Laparoscopic management of a nonobstetric emergency in the third trimester of pregnancy

Diagnostic value of the pregnancy index for acute appendicitis in pregnant women

Acute appendicitis is one of the most common non-gynecological and non-obstetric causes of acute abdominal conditions requiring urgent surgery during pregnancy. Due to the similarity between the symptoms of the disease and those of pregnancy, laboratory findings become particularly important in diagnosis. This study aimed to evaluate these parameters for the first time using a new index definition. Between 2015 and 2021, a total of 120 patients were included in the study, divided into the four groups: healthy pregnant woman (HPW), healthy woman (HW), unhealthy pregnant woman (UPW, pregnant patient with acute appendicitis), and unhealthy woman (UW, non-pregnant patient with acute appendicitis). Laboratory parameters, including white blood cell count (WBC), C-reactive protein (CRP), neutrophil-lymphocyte ratio (NLR), ischemia-modified albumin (iMA), and platelet-lymphocyte ratio (PLR), were assessed. In this study, significant differences were observed in various laboratory parameters between groups, such as WBC, CRP, NLR, and PLR, indicating potential markers for differentiating between pregnant women with and without appendicitis. An index was created for the diagnosis of acute appendicitis in pregnant women and was named the Pregnant Index. The Pregnant Index (PGIndex) values of pregnant women without appendicitis were compared with those of pregnant women with appendicitis. It was found that the PGIndex value was significantly higher in pregnant women with appendicitis (p < 0.001). Using the ROC curve and Youden index, the PGIndex cut-off value to best differentiate between the two groups was 10.62. This value provided a sensitivity of 73.3%, specificity of 96.7%, positive predictive value of 95.7%, negative predictive value of 78.7%, and test accuracy of 85% for identifying pregnant women with appendicitis. Compared to other markers, the PGIndex had the highest accuracy value, and it was observed that patients with a PGIndex value above 10.62 had a significantly increased likelihood of having appendicitis. These results indicate that the PGIndex is a significant marker for detecting appendicitis in pregnant women. Laboratory parameters, particularly NLR and PLR, show promise as diagnostic tools for appendicitis in pregnant women. Incorporating these markers, the Pregnant Index (PGIndex) demonstrated high sensitivity and specificity in distinguishing between pregnant women with and without appendicitis. This is the first study using the Pregnant Index in pregnant women to diagnose appendicitis. Early diagnosis is crucial for preventing maternal and fetal morbidity and mortality associated with appendicitis during pregnancy.

Mastering nonobstetric surgery in pregnancy: Insights, guidelines evaluation, and point-by-point discussion

For surgeons and clinicians, nonobstetric surgery during pregnancy has certain difficulties and considerations. In order to aid in decision-making in these situations, this manuscript offers a thorough review of the guidelines currently in place from renowned obstetric and surgical societies, such as the American College of Obstetricians and Gynecologists, the Royal College of Obstetricians & Gynecologists, and others. Using AGREE II-S methodology, a comprehensive analysis of guidelines reveals differences in recommendations for anesthetics, surgical procedures, imaging modalities, and thromboembolic prophylaxis. Furthermore, a thorough discussion of strategic surgical planning is provided, covering aspects such as patient positioning, trocar placement, pneumoperitoneum generation, and thromboembolic risk management. The publication highlights that in order to maximize the results for both the mother and the fetus after nonobstetric surgery performed during pregnancy, a multidisciplinary approach and evidence-based decision-making are essential.

General Surgery During Pregnancy and Gynecologic Emergencies

Nonobstetrical surgical emergencies can occur throughout pregnancy but are often difficult to diagnose due to the physiologic and anatomical changes that occur during pregnancy. Medical providers should have insight into these changes and be familiar with options for the diagnosis and management of common nonobstetrical surgical emergencies, such as appendicitis, cholecystitis, and small bowel obstruction. Surgeons should also be aware of obstetrical emergencies, such as ectopic pregnancy and severe vaginal bleeding, which may be life threatening to mother and the fetus. Intraoperatively, surgeons should be familiar with minimally invasive approaches for surgical diseases and special anesthetic considerations for pregnant patients.

Cushing's syndrome in pregnancy in which laparoscopic adrenalectomy was safely performed by a retroperitoneal approach

Introduction

Laparoscopic adrenalectomy is the standard treatment for adrenal tumors caused by Cushing's syndrome. However, few pregnant women have undergone adrenalectomy because of the risk of general anesthesia and surgery.

Case presentation

A 28-year-old woman presented with gradually worsening Cushing's signs at around 12 weeks of pregnancy. Magnetic resonance imaging displayed a 38-mm left adrenal tumor, which was the cause of the adrenal Cushing's syndrome. Metyrapone was started, which increased androgen levels. Since the management of Cushing's syndrome by medication alone is challenging, unilateral laparoscopic adrenalectomy by a retroperitoneal approach was performed at 23 weeks of the pregnancy. No perioperative complications were noted.

Conclusion

Adrenalectomy is considered safe in pregnant women with Cushing's syndrome. Laparoscopic adrenalectomy by retroperitoneal approach should be chosen and performed between 14 and 30 weeks of pregnancy to prevent mother and fetal complications.

Gasless laparoendoscopic single-site assisted extracorporeal ovarian cystectomy through the umbilicus for the management of ovarian torsion at 33 weeks of gestation: A case report with literature review

Ovarian torsion in the third trimester of pregnancy is a rare but potentially dangerous non-obstetric complication for both mother and fetus and presents a diagnostic and therapeutic challenge for the treating physicians. A 39-year-old woman (gravida 2, para 1) presented at 7 weeks of gestation. Asymptomatic bilateral small ovarian cysts were diagnosed at the initial presentation. Progesterone was intramuscularly administered every 2 weeks after 28 weeks of gestation because of uterine cervical length shortening. Sudden onset of right lateral abdominal pain was reported at 33 weeks and 2 days of gestation. Emergency laparoendoscopic single-site (LESS) surgery was performed through the umbilicus under strong suspicion of right adnexal torsion with ovarian cyst, as indicated by magnetic resonance imaging a day after admission. Isolated right ovarian torsion without fallopian tube involvement was identified under laparoscopic view. The contents of the right ovarian cyst were aspirated after confirming resumption of color tone of the right ovary after detorsion. Then, the right adnexal tissue was grasped through the umbilicus, followed by a successful ovarian cystectomy under direct vision. Tocolysis was postoperatively attempted by intravenous ritodorine hydrochloride and magnesium sulfate administration, which was continued through to 36 weeks and 4 days of gestation, because of increased uterine contraction frequency. The next day, spontaneous labor occurred, followed by the vaginal delivery of a healthy 2108-g female infant. The postnatal course was uneventful. Transumbilical LESS-assisted extracorporeal ovarian cystectomy is a feasible and minimally invasive option for ovarian torsion management in the third trimester of pregnancy.

