Critical Care Obstetrics part 72 pps

The inci-dence of invasive cervical cancer in pregnancy is low, comprising only approximately 1% of total cervical cancers diagnosed; however, preinvasive cervical neoplasia is quite com

Critical Care Obstetrics, 5th edition Edited by M Belfort, G Saade,

M Foley, J Phelan and G Dildy © 2010 Blackwell Publishing Ltd.

Maternal Complications

Robert H Ball 1 & Michael A Belfort 2

1 HCA Fetal Therapy Initiative, St Mark ’ s Hospital, Salt Lake City and Division of Perinatal Medicine and Genetics,

Departments of Obstetrics, Gynecology and Reproductive Sciences, UCSF Fetal Treatment Center, University of California, San Francisco, CA, USA

2 Department of Obstetrics and Gynecology, Division of Maternal - Fetal Medicine, University of Utah, Salt Lake City, UT

and HCA Healthcare, Nashville, TN, USA

Introduction

A discussion of the potential maternal complications of fetal

surgery is pertinent given the fact that such complications are in

theory absolutely avoidable As the term suggests, fetal surgery is

performed for the sole physical benefi t of the fetus, and any risk

to which the mother is exposed is for a purely altruistic purpose

There is no direct health benefi t to the mother

Many of the fi rst fetal surgical procedures depended on

mater-nal laparotomy to expose the uterus and hysterotomy to expose

the fetus This approach then evolved into laparotomy with

uterine endoscopy rather than hysterotomy to preserve the

integ-rity of the uterus With further experience laparotomy has been

for the most part been replaced with percutaneous procedures

using telescopic devices with a diameter of 3 mm or less The

progression to microinvasive fetoscopic approaches has reduced

the potential for morbidity, but not eliminated it [1] (Table

49.1 ) Each one of these approaches and associated

complica-tions will be discussed in more detail below

Hysterotomy

Hysterotomy, while less frequently used now, is still employed in

some cases where endoscopic techniques are not possible These

include repair of neural tube defects, and the removal of

sacro-coccygeal teratomas and other masses Hysterotomy - based

pro-cedures are usually dependent on intraoperative ultrasound

guidance (both before and after abdominal wall incision) Once

the patient has had anesthesia (general endotracteal) and the

sterile fi eld has been established, ultrasound is used to determine

the fetal lie If the lie is unsuitable for the proposed surgery, external version and transabdominal manipulation is employed under ultrasound guidance to position the fetus such that the fetal surgical site is near the fundus Depending on the maternal body habitus and fetal size and position this may be quite chal-lenging Laparotomy is then performed and the ultrasound trans-ducer, covered in a sterile sleeve, is placed directly on the surface

of the uterus The placental edge is identifi ed, a critical step in making the decision on where to perform the uterine entry Ideally the uterine incision is best centered as far from the pla-cental edge as possible because once amniotic fl uid escapes the uterus defl ates Despite taking this precaution the uterine incision will almost always still be in relatively close proximity to the placental edge – which increases the risk of bleeding and abrup-tion If signifi cant bleeding cannot be readily controlled immedi-ate delivery will be required for mimmedi-aternal safety

Generally the incision in the uterus will have been made such

as to have optimal access to the fetal part to be surgically addressed Ultrasound is used for transuterine monitoring of the fetal heart during the procedure

Following completion of the fetal intervention, the membranes and myometrium are closed with several layers of suture A cath-eter is left in the uterine cavity to allow lactated Ringer ’ s solution

to be infused together with antibiotics Ultrasound is used to determine the volume of “ amniotic ” fl uid, which generally is left

at a low normal level to minimize stress on the suture line Postoperative management usually involves tocolytic therapy

of some sort The regimen in San Francisco included 24 hours of intravenous magnesium sulfate and oral indomethacin for a total

of 48 hours Long - term tocolytic maintenance with nifedipine is then substituted and continued until delivery Prophylactic anti-biotics are continued for 24 hours Ultrasound monitoring is used daily to evaluate fetal health (biophysical profi le and ductus arteriosus patency), amniotic fl uid volume, and cervical length Hospital discharge generally occurs 4 – 5 days after surgery If all goes well long - term monitoring with ultrasound continues at a weekly frequency

labor, premature rupture of the membranes, and preterm deliv-ery Infectious complications are rare, except when premature rupture of the membranes leads to prolonged latency An impor-tant additional discussion point is that all subsequent deliveries, including the index pregnancy, must be by cesarean section Data regarding future fertility are reassuring, with no increased inci-dence of infertility in the UCSF experience in those patients attempting pregnancy [6] Experience from the Children ’ s Hospital of Phildelphia (CHOP) suggests a concerning risk for uterine rupture/dehiscence in subsequent pregnancies that may

