women are at increased risk of cholelithiasis, of which the etiology is multifactorial. Early surgical management is advised as recurrence of symptoms can lead to more hospitalizations and progression to complicated biliary disease. Complications such as cholangitis and pancreatitis are aimed to be treated non-surgically.
Inflammatory bowel disease -
IBD patients are advised to conceive during quiescent disease. Proctectomy should be avoided during pregnancy. Ostomy during pregnancy can give mechanical complications but does not influence gestation or delivery. In patients with mild or quiescent IBD, vaginal delivery has been proven to be safe for. Active perianal disease, active disease with rectal involvement (and ileal pouch-anal anastomosis) are considered (relative) indications for cesarean section.