The Acute Abdomen in Pregnant Women After Roux-en-Y Gastric Bypass: Encouraging Results from a National Referral Centre

Imaging of Acute Abdominopelvic Pain in Pregnancy and Puerperium-Part II: Non-Obstetric Complications

Emergency imaging in pregnancy and puerperium poses unique challenges both for clinicians and radiologists, requiring timely and accurate diagnosis. Delay in treatment may result in poor outcomes for both the patient and the foetus. Pregnant and puerperal patients may present in the emergency setting with acute abdominopelvic pain for various complications that can be broadly classified into obstetric and non-obstetric related diseases. Ultrasonography (US) is the primary diagnostic imaging test; however, it may be limited due to the patient's body habitus and the overlapping of bowel loops. Computed tomography (CT) carries exposure to ionising radiation to the foetus, but may be necessary in selected cases. Magnetic resonance imaging (MRI) is a valuable complement to US in the determination of the etiology of acute abdominal pain and can be used in most settings, allowing for the identification of a broad spectrum of pathologies with a limited protocol of sequences. In this second section, we review the common non-obstetric causes for acute abdominopelvic pain in pregnancy and post partum, offering a practical approach for diagnosis and pointing out the role of imaging methods (US, MRI, CT) with the respective imaging findings.

Surgical complications in pregnancy after bariatric surgery; a case series

BACKGROUND

Obesity is a rising world-wide problem and bariatric surgery, also in the reproductive age, is increasingly performed. Bariatric procedures are associated with surgical complications during pregnancy, such as internal herniation.

CASES

In this case series three cases with severe surgical complications after Roux-Y gastric bypass are described. In all three cases surgery was needed to prevent further complications. In one case subtotal bowel resection had to be performed because of extensive necrosis and intra-uterine fetal death was found.

CONCLUSION

Though surgical complications after Roux-Y gastric bypass are not very common, complications can be very serious and lead to severe morbidity and even mortality for mother and fetus. Because of the severity of complications, delaying bariatric surgery or considering alternative bariatric techniques with fewer (severe) complications should be considered in obese women in childbearing age.

Adverse Fetal Outcomes and Maternal Mortality Following Nonobstetric Abdominopelvic Surgery in Pregnancy: A Systematic Review and Meta-analysis

OBJECTIVE

To quantify the absolute risks of adverse fetal outcomes and maternal mortality following nonobstetric abdominopelvic surgery in pregnancy.

SUMMARY BACKGROUND DATA

Surgery is often necessary in pregnancy, but absolute measures of risk required to guide perioperative management are lacking.

METHODS

We systematically searched MEDLINE, EMBASE, and EvidenceBased Medicine Reviews from January 1, 2000, to December 9, 2020, for observational studies and randomized trials of pregnant patients undergoing nonobstetric abdominopelvic surgery. We determined the pooled proportions of fetal loss, preterm birth, and maternal mortality using a generalized linear random/mixed effects model with a logit link.

RESULTS

We identified 114 observational studies (52 [46%] appendectomy, 34 [30%] adnexal, 8 [7%] cholecystectomy, 20 [17%] mixed types) reporting on 67,111 pregnant patients. Overall pooled proportions of fetal loss, preterm birth, and maternal mortality were 2.8% (95% CI 2.2-3.6), 9.7% (95% CI 8.3-11.4), and 0.04% (95% CI 0.02-0.09; 4/10,000), respectively. Rates of fetal loss and preterm birth were higher for pelvic inflammatory conditions (eg, appendectomy, adnexal torsion) than for abdominal or nonurgent conditions (eg, cholecystectomy, adnexal mass). Surgery in the second and third trimesters was associated with lower rates of fetal loss (0.1%) and higher rates of preterm birth (13.5%) than surgery in the first and second trimesters (fetal loss 2.9%, preterm birth 5.6%).

CONCLUSIONS

Absolute risks of adverse fetal outcomes after nonobstetric abdom- inopelvic surgery vary with gestational age, indication, and acuity. Pooled estimates derived here identify high-risk clinical scenarios, and can inform implementation of mitigation strategies and improve preoperative counselling.

Risk factors of lower birth weight, small-for-gestational-age infants, and preterm birth in pregnancies following bariatric surgery: a scoping review

PURPOSE

Bariatric surgery increases the risk of lower birth weight, small-for-gestational-age (SGA) infants, and preterm birth in a subsequent pregnancy. However, the factors that contribute to these adverse birth outcomes are unclear. This review aimed to collate available information about risk factors of lower birth weight, SGA, and preterm birth following bariatric surgery.

METHODS

A literature search was conducted using five databases (PubMed, PsycINFO, EMBASE, Web of Science, and Cochrane Library) to obtain relevant studies.

RESULTS

A total number of 85 studies were included. Studies generally excluded surgery-to-conception interval, pregnancy complications, cigarette use, and maternal age as influencing factors of birth weight, SGA, or preterm birth. In contrast, most studies found that malabsorptive procedures, lower gestational weight gain, lower glucose levels, abdominal pain, and insufficient prenatal care were associated with an elevated risk of adverse birth outcomes. Findings were mixed regarding the effects of surgery-to-conception weight loss, pre-pregnancy body mass index, micronutrient deficiency, and lipid levels on birth outcomes. The examination of maternal microbiome profiles, placental function, alcohol use, and exercise was limited to one study; therefore, no conclusions could be made.

CONCLUSION

This review identified factors that appear to be associated (e.g., surgery type) or not associated (e.g., surgery-to-conception interval) with birth outcomes following bariatric surgery. The mixed findings and the limited number of studies on several variables (e.g., micronutrients, exercise) highlight the need for further investigation. Additionally, future studies may benefit from exploring interactions among risk factors and expanding to assess additional exposures such as maternal mental health.

Pregnant Women After Bariatric Surgery: Diagnostic Accuracy of Magnetic Resonance Imaging for Small Bowel Obstruction

BACKGROUND

Small bowel obstruction (SBO) is a late complication of Roux-en-Y gastric bypass (RYGB). In non-pregnant patients, computed tomography (CT) is the first choice of imaging. During pregnancy, magnetic resonance imaging (MRI) is preferred to limit exposure to ionizing radiation. However, literature regarding the diagnostic accuracy of MRI for SBO is scarce.

OBJECTIVE

To describe the diagnostic accuracy of MRI for SBO during pregnancy.

METHODS

Pregnant women with RYGB suspected for SBO who presented at our center between September 2015 and April 2020 and who received an MRI scan (index) and underwent surgery (reference) were included. Original reports were retrospectively evaluated. Available MRI scans were structurally reinterpreted by two experienced radiologists. Statistical analysis included sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and Cohen's kappa.

RESULTS

Twenty-seven original MRI reports were included. Twenty-four (89%) MRIs were of good quality. Sensitivity was 67% (confidence interval (CI) 0.43-0.85), specificity 67% (CI 0.13-0.98), PPV 93% (CI 0.66-0.99), and NPV 22% (CI 0.04-0.60). MRI was unable to detect SBO in 1 out of 3 patients. The presence of swirl sign, SBO sign, or clustered loop sign increases the likelihood of SBO. The interobserver agreement was overall wide, with the highest score for swirl sign (κ 0.762).

DISCUSSION

MRI is a safe and feasible alternative for CT. The value is doubtful as diagnostic accuracy shows wide ranges with considerable variability in the interobserver agreement. We would cautiously advise to perform MRI in case of a mild clinical presentation, but in case of a severe clinic, the diagnostic laparoscopy should remain the gold standard.