be as high as 6 – 12% [7] , which would be considerably higher than the risk after previous low transverse cesarean section (1% or less) [8] or classical cesarean section (5 – 10%) [9] Another theoretical risk in subsequent pregnancies is placenta accreta This is because the hysterotomy performed in the second trimester is never in the transverse lower uterine segment and therefore the patient is exposed to two uterine incisions during the pregnancy The risk

of accreta increases when implantation is in an area of uterine scarring and multiple incisions will increase the likelihood of implantation in such an area To our knowledge there has not been a single case of placenta accreta in a fetal surgical patient from UCSF in a subsequent pregnancy

Fetoscopy

The growing popularity of videoendoscopic surgery in the 1990s, combined with the earlier experience with fetoscopy, paved the way for endoscopic fetal surgery The belief was that a smaller disruption of the amniotic membranes would ameliorate some of the limiting steps in fetal surgery, viz (i) preterm labor, which was believed to be triggered by the large uterine incision required

We have recently reviewed our experience at UCSF with

mater-nal hysterotomy [1] (Table 49.1 ) Eighty - seven hysterotomies

were performed between 1989 and 2003 There were signifi cant

immediate postoperative complications In the early experience,

pulmonary edema was common and is believed to be related to

the use of multiple tocolytic agents (particularly nitroglycerin and

beta stimulants) combined with steroid use and aggressive fl uid

management [2] Thirteen per cent of women having a

hyster-otomy required transfusion for intraoperative blood loss Fifty

two per cent of these patients suffered postoperative preterm

premature rupture of the membranes (PPROM) and 33%

devel-oped preterm contractions refractory to maximal therapy and

delivered preterm The mean time from hysterotomy to delivery

was 4.9 weeks (range 0 – 16 weeks) The mean gestational age at

the time of delivery was 30.1 weeks (range 21.6 – 36.7 weeks)

Others [3,4] have had similar experience with preterm delivery

following hysterotomy With experience much of the morbidity

associated with hysterotomy has decreased and clinically signifi

-cant pulmonary edema and blood loss are now less common The

mean gestational age at the time of delivery following repair of

meningomyelocele (MMC) is now approximately 34 weeks [5]

Discussion of the risks, benefi ts and alternatives of the

proce-dure are important, and must include a clear disclosure of the

experimental nature of the surgery The risks to the mother are

similar to those seen in any major abdominal surgery, although

in this case as mentioned above, there is no direct physical benefi t

to her She should understand the risks associated with aggressive

tocolytic therapy and those resulting from bed rest in a

hyperco-agulable state (venous thromboembolism) The risks to the fetus

are primarily the result of intraoperative vascular instability and

hypoperfusion (leading to injury or death) and the pathology of

preterm delivery The risks to the pregnancy are primarily preterm

Table 49.1 Maternal morbidity and mortality for 178 interventions at UCSF with postoperative continuing pregnancy and divided into operative subgroups

Operative technique Open hysterotomy Endoscopy

FETENDO/Lap - FETENDO

Percutaneous FIGS/Lap - FIGS

All interventions

Bleeding requiring blood transfusion 11/87 (12.6%) 2/69 (2.9%) 0/31 (0.0%) 13/187 (7.0%) PTL leading to delivery 26/79 (32.9%) 18/68 (26.5%) 4/31 (12.9%) 48/178 (27.0%) Preterm premature rupture of membranes (PPROM) 41/79 (51.9%) 30/68 (44.1%) 8/31 (25.8%) 79/178 (44.4%)

FETENDO, fetal endoscopic procedure; Lap - FETENDO, laparotomy and fetal endoscopic procedure; FIGS, fetal image - guided surgery; Lap - FIGS, laparotomy and fetal image - guided surgery

cavity It may also improve placental perfusion and makes the patient more comfortable In many cases little or no tocolytic medication is needed and patients are generally discharged within

24 hours or less of the procedure

The risks of fetoscopy are related to uterine puncture

as well as to the specifi c procedure that is being treated In some cases adverse outcomes may be inherent in the disease state itself such as mirror syndrome (Ballantyne syndrome) in TTTS [11]

