Williams Manual of Pregnancy Complications, 23 ed.

CHAPTER 88. Surgery during Pregnancy

EFFECT OF SURGERY AND ANESTHESIA ON PREGNANCY OUTCOME

The risk of an adverse pregnancy outcome is not appreciably increased in women who undergo most uncomplicated surgical procedures. However, the risk may be increased when there are complications. For example, perforative appendicitis with feculent peritonitis has significant maternal and perinatal morbidity and mortality even if surgical and anesthetic techniques are flawless. Conversely, procedure-related complications may adversely affect pregnancy outcome. For example, a woman who has uncomplicated removal of an inflamed appendix may suffer aspiration of acidic gastric contents during extubation.

Traditional obstetric teaching has been that midpregnancy is the preferred time to perform elective abdominal procedures. There is little evidence that surgical procedures (or the required anesthetic agents) induce fetal malformations. A good principle of management is to never forego a surgical procedure when maternal health and welfare would ordinarily mandate completion of the procedure if the woman had not been pregnant. The policy at Parkland Hospital is to wait until the second trimester to perform elective surgery (e.g., a pelvic adnexal mass) and otherwise promptly operate when maternal health would be jeopardized without surgery—and regardless of gestational age.

LAPAROSCOPIC SURGERY DURING PREGNANCY

Over the past decade, the use of laparoscopic techniques has become common for diagnosis and management of a number of surgical disorders complicating pregnancy. The obvious application is for the diagnosis and management of ectopic pregnancy (see Chapter 2). Laparoscopy has also been used for exploration and treatment of adnexal masses and for cholecystectomy or appendectomy.

The precise effects of laparoscopy in the human fetus are currently unknown. Potential risks that are unique to laparoscopy include inadvertent intrauterine placement of the Veress needle and reduced uteroplacental blood flow associated with excessive insufflation of the peritoneum with carbon dioxide. To avoid these risks, some clinicians now recommend open or gasless laparoscopy during pregnancy. Importantly, however, there have been no significant differences in outcomes when laparoscopy has been compared with laparotomy during pregnancy.


For further reading in Williams Obstetrics, 23rd ed.,

see Chapter 41, “General Considerations and Maternal Evaluation.”