Adnexal torsion in pregnancy: A systematic review of case reports and case series

OBJECTIVES

This study aimed to investigate clinical presentations, surgical procedures and findings, complications, and predisposing factors of adnexal torsion in pregnant women.

METHODS

We searched PubMed/Medline, Embase, and Web of Science from January 2000 to March 2022. All case reports and case series with full-text English language reporting adnexal torsion in pregnant women were included. Medical history, clinical presentations, surgical procedures and findings, complications related to adnexal torsion, and predisposing factors were independently extracted by two investigators.

RESULTS

A total of 182 articles reporting 662 pregnant women with adnexal torsion were included. Most of the adnexal torsions occurred during the first trimester (54.63%), while others occurred during the second (26.36%) and third (19.00%) trimesters. The most common symptom of adnexal torsion was sudden-onset pain (80.60%). Enlargement of the adnexa was the most prevalent ultrasound finding in a twisted adnexa (95.20%). Additionally, about half of the patients had decreased blood flow in Doppler ultrasound (53.80%). Laparoscopic surgery was the favorite option (56.88%), while cystectomy and detorsion were the most commonly performed procedure (29.06%). Expectant management was reported in only 2.99% of the patients. In addition, the most common complications were preterm labor (27.58%) and emergent cesarean sections (25.28%).

CONCLUSIONS

Clinicians should think of adnexal torsion when pregnant women complain of sudden-onset pain. Then, using ultrasound, adnexal enlargement or masses should be explored seriously. They should take invasive and urgent therapy to preserve ovaries and prevent complications.

Laparoscopic surgery for fallopian tube torsion due to benign tumour in the third trimester of pregnancy: a case report and literature review

Isolated fallopian tubal torsion is rare among women of reproductive age, and it is even rarer during pregnancy. Despite its rare incidence, it is important to consider this diagnosis to facilitate prompt and effective intervention. We present the case of a pregnant woman in her third trimester who presented with acute right abdominal pain. A 32-year-old primigravida woman at 29 weeks and four days of gestation visited the emergency department with acute right flank and abdominal pain. Sonography and MRI revealed the presence of a right adnexal cystic mass. Exploratory laparoscopy revealed isolated right tubal torsion and a normal ovary. To avoid torsion recurrence, we performed laparoscopic right salpingectomy. The remainder of her gestation was uneventful. Histopathological examination revealed serous cystadenoma with haemorrhagic infarction. We reviewed the literature for cases of isolated tubal torsion in the past 11 years. Twenty-three case reports were included in this study, and the average time from presentation to surgical intervention was 35.6 hours. In these cases, most of the patients underwent laparotomy and had good pregnancy outcomes. Although the approach may vary depending on the situation, the laparoscopic approach should be preferred to laparotomy in the third trimester of pregnancy.

Management of Nephrolithiasis in Pregnancy: Multi-Disciplinary Guidelines From an Academic Medical Center

Introduction: The management of nephrolithiasis during pregnancy can be stressful for urologists due to concerns for investigations and treatments that may pose risk of fetal harm, and unfamiliarity with optimal management of these complex patients. In response, we created multi-disciplinary evidence-based guidelines to standardize the care for obstetric patients presenting with flank pain and suspicion for nephrolithiasis. Methods: A multi-disciplinary team involving Urology, Obstetric Anesthesiology, Obstetrics and Gynecology, Diagnostic Radiology, and Interventional Radiology from a single academic medical center was assembled. A PubMed search was performed using keywords of pregnancy/antepartum, nephrolithiasis/calculi/kidney stones, ureteroscopy, non-obstetric surgery, complications, preterm delivery, MRI, computerized tomography, renal bladder ultrasound (RBUS), and anesthesia to identify relevant articles. Team members reviewed their respective areas to create a comprehensive set of guidelines. One invited external expert reviewed the guidelines for validation purposes. Results: A total of 54 articles were reviewed for evidence synthesis. Four guideline statements were constructed to guide diagnosis and imaging, and seven statements to guide intervention. Guidelines were then used to create a diagnostic and intervention flowchart for ease of use. In summary, RBUS should be the initial diagnostic study. If diagnostic uncertainty still exists, a non-contrast CT scan should be obtained. For obstetric patients presenting with a septic obstructing stone, urgent decompression should be achieved. We recommend ureteral stent placement as the preferred intervention if local factors allow. Conclusions: We present a standardized care pathway for the management of nephrolithiasis during pregnancy. Our aim is to standardize and simplify the clinical management of these complex scenarios for urologists.

Analysis of 190 Female Patients after Appendectomy

This study is a retrospective cohort review carried out at a single, private tertiary center. We included 190 female patients who underwent surgery for acute appendicitis between January 2016 and December 2018. Two groups of patients were analyzed based on the pregnancy. The main outcome measures were complication rate and risk of abortion during or after surgery. Out of 190 female patients, eight of them were pregnant (4.2%). The pregnant group more significantly underwent ultrasound investigation compared to the nonpregnant group. Complicated appendicitis present in two pregnant patients at advanced gestational age was not statistically significant from nonpregnant. Laparoscopic appendectomy was performed in 6/8 (75%) of pregnant compared to 158/182 (87%) in nonpregnant (p = 0.415). Compared to the nonpregnant, the pregnant group has a more fecolith, positive peritoneal fluid culture, and wound infection, with E. coli more frequently isolated in 25%. None of the pregnant patients had an abortion, preterm labor, or mortality during or after surgery. In conclusion, laparoscopic appendectomy is a low-risk operation for pregnant with acute appendicitis.