Preoperative measurement of the cervix can be used to assess the risk for premature delivery after fetoscopy [12] When the cervix is less than 30 mm the data suggest a 74% risk for delivery prior to 34 weeks If the cervix is shorter than 20 mm the vast majority of patients miscarry After fetoscopy the risk for preterm premature rupture of membranes (PPROM) is estimated to be approximately 10 % or less and the risk for abruption is 1 – 2% The rate of abruption is believed to be related more to the amnio-reduction than the use of the fetscope Less common complica-tions are chorioamnionitis and hemorrhage

Shunts and r adiofrequency a blation

Shunts are used for chronic drainage of fl uid - fi lled fetal cavities, organs and cysts The fi rst shunt was developed by Harrison at UCSF in the early 1980s [13] This was essentially a double pigtail shunt introduced through a 14G introducer (Cook Medical, USA) The Rodeck shunt, developed during the same time period

in the UK, is also a double pigtail shunt, but is longer and has a greater diameter (Rocket Medical, UK) than the Harrison shunt, and it uses a larger diameter introducer [14] These shunts are placed in fetuses with an obstructed bladder, pleural effusion(s) and large type I congenital cystic adenomatoid malformations (CCAMs) With most shunt procedures, a small incision is made

in the maternal skin, and the introducer with the trochar in place

is advanced into the amniotic cavity Care is taken to evaluate the myometrium that will be traversed with a high - frequency trans-ducer (to improve the resolution of the tissue) and with color

fl ow Doppler with low fl ow settings, to avoid damaging large veins We generally avoid a transplacental approach but if no other approach is available shunts can be placed transplacentally The trochar and introducer are then advanced into the area to be drained Once in position the trochar is removed and care is taken

to not allow sudden decompression of the fl uid - fi lled cavity by placing a fi nger over the end of the introducer The shunt is then loaded into the introducer and advanced using a pusher until the internal coils exit the introducer It is critical to continuously image this process with ultrasound Once the inner coils are appropriately positioned, the introducer is carefully withdrawn, while at the same time advancing the shunt so that the outer coil

is positioned on the skin of the fetus, within the amniotic cavity Care must be taken to have suffi cient amniotic fl uid between the

for open fetal surgery, and (ii) signifi cant maternal morbidity

associated with a large laparotomy The ultimate hope was that

fetoscopic interventions would be possible by a percutaneous

approach

Patients are given a preoperative tocolytic agent, often

indo-methacin, and also receive prophylactic IV antibiotics The

pro-cedures are performed under local or regional anesthesia

Depending on the gestational age and the tradition of the

center, the surgery may be performed in the surgical operating

rooms, the labor and delivery operating room, or the ultrasound

suite The endoscopes and fetoscopic instruments have

under-gone tremendous development and improvement over the last

decade Operative fetoscopy has now evolved into a combined

sono - endoscopic procedure in which the fetal surgical team

use both the ultrasound and fetoscopic images simultaneously

to perform the operations Purpose - designed embryo - or

feto-scopes typically have remote eyepieces, to reduce weight and

facilitate precise movements Nearly all are bendable fi bre -

endoscopes rather than conventional rod lens scopes, and as the

number of pixels increases over time, image quality improves

Typical diameters are between 1.0 and 2.0 mm Thin - walled

semi - fl exible plastic cannulas (7 – 10 French diameter) are used

to provide access to the amniotic sac and this allows different

instruments to be inserted into the uterus without multiple

puncture wounds

Ultrasound is used to identify an appropriate entry point and

is then used to direct the trochar into the amniotic cavity,

avoid-ing the placenta, fetus, and maternal organs such as bowel and

bladder One group has documented the safety, in their hands,

of a transplacental approach [10] but most operators still

avoid deliberate transplacental passage of instruments if at all

possible

Ultrasound is initially used to direct and position the fetoscope

within the uterus, since its fi eld and depth of view can be relatively

limited These procedures are truly “ sono - endoscopic ”

One of the most commonly performed fetoscopic procedures

is laser ablation of placental blood vessels in twin – twin

transfu-sion syndrome (TTTS) In these cases the endoscope is placed

into the sac of the recipient twin, which is the sac with

polyhy-dramnios The insertion point of the fetoscope is determined by

placental location, the lie of the donor baby, the umbilical cord

insertion sites and the presumed membrane and vascular

equa-tors between the twins Once the fetoscope is positioned and the

placental surface is being visualized, the whole vascular equator

is then explored Unpaired vessels consistent with abnormal

com-munications are ablated using a laser fi ber that is advanced

through the operating channel of the endoscope sleeve After

ablation of the abnormal communications the endoscope is

with-drawn and the polyhydramnios is then drained through the

cannula under ultrasound guidance Once the fl uid has reached

a normal level (deepest vertical pocket of around 5 – 6 cm) the

cannula is removