Cardiovascular
↑Plasma blood volume (40–50 %)
↑SV
↑CO (50 %)
↓SVR
↓BP, ↑HR
Pulmonary
↔TLC
↓FRC
↑IC
↑MV
Hematology
↑RBC volume
↓Hcta
↑Hypercoagulable state
Gastrointestinal
↓Gastric emptying
↓GEJ tone
↓Colonic motility
The cardiovascular system is affected by an increased plasma blood volume of 40–50 %. This triggers an augmented stroke volume and a 50 % increase in cardiac output [8]. Circulating increased progesterone levels cause a decrease in systemic vascular resistance and subsequent lower blood pressure with an increased heart rate by an average of 15 beats per minute. Additionally, there is a 20–30 % increase in red blood cell volume, which combined with increased plasma blood volume causes a purely dilutional decrease in the patient’s hematocrit. Furthermore, increased hepatic production of coagulation factors causes a hypercoagulable state, which in addition to decreased activity can result in a significant risk for developing blood clots and emboli.
Changes in the respiratory system during pregnancy also take place. The enlarging uterus displaces the diaphragm cephalad and increases intra-abdominal pressure [9]. To compensate, relaxation of the rib-cage ligaments occurs with a resultant increase in chest wall size. While the total lung capacity (TLC) remains the same in pregnancy, there is a 20–30 % decrease in functional residual capacity (FRC) and its components: expiratory reserve volume (ERV) and residual volume (RV). A compensatory increase in inspiratory capacity (IC), through a 30–50 % increase in tidal volume (Vt), maintains the TLC. This maintenance of lung capacity is evident in spirometry testing (i.e., FEV1), which is not significantly different between pregnant and nonpregnant patients. Finally, there is an increase in minute ventilation, which is also attributed to an increased tidal volume. Clinically, 60–70 % of pregnant patients complain of dyspnea on exertion with 20 % of patients experiencing dyspnea at rest [10]. This dyspnea is attributed to the ventilatory stimulating effect of progesterone.
Gastrointestinal effects include delayed gastric emptying, decreased gastroesophageal tone and decreased colonic motility [11]. Clinically, patients are more prone to abdominal bloating, acid reflux, and constipation. All of these are important considerations when contemplating general anesthesia.
In addition to the physiologic changes that occur during pregnancy, significant anatomical alterations occur. Weight gain, which is expected to be between 25 and 35 lb during pregnancy [12], can vary drastically from patient to patient and may affect surgical approach. Additionally, the gravid uterus increases in size from 7.5 to 35 cm and enters into the abdominal cavity at the beginning of the second trimester, thus potentially affecting surgical approach and trocar placement.
Indications for Laparoscopy
Indications for laparoscopy in pregnancy are the same as those in the nonpregnant patient (Table 33.2) [3]. Benefits of laparoscopy including less postoperative pain, decreased postoperative ileus, shorter length of hospital stay, and quicker return to work are similar in pregnant and nonpregnant patients [13]. Historical recommendations included delaying surgery until the second trimester as a strategy to avoid fetal loss during the first trimester. This has been challenged with reports that show that laparoscopy can be performed safely in any trimester [13, 14]. In fact, postponing surgery may result in increased maternal and fetal morbidity, as noted by Babler in 1908, who stated that the “the mortality of appendicitis complicating pregnancy is the mortality of delay” [15].
Table 33.2
Indications for laparoscopy during pregnancy
What can wait | What can’t wait |
|---|---|
Small bowel obstruction (early) | Acute appendicitis |
Acute uncomplicated diverticulitis | Acute cholecystitis, recurrent cholelithiasis |
Inflammatory bowel disease exacerbation (mild) | Small bowel obstruction (late, complete) |
Acute complicated diverticulitis | |
Incarcerated hernia | |
Volvulus/necrotic bowel | |
Peritonitis | |
Inflammatory bowel disease exacerbation (severe) | |
Colorectal cancera |
What Can Wait?
Small Bowel Obstruction (Early)
Small bowel obstruction secondary to adhesions in a pregnant patient can be managed expectantly as in the nonpregnant patient. Failed conservative management, complete bowel obstruction, worsening abdominal pain, fever, leukocytosis, or other signs of deterioration should prompt immediate surgical intervention.
Acute Uncomplicated Diverticulitis
Acute diverticulitis can occur in young patients and may occur during pregnancy. If a patient presents with an episode of uncomplicated diverticulitis, i.e., mild abdominal pain and leukocytosis, without evidence of sepsis or free perforation, conservative management with IV or oral antibiotics and decreased po intake is acceptable. Inpatient observation should be considered to ensure the patient responds appropriately.
Mild Inflammatory Bowel Disease Exacerbations
Inflammatory bowel disease (IBD) occurs most frequently in young adults during their reproductive years, making it a possible manifestation of abdominal pain in the pregnant patient. While the course of IBD is similar in the pregnant and nonpregnant patient, approximately one-third to one-half of patients with quiescent disease at the time of conception will relapse during the first trimester or postpartum period [11, 16, 17]. These exacerbations are more common in patients with active or uncontrolled disease at the time of conception [16]. Mild and moderate attacks should be managed medically with aminosalicylates, antibiotics, steroids, and, when necessary, immunosuppressive therapy. Variable effects on preterm labor and fetal outcome have been reported [11, 18]. It has been shown, however, that the majority of patients can be managed successfully with medical therapy and carry their fetuses to term [16]. In the setting of clinical deterioration or nonresponse to medical management, pregnant patients should be managed surgically as the nonpregnant patient.
What Can’t Wait?
Acute Appendicitis
Appendicitis is the most common indication for non-obstetrical surgery during pregnancy with an incidence of 1:500 to 1:3,000 pregnancies [2, 19]. Acute appendicitis is considered a surgical emergency in pregnancy, with perforated appendicitis being the most common surgical cause of fetal loss [20]. While appendicitis during pregnancy was historically considered a contraindication to laparoscopy, many patients have been successfully treated with this procedure since it was first performed by Semm in 1981 [21]. Subsequently, multiple studies have shown that this approach offers similar advantages of shorter hospital stay, less postoperative pain, and faster return to daily activities over the open approach [22, 23]. Additionally, the ability to locate an ectopic appendix displaced by a gravid uterus, decreased manipulation of the uterus (which may result in decreased irritability and fetal loss), and an ability to explore the abdominal cavity for an alternate source of pain when a normal appendix is encountered are all benefits of laparoscopy [13, 22–24].
Acute Cholecystitis and Symptomatic Cholelithiasis
Acute cholecystitis associated with repeated attacks, obstructive jaundice, gallstone pancreatitis, and peritonitis is an indication for cholecystectomy during pregnancy. Whether to perform cholecystectomy for symptomatic cholelithiasis during pregnancy has remained a controversial issue. Historically, nonoperative management was advocated. Yet, several studies have shown that conservative management results in higher morbidity and pregnancy-related complications [6, 7, 25]. In patients treated nonoperatively, the number of recurrent episodes of biliary symptoms, emergency department visits, and hospitalizations is higher. Additionally, early induction of labor is more common in these patients [6, 25]. In contrast, laparoscopic cholecystectomy performed in any trimester of pregnancy can be performed safely with a very low risk to the patient and fetus [13, 25]. These findings, combined with the ability to decrease morbidity from recurrent attacks, have made laparoscopic cholecystectomy the treatment of choice in pregnant patients, regardless of the trimester [3].
Small Bowel Obstruction (Late, Complete)
While conservative management of bowel obstruction in pregnancy should be utilized as the first management strategy, bowel obstruction remains the third most common cause for non-obstetrical surgery in pregnancy. It is most common in the third trimester because of the enlarged gravid uterus and has increased in incidence as a greater number of patients undergo intestinal Roux-en-Y gastric bypass procedures. Surgical therapy is indicated when a patient fails conservative management with bowel rest and fluid and electrolyte replacement or when a complete bowel obstruction, intussusception, or internal hernia is present [26]. The use of laparoscopy to address bowel obstruction has been successfully reported during pregnancy regardless of the trimester [5, 27], although laparoscopy may be technically challenging due to the loss of abdominal domain from the enlarged gravid uterus and dilated bowel.
Acute Complicated Diverticulitis
Acute complicated diverticulitis in pregnancy (i.e., free perforation, abscess, and/or sepsis) is a rare complication with only a few cases reported in the literature [4, 28, 29]. While there are no defined protocols for diagnosis and treatment in pregnancy, these patients should be managed in the same manner as the nonpregnant patient, with laparoscopic intervention utilized when possible. The use of laparoscopic lavage in selected patients with acute complicated diverticulitis has gained acceptance, and this may also be an option in the pregnant patient who presents with diverticulitis. One report of right-sided diverticulitis at 20 weeks gestation with localized rebound tenderness and low-grade fever demonstrated successful laparoscopic peritoneal drainage without complications to the fetus or resultant preterm labor [4].
Peritonitis
Any pregnant patient presenting with an acute abdomen or clinical findings consistent with peritonitis warrants immediate surgical intervention. It is important to note that preterm labor associated with the inflammatory pathway is well established in the obstetrical literature. Inflammation is responsible for about a 10 % fetal loss in pregnant women with perforation and peritonitis [1]. Therefore, immediate surgical intervention, either via laparotomy or laparoscopy, is necessary for both improved maternal and fetal outcomes.
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