Laparoscopic treatment for appendicitis during pregnancy: Retrospective cohort study

Background

Acute appendicitis is the most frequent non-obstetric surgical emergency during pregnancy. The benefits of laparoscopy during pregnancy are well known, but complications can occur, and these can affect both the mother and/or the foetus.We present results of laparoscopic surgical treatment of acute appendicitis in pregnant women, analysing the occurrence of adverse postoperative, obstetric and foetal outcomes and reviewing literature.

Materials and methods

Retrospective observational study on pregnant women with a preoperative diagnosis of acute appendicitis.

Results

n = 63, mean age 28.4 years, average gestational age of 17.7 weeks (3-30 weeks). 6.4 % exploratory laparoscopies, 92 % laparoscopic appendectomies and one right colectomy were performed. Conversion rate was 3.2 %. When symptoms begun within 48 hours prior to surgery, a perforated appendicitis was found in 11 %; whereas when the time from symptom onset to surgery was greater than or equal to 48 hours, it was evident in 31 % of the cases (p 0.008). The only independent variable associated with the presence of postoperative complications was symptom duration prior to surgery greater than or equal to 48 hours (OR 4.8; 95 % CI 1.1-16.2; p 0.04). Seven minor and 2 mayor postoperative complications were observed. Patients with complications spent, on average, twice as many days hospitalized (p < 0.001); and had 8 times more risk of preterm delivery (p 0.03). Obstetric complications were more frequent in pregnant women operated during the first trimester. Foetal mortality was 1.6 %.

Conclusion

Surgical morbidity of acute appendicitis in pregnant women is linked to the delay in the diagnosis and treatment of the inflammatory condition. Laparoscopic appendectomy during pregnancy is not exempt from postoperative, obstetric and foetal complications. It is necessary to standardize the definitions of "complication" in order to collate reliably the outcomes presented in the literature.

Adnexal Masses in Pregnancy

Importance

Adnexal masses are identified in approximately 0.05% to 2.4% of pregnancies, and more recent data note a higher incidence due to widespread use of antenatal ultrasound. Whereas most adnexal masses are benign, approximately 1% to 6% are malignant. Proper diagnosis and management of adnexal masses in pregnancy are an important skill for obstetricians.

Objective

The aim of this study was to review imaging modalities for evaluating adnexal masses in pregnancy and imaging characteristics that differentiate benign and malignant masses, examine various types of adnexal masses, and understand complications of and explore management options for adnexal masses in pregnancy.

Evidence Acquisition

This was a literature review using primarily PubMed and Google Scholar.

Results

Ultrasound can distinguish between simple-appearing benign ovarian cysts and masses with more complex features that can be associated with malignancy. Radiologic information can help guide physicians toward recommending conservative management with observation or surgical removal during pregnancy to facilitate diagnosis and treatment. The risks of expectant management of an adnexal mass during pregnancy include rupture, torsion, need for emergent surgery, labor obstruction, and progression of malignancy. Historically, surgical removal was performed more routinely to avoid such complications in pregnancy; however, increasing knowledge has directed management toward conservative measures for benign masses. Surgical removal of adnexal masses is increasingly performed via minimally invasive techniques including laparoscopy and robotic surgery due to a decreased risk of surgical complications compared with laparotomy.

Conclusions and Relevance

Adnexal masses are increasingly identified in pregnancy because of the use of antenatal ultrasound. Clear and specific guidelines exist to help differentiate between benign and malignant masses. This is important for management as benign masses can usually be conservatively managed, whereas malignant masses require excision for diagnosis and treatment. A multidisciplinary approach, including referral to gynecologic oncology, should be used for masses with complex features associated with malignancy. Proper diagnosis and management of adnexal masses in pregnancy are an important skill for obstetricians.

Antibiotic is a safe and feasible option for uncomplicated appendicitis in pregnancy - A retrospective cohort study

INTRODUCTION

Acute appendicitis is the commonest surgical emergency during pregnancy. The aim of this study is to evaluate the outcomes between antibiotic therapy and appendectomy in the management of uncomplicated appendicitis during gestation.

METHODS

From January 2015 to April 2019, there were 2174 emergency appendicitis diagnosed in the University of Hong Kong-Shenzhen Hospital. Among them, 54 pregnant women were diagnosed with acute uncomplicated appendicitis and the clinical records were reviewed. Clinical demographics and outcomes including gestational age at delivery, mode of delivery, birth weight, APGAR score at 1 minute, fetal loss and overall length of stay were compared between the operation group and the antibiotic treatment group.

RESULTS

The baseline characteristics showed no statistically significant difference between the two groups (P > .05). In the appendectomy group (n = 20), one patient had wound infection while none of the patients in the antibiotic therapy group (n = 34) experienced any complication. In the antibiotic treatment group, appendicitis recurred in one patient during pregnancy and in two patients after deliveries, which were all treated with appendectomy. The mean hospital stay of the antibiotic treatment group was shorter than that of the appendectomy group, but there was no significant difference (4.94 ± 2.6 days vs 6.25 ± 3.5 days, P = .540). There was no difference in gestational age at delivery, mode of delivery, birth weight and APGAR scores between the two groups (P > .05).

CONCLUSIONS

For acute uncomplicated appendicitis during pregnancy, antibiotics treatment is a safe and feasible option.

Approach to Cushing's syndrome in pregnancy: two cases of Cushing's syndrome in pregnancy and a review of the literature

Cushing's syndrome (CS) rarely occurs during pregnancy. The primary aim of this article is to propose a therapeutic approach to CS in pregnancy. Here, we present two cases of CS in pregnancy and a literature review. This article proposes the early diagnostic points, especially the clinical approach to this medical condition, mainly for pregnant women without a previous diagnosis of CS. More importantly, we present therapeutic strategies for CS during pregnancy, especially glucocorticoid replacement for perioperative, postoperative, and perinatal periods in pregnant women with CS in order to minimize complications for both mother and fetus. At the same time, we also assess the anxiety status of patients. This article summarizes the approach to CS in pregnancy, not only with a physiological assessment but with a psychological assessment as well.

Urgent Laparoscopic Surgeries during the Third Trimester of Pregnancy: A Case Series

STUDY OBJECTIVE

Laparoscopic management of nonobstetric acute abdominal pain in the third trimester of pregnancy remains controversial with limited data regarding procedure safety and feasibility. This study aimed to investigate the feasibility, immediate complications, and short-term outcomes of laparoscopic surgery at an advanced gestational age.

DESIGN

Case-series.

SETTING

Sheba Medical Center, a tertiary referral center.

PATIENTS

Pregnant women who underwent urgent laparoscopic surgery at 27 weeks of gestation and above.

INTERVENTION

Emergent laparoscopic surgery.

MEASUREMENTS AND MAIN RESULTS

Clinical data were retrospectively collected and analyzed. A telephone questionnaire was administered in cases of missing data. Clinical information obtained included detailed medical and obstetric history; preoperative, intraoperative, and postoperative data; complications; and pregnancy outcomes. Between January 2010 and July 2017, 12 patients underwent emergent laparoscopic surgeries during the third trimester of pregnancy. The gestational age at the time of the surgery ranged between 27 and 38 weeks. All women had singleton pregnancies. Laparoscopic surgeries included 7 appendectomies, 4 adnexal surgeries, and 1 diagnostic laparoscopy. No complications related to the access route for any of the 12 laparoscopic surgeries occurred. The laparoscopic surgical procedure was successfully completed in 11 patients; only 1 laparoscopic appendectomy for perforated acute appendicitis with purulent peritonitis at 30 weeks of gestation was converted to laparotomy because of a limited operative field. Two patients had preterm labor at 35 and 36 weeks of gestation, respectively. None of the women was complicated with intrauterine fetal demise or low Apgar scores.

CONCLUSION

Our results demonstrate that urgent laparoscopic surgeries in the third trimester of pregnancy are feasible and can be safely performed with minimal risk for the patient and fetus. Larger prospective studies are required to validate these recommendations.

Laparoscopic appendectomy versus open appendectomy for suspected appendicitis during pregnancy: a systematic review and updated meta-analysis

BACKGROUND

Recently, laparoscopic appendectomies (LAs) have been widely performed instead of open appendectomies (OAs) during pregnancy. However, concerns about the safety of LA during pregnancy remain. This systematic review and meta-analysis aimed to evaluate the current evidence relating to the safety of LA versus OA for suspected appendicitis during pregnancy.

METHODS

Comprehensive literature searches were conducted using the PubMed, EMBASE, and Cochrane Library databases to identify articles describing LA versus OA in pregnancy, without restrictions regarding the publication date. The primary endpoints were fetal loss and preterm delivery.

RESULTS

After screening 801 studies, 22 comparative cohort studies were included in the analysis, which involved 4694 women, of whom 905 underwent LAs and 3789 underwent OAs. Fetal loss was significantly higher among those who underwent LAs compared with those who underwent OAs, and the pooled odds ratio (OR) was 1.72 (95% confidence interval [CI]: 1.22-2.42) without heterogeneity. The sensitivity analysis showed that the effect size was influenced by one of the studies, because its removal resulted in there being no significant difference between LA and OA with respect to the risk of fetal loss (OR 1.163, 95% CI: 0.68-1.99; P = 0.581). A significant difference was not evident between LA and OA with respect to preterm delivery (OR 0.76, 95% CI: 0.51-1.15), a result that did not change following the sensitivity analysis. The patients who underwent LA had shorter hospital stays (mean difference - 1.01, 95% CI: -1.61--0.41) and a lower wound infection risk (OR 0.40, 95% CI: 0.21-0.76) compared with those who underwent OA.

CONCLUSION

It is not reasonable to conclude that LA in pregnant women might be associated with a greater risk of fetal loss. The difference between LA and OA with respect to preterm delivery was not significant.

Is the laparoscopic approach a safe choice for the management of acute appendicitis in pregnant women? A meta-analysis of observational studies

INTRODUCTION

Acute appendicitis is a common and serious situation during pregnancy, because of the increased risk of fetal loss and perforation in the third trimester, as well as a diagnostic difficulty. During recent years laparoscopic approach has been introduced to clinical practice with encouraging results. The purpose of this meta-analysis is to compare the surgical and obstetrical outcomes between laparoscopic and open appendectomy during pregnancy.

MATERIALS AND METHODS

MEDLINE, SCOPUS, Clinicaltrials.gov, CENTRAL and Google Scholar were searched for studies reporting on postoperative outcomes between laparoscopic and open appendectomy during pregnancy. The random effects model (DerSimonian-Laird) was used to calculate pooled effect estimates when high heterogeneity was encountered, otherwise the fixed-effects (Mantel-Haenszel) model was implemented.

RESULTS

Twenty-one studies that enrolled 6276 pregnant women are included in the present meta-analysis. Of these women, 1963 underwent laparoscopic appendectomy and 4313 underwent an open appendectomy. Women who underwent laparoscopic appendectomy demonstrated an increase in fetal loss risk, while neonates of women that underwent open appendectomy presented decreased Apgar score at five minutes after birth. All the rest outcomes were similar between the two groups. The time that each study took place seemed to affect the comparison of birth weight and postoperative hospital stay between the two groups.

CONCLUSION

Laparoscopic appendectomy seems to be a relatively safe therapeutic option in pregnancy when it is indicated. Thus, it should be implemented in clinical practice, always considering the experience of the surgeon in such procedures. Nevertheless, the need of new studies to enhance this statement remains crucial.

Management of acute abdomen in pregnancy: current perspectives

Acute abdomen in pregnancy represents a unique diagnostic and therapeutic challenge. Acute abdominal pain in pregnancy can occur due to obstetric factors as well for reasons that are unrelated to pregnancy. The diagnostic approach of acute abdomen during pregnancy can be tricky owing to the altered clinical presentations brought about by the anatomical and physiological changes of gestation along with the reluctance to use certain radiological investigations for fear of harming the fetus. Delay in diagnosis and treatment can lead to adverse outcomes for both the mother and fetus. In this article, we attempt to review and discuss the various etiologies, the current concepts of diagnosis, and treatment, with a view to developing a strategy for timely diagnosis and management of pregnant women presenting with acute abdominal pain.

Laparoscopic appendectomy during the third trimester: Case presentation and literature review

Acute appendicitis is the most common general surgical problem encountered during pregnancy. Laparoscopic appendectomy (LA) is widely accepted as a minimally invasive procedure for acute appendicitis. However, LA during the third trimester is associated with problems, including technical difficulty, risk of preterm delivery, and fetal loss. We successfully managed three cases of LA during the third trimester between 2011 and 2016. None of the cases required conversion to an open procedure, and none of the patients had postoperative complications and/or fetal loss. We reviewed the literature using the PubMED database from 2007 to 2016 to acquire further evidence and identified 6 reports and 17 cases. The conversion rate was 11.8% (2 cases), the complication rate was 6.67% (1 case), and the preterm delivery rate was 20% (3 cases); no fetal loss was observed. Our study and literature review highlights the role of LA as a potentially feasible treatment approach for appendicitis during the third trimester.

Adnexal Torsion during Pregnancy: Outcomes after Surgical Intervention-A Retrospective Case-Control Study

STUDY OBJECTIVE

To investigate the pregnancy and neonatal outcomes of surgical treatment for adnexal torsion (AT) during pregnancy.

DESIGN

A retrospective case-control study (Canadian Task Force classification II-2).

SETTING

A tertiary care academic medical center.

MEASUREMENTS AND MAIN RESULTS

The study group included all parturients who underwent surgery for suspected AT during pregnancy from January 2005 to January 2017. The control group included parturients with an uneventful pregnancy matched by maternal age, parity, multiple gestation, and pregnancy complications. The primary outcome was gestational age at delivery. Secondary outcomes were perinatal outcomes and intraoperative and immediate postoperative complications. Among 85 study group patients with suspected AT, 78 (91.7%) underwent laparoscopy and 7 (8.3%) laparotomy. Torsion was diagnosed in 84 patients (98.8%). The gestational age at delivery was similar between the study and control groups (38.7 ± 1.5 vs 38.6 ± 1.6 weeks, respectively; p = .908) as was preterm labor (5.8% in both groups, p = 1.00). There was no significant difference between the study and control groups in pregnancy and neonatal outcomes, including Apgar scores, mean cord blood pH (7.25 ± 0.1 and 7.26 ± 0.08, respectively), and birth weight (3040 ± 473 g and 3115 ± 584 g, respectively). In the study group, the mean gestational age at surgery was 11.2 ± 6 weeks (range, 4-34 weeks). The average operative time was 40.2 ± 22 minutes. In the postoperative follow-up, 3 (3.5%) patients had a first trimester miscarriage. A previous cesarean delivery was a risk factor for ovarian torsion during pregnancy (p = .012).

CONCLUSION

Adnexal detorsion with or without additional surgical procedures during pregnancy did not affect the gestational age at delivery and did not appear to increase fetal or maternal complication rates.

Outcomes after open and laparoscopic appendectomy during pregnancy: A meta-analysis

OBJECTIVES

Acute appendicitis is the most prevalent cause of non-obstetrical surgical disease during pregnancy. There is no consensus on the optimal surgical management of acute appendicitis in pregnancy. Our aim is to identify surgical and obstetrical outcomes of laparoscopic (LA) and open approach (OA) in pregnant patients with acute appendicitis.

STUDY DESIGN

Medline, Scopus, Google Scholar, Cochrane CENTRAL Register of Controlled Trials and Clinicaltrials.gov databases were searched for articles published up to May 2017, along with the references of all articles. Prospective and retrospective trials reporting outcomes among pregnant women undergoing laparoscopic and open appendectomy were included. Of the 493 records screened, 20 were eligible for meta-analysis. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Statistical meta-analysis was performed using the RevMan 5.3 software.

RESULTS

A total of 6210 pregnant women from twenty studies were included in meta-analysis. Laparoscopic appendectomy was associated with significantly lower overall complication rates and shorter hospital stays (1835 patients OR 0.48 95% CI 0.29, 0.80 p = 0.005). While the open appendectomy group showed prolongation of gestational age for term deliveries, laparoscopic appendectomy patients had higher rates of fetal loss (543 patients MD -0.46 weeks 95% CI-0.87 to -0.04, p = 0.03 and 4867 patients OR 1.82 95% CI 1.30 to 2.57, p = 0.0006, respectively).

CONCLUSIONS

Current literature remains inconclusive on the optimal approach of appendectomy in pregnant women. Further larger-volume studies are needed in order to elucidate the critical effect of laparoscopic appendectomy on fetal loss rates.

Maternal Exposure of Rats to Isoflurane during Late Pregnancy Impairs Spatial Learning and Memory in the Offspring by Up-Regulating the Expression of Histone Deacetylase 2

Increasing evidence indicates that most general anesthetics can harm developing neurons and induce cognitive dysfunction in a dose- and time-dependent manner. Histone deacetylase 2 (HDAC2) has been implicated in synaptic plasticity and learning and memory. Our previous results showed that maternal exposure to general anesthetics during late pregnancy impaired the offspring's learning and memory, but the role of HDAC2 in it is not known yet. In the present study, pregnant rats were exposed to 1.5% isoflurane in 100% oxygen for 2, 4 or 8 hours or to 100% oxygen only for 8 hours on gestation day 18 (E18). The offspring born to each rat were randomly subdivided into 2 subgroups. Thirty days after birth, the Morris water maze (MWM) was used to assess learning and memory in the offspring. Two hours before each MWM trial, an HDAC inhibitor (SAHA) was given to the offspring in one subgroup, whereas a control solvent was given to those in the other subgroup. The results showed that maternal exposure to isoflurane impaired learning and memory of the offspring, impaired the structure of the hippocampus, increased HDAC2 mRNA and downregulated cyclic adenosine monophosphate (cAMP) response element binding protein (CREB) mRNA, N-methyl-D-aspartate receptor 2 subunit B (NR2B) mRNA and NR2B protein in the hippocampus. These changes were proportional to the duration of the maternal exposure to isoflurane and were reversed by SAHA. These results suggest that exposure to isoflurane during late pregnancy can damage the learning and memory of the offspring rats via the HDAC2-CREB -NR2B pathway. This effect can be reversed by HDAC2 inhibition.

Propofol exposure during late stages of pregnancy impairs learning and memory in rat offspring via the BDNF-TrkB signalling pathway

The brain‐derived neurotrophic factor (BDNF)‐tyrosine kinase B (TrkB) (BDNF‐TrkB) signalling pathway plays a crucial role in regulating learning and memory. Synaptophysin provides the structural basis for synaptic plasticity and depends on BDNF processing and subsequent TrkB signalling. Our previous studies demonstrated that maternal exposure to propofol during late stages of pregnancy impaired learning and memory in rat offspring. The purpose of this study is to investigate whether the BDNF‐TrkB signalling pathway is involved in propofol‐induced learning and memory impairments. Propofol was intravenously infused into pregnant rats for 4 hrs on gestational day 18 (E18). Thirty days after birth, learning and memory of offspring was assessed by the Morris water maze (MWM) test. After the MWM test, BDNF and TrkB transcript and protein levels were measured in rat offspring hippocampus tissues using real‐time PCR (RT‐PCR) and immunohistochemistry (IHC), respectively. The levels of phosphorylated‐TrkB (phospho‐TrkB) and synaptophysin were measured by western blot. It was discovered that maternal exposure to propofol on day E18 impaired spatial learning and memory of rat offspring, decreased mRNA and protein levels of BDNF and TrkB, and decreased the levels of both phospho‐TrkB and synaptophysin in the hippocampus. Furthermore, the TrkB agonist 7,8‐dihydroxyflavone (7,8‐DHF) reversed all of the observed changes. Treatment with 7,8‐DHF had no significant effects on the offspring that were not exposed to propofol. The results herein indicate that maternal exposure to propofol during the late stages of pregnancy impairs spatial learning and memory of offspring by disturbing the BDNF‐TrkB signalling pathway. The TrkB agonist 7,8‐DHF might be a potential therapy for learning and memory impairments induced by maternal propofol exposure.

Laparoscopic surgery performed in advanced pregnancy compared to early pregnancy

PURPOSE

The aim of our study was to assess the clinical and obstetric outcomes of laparoscopic surgeries performed during advanced pregnancy compared to those performed in early pregnancy.

METHODS

We retrospectively reviewed all cases of patients who underwent laparoscopic surgery during pregnancy in our institution between 1996 and 2013.

RESULTS

We reviewed cases of 117 pregnant women who underwent laparoscopic surgery during the study period. There were no conversions to laparotomy. 71 surgeries were performed in the first trimester (group 1, mean gestational age 7.7 ± 1.9 weeks) and 46 were performed in the second and third trimesters (group 2, mean gestational age 18.1 ± 4.3 weeks). More patients in group 1 underwent surgery for suspected adnexal torsion (p < 0.001), while more patients in group 2 underwent surgery for presumptive cholecystitis (p = 0.014) and persistent ovarian mass (p = 0.011). The interval between admission and surgery differed significantly between the groups and was longer in group 2 compared to group 1 (18.2 ± 24.0 vs. 6.8 ± 10.6 h, p = 0.001). No difference was found between the two groups regarding surgical complications, histopathological findings and pregnancy outcomes.

CONCLUSION

In our experience, laparoscopic surgery in advanced pregnancy was found to be feasible and safe as in early pregnancy, without any adverse effects on pregnancy outcome.

Abdominal surgery in pregnancy--an interdisciplinary challenge

BACKGROUND

Abdominal operations are performed during ca. 2% of all pregnancies. They represent an unusual situation not only for the patient, but also for the involved surgeons and anesthesiologists. Appendectomy, followed by cholecystectomy are the two most common types of operation performed during pregnancy. Special questions arise with regard to the peri- and intraoperative management and the optimal surgical approach.

METHOD

This review is based on pertinent articles retrieved by a selective search in the PubMed database.

RESULTS

The question of laparoscopy versus laparotomy during pregnancy has been addressed to date only in case series and a few meta-analyses. Two meta-analyses have shown a significantly higher rate of miscarriage after laparoscopic, compared to open, appendectomy (relative risk [RR] 1.91, 95% confidence interval [CI] 1.31-2.77). The risk of preterm birth is also somewhat higher after laparoscopic appendectomy according to one meta-analysis on this subject (RR 1.44, 95% CI 0.78-1.76), but significantly lower according to another meta-analysis (2.1% vs. 8.1%, p<0.0001). For cholecystectomy, laparoscopy was associated with a lower miscarriage rate than laparotomy (1 in 89 cases, versus 2 in 69 cases), but with a somewhat higher preterm birth rate (6 in 89 cases, versus 2 in 69 cases). Delay or non-performance of surgery in a patient with appendicitis or cholecystitis can lead to additional hospitalizations, a higher miscarriage rate, premature rupture of the membranes, and preterm birth.

CONCLUSION

Laparoscopy in experienced hands is safe even during pregnancy, with the recognized advantages of minimally invasive surgery, yet it carries a higher miscarriage rate than laparotomy, with a comparable preterm birth rate. Before surgery, patients should be thoroughly informed about the operation they are about to undergo and the advantages and disadvantages of the available surgical approaches.

A Pregnant Woman Who Underwent Laparoscopic Adrenalectomy due to Cushing's Syndrome

Cushing's syndrome (CS) may lead to severe maternal and fetal morbidities and even mortalities in pregnancy. However, pregnancy complicates the diagnosis and treatment of CS. This study describes a 26-year-old pregnant woman admitted with hypertension-induced headache. Hormonal analyses performed due to her cushingoid phenotype revealed a diagnosis of adrenocorticotropic hormone- (ACTH-) independent CS. MRI showed a 3.5 cm adenoma in her right adrenal gland. After preoperative metyrapone therapy, she underwent a successful unilateral laparoscopic adrenalectomy at 14-week gestation. Although she had a temporary postoperative adrenal insufficiency, hormonal analyses showed that she has been in remission since delivery. Findings in this patient, as well as those in previous patients, indicate that pregnancy is not an absolute contraindication for laparoscopic adrenalectomy. Rather, such surgery should be considered a safe and efficient treatment method for pregnant women with cortisol-secreting adrenal adenomas.

Laparoscopic appendicectomy in pregnancy: a systematic review of the published evidence

Surgical intervention for acute appendicitis during pregnancy carries significant risk to both mother and foetus. The safety of Laparoscopic Appendicectomy in pregnancy has been a matter of debate among clinicians. We have critically reviewed the available published evidence in regards with this debate.

CONCLUSION

There is no strong current evidence as to the preferred modality of appendicectomy; open or laparoscopic, during pregnancy from the prospect of foetal or maternal safety. However, low grade evidence shows that laparoscopic appendicectomy during pregnancy might be associated with higher rates of foetal loss.

Clinical outcomes compared between laparoscopic and open appendectomy in pregnant women

BACKGROUND

Despite the initial absolute or relative contraindication of laparoscopic surgery during pregnancy, in the last decade, laparoscopic appendectomy (LA) has been performed in pregnant women. But few studies compare the outcomes of LA compared with open appendectomy (OA). We investigated clinical outcomes to evaluate the safety and efficacy of LA compared with OA in pregnant women.

METHODS

We recruited consecutive pregnant patients with a diagnosis of acute appendicitis who were undergoing LA or OA between May 2007 and August 2011 into the study.

RESULTS

Sixty-one patients (22 LA and 39 OA) enrolled in our study. There were no significant differences in duration of surgery, postoperative complication rate and obstetric and fetal outcomes, including incidence of preterm labour, delivery type, gestation age at delivery, birth weight and APGAR scores between the 2 groups. However, the LA group had shorter time to first flatus (2.4 ± 0.4 d v. 4.0 ± 1.7 d, p = 0.034), earlier time to oral intake (2.3 ± 1.6 d v. 4.1 ± 1.9 d, p = 0.023) and shorter postoperative hospital stay (4.2 ± 2.9 d v. 6.9 ± 3.7 d, p = 0.043) than the OA group.

CONCLUSION

Laparoscopic appendectomy is a clinically safe and effective procedure in all trimesters of pregnancy and should be considered as a standard treatment alternative to OA. Further evaluation including prospective randomized clinical trials comparing LA with OA are needed to confirm our results.

Systematic review and meta-analysis of safety of laparoscopic versus open appendicectomy for suspected appendicitis in pregnancy

BACKGROUND

Laparoscopic appendicectomy has gained wide acceptance as an alternative to open appendicectomy during pregnancy. However, data regarding the safety and optimal surgical approach to appendicitis in pregnancy are still controversial.

METHODS

This was a systematic review and meta-analysis of studies comparing laparoscopic and open appendicectomy in pregnancy identified using PubMed and Scopus search engines from January 1990 to July 2011. Two reviewers independently extracted data on fetal loss, preterm delivery, wound infection, duration of operation, hospital stay, Apgar score and birth weight between laparoscopic and open appendicectomy groups.

RESULTS

Eleven studies with a total of 3415 women (599 in laparoscopic and 2816 in open group) were included in the analysis. Fetal loss was statistically significantly worse in those who underwent laparoscopy compared with open appendicectomy; the pooled relative risk (RR) was 1·91 (95 per cent confidence interval (c.i.) 1·31 to 2·77) without heterogeneity. The pooled RR for preterm labour was 1·44 (0·68 to 3·06), but this risk was not statistically significant. The mean difference in length of hospital stay was - 0·49 (-1·76 to - 0·78) days, but this was not clinically significant. No significant difference was found for wound infection, birth weight, duration of operation or Apgar score.

CONCLUSION

The available low-grade evidence suggests that laparoscopic appendicectomy in pregnant women might be associated with a greater risk of fetal loss.

Adrenalectomy for adrenocortical adenoma causing Cushing's syndrome in pregnancy: a case report and review of literature

We present a case of adrenocorticotropic hormone (ACTH)-independent Cushing's syndrome diagnosed in a patient in the third trimester of her pregnancy, with an adrenal mass observed on imaging studies. Laparoscopic adrenalectomy was performed successfully at 32 weeks. To the best of our knowledge, this is the latest gestational age at which laparoscopic adrenalectomy has been reported. We present the various considerations for determining the surgical approach and the optimal timing for surgery. Adrenalectomy during pregnancy for the treatment of Cushing's syndrome caused by adrenocortical adenoma has been reported in 23 patients in the English-language medical literature to date and seems safe and beneficial. According to the data, surgical treatment has led to a reduction in perinatal mortality and maternal morbidity rates, but has not affected the occurrence of preterm birth and intrauterine growth restriction. The best outcome can be achieved by a multidisciplinary approach, with a team comprising a maternal-fetal medicine specialist, an endocrinologist and a surgeon. The timing of surgery and the surgical approach need to be determined according to the surgeon's expertise, the severity of the condition, the patient's preferences, and gestational age. Laparoscopy may prove to be the preferred surgical approach. The small number of cases precludes providing evidence-based recommendations.

Obstetric complications of ureteroscopy during pregnancy

PURPOSE

During pregnancy a ureteral stone and its management may pose risks for the mother and fetus. Definitive ureteroscopic management of an obstructing stone during pregnancy has been increasingly used without a reported increased incidence of urological complications. However, the rate of obstetric complications of ureteroscopy during pregnancy remains undefined.

MATERIALS AND METHODS

Charts of pregnant women who had undergone ureteroscopy at 5 tertiary centers were reviewed. Patient and procedure characteristics were collected. Records were evaluated for the occurrence of obstetric complications in the postoperative period.

RESULTS

A total of 46 procedures were performed in 45 patients at 5 institutions. There were 2 obstetric complications (4.3%), including 1 preterm labor managed conservatively and 1 preterm labor resulting in preterm delivery. There was no fetal loss. No statistically significant characteristics were identified differentiating those patients having obstetric complications.

CONCLUSIONS

Ureteroscopy performed during pregnancy has been previously reported to be urologically safe and effective for addressing ureteral stones. In our multi-institutional series a 4% rate of obstetric complications was observed. Based on this risk a multidisciplinary approach is prudent for the pregnant patient undergoing ureteroscopy.

Laparoscopic management of fallopian tube torsion at 35 weeks of gestation: case report

Isolated fallopian tube torsion requiring surgical intervention in pregnancy is rare. Herein is reported a case of fallopian tube torsion that was managed laparoscopically at 35 weeks of gestation.

Risks associated with laparoscopic entry: guidelines for clinical practice from the French College of Gynaecologists and Obstetricians

The aim of these recommendations of the French National College of Gynaecologists and Obstetricians was to focus the surgeon's attention on those aspects which could allow him/her to prevent, or at least limit, the incidence of these serious complications, in the absence of a previous laparotomy or specific risk factors (obesity, gauntness, large pelvic mass or pregnancy), four widely evaluated techniques can be used in a first line approach (Grade B): blind trans-umbilical technique following creation of pneumoperitoneum with a needle, open laparoscopy (Hasson technique), left upper quadrant entry (pneumoperitoneum and insertion of the first trocar) and direct trans-umbilical trocar with no prior pneumoperitoneum. The currently existing trials do not allow one or another of these techniques to be preferred. Radially expanding insertion systems and optical trocars cannot be recommended as a first-line approach, as a consequence of their currently insufficient degree of evaluation (Grade C). Trans-umbilical (blind or open) laparoscopic entry in a slim woman must be associated with care, as a result of the proximity of the large vessels (Grade B). If a blind trans-umbilical insertion technique is decided upon, one option can be to insufflate into the left upper quadrant (professional consensus). In the case of a previous midline laparotomy, whatever the technique used, initial entry is recommended at a distance from the scars (Grade B). It is recommended to carry out micro-laparoscopy in the LUQ, because this is the most completely evaluated technique for this indication (Grade C). One option is to use open laparoscopy at a distance from the existing scars (professional consensus). During pregnancy, the insertion position of the first laparoscopic trocar will need to be adapted according to the volume of the uterus (Grade B). Starting from 14WG, trans-umbilical Veress needle insufflation is contraindicated (Grade C). Two trocar insertion techniques are thus recommended: open laparoscopy (using the trans-umbilical or supra-umbilical routes, depending on the volume of the uterus) or micro-laparoscopy via the left upper quadrant (Grade C). After the second quarter of pregnancy, with laparoscopy the patient will need to be placed on a table inclined towards her left side, in order to minimize compression of the inferior vena cava (Grade B). In the case of laparoscopy during pregnancy, the insufflation pressure must be maintained at a maximum of 12mmHg (Grade B). After 24WG, if laparoscopy is performed, it is recommended to apply open laparoscopy, above the level of the umbilicus (professional consensus). Patients must be informed of the risks inherent to the insertion of trocars during laparoscopy (vascular, bowel or bladder injury) (Grade B). The more benign the pathology requiring an operation, the more detailed the supplied information must be, including that concerning rare but serious complications (Grade B).

Appendectomy during the third trimester of pregnancy in a 27-year old patient: case report of a "near miss" complication

The management of acute appendicitis during pregnancy is not fully established, especially regarding the choice between open and laparoscopic surgery during the third trimester. We report herein the case of a major uterine variecele hemorrhage during a laparoscopic appendectomy in a 27-year old pregnant patient at 33 weeks of amenorrhea. After conversion to a Pfannenstiel incision, the baby was delivered, the bleeding stopped and the appendectomy completed. While both mother and child fully recovered, this «near miss» complication underlines the challenges linked to the management of acute appendicitis during pregnancy. Based on a literature review, we propose an algorithm favoring the laparoscopic approach during the first and second trimesters, and the open approach during the third trimester (especially after the 26th week of amenorrhea). In case of unclear pre-operative diagnosis, a laparoscopy should be conducted even during the third trimester with a Mc Burney conversion when the diagnosis of appendicitis is confirmed.

Laparoscopic cholecystectomy in the third trimester of pregnancy: report of 3 cases

AIM

Symptomatic cholelithiasis and acute appendicitis are the most common surgical conditions requiring nonobstetric abdominal surgery during pregnancy. Cholelithiasis is diagnosed in 0.07% of pregnancy and in about 40% of these patients surgery may be required. Pregnancy was once considered an absolute contraindication for laparoscopic surgery, but pregnant patients undergoing laparoscopic surgery have been reported increasingly in the past decade. However, most case reports and case series are confined to patients in the first and second trimester. We report here 3 patients who underwent laparoscopic cholecystectomy in the third trimester and review the relevant literature.

METHODS

Pregnant women in the third trimester who underwent laparoscopic cholecystectomy were reviewed between the years 2000 and 2004 at our hospital.

RESULTS

Three pregnant patients in the third trimester at a gestational age of 28 weeks, and 2 at 26 weeks underwent laparoscopic cholecystectomy. Initial port was placed in all patients by Hasson open technique, few centimeters cephalad to fundal height. The insufflation pressure was maintained between 12 to 14 mm Hg. The duration of surgery ranged from 64 to 80 minutes (mean: 72 min). Obstetric assessment was carried out preoperatively and fetal well-being was monitored postoperatively. Tocolytic agents were used in 2 patients. There were no intraoperative or postoperative complications. All patients were discharged on the second postoperative day. All the 3 patients delivered healthy babies normally at full term (range: 39 to 40 wk).

CONCLUSION

Laparoscopic cholecystectomy can be carried out safely in the third trimester of pregnancy with minimal risk to the fetus and the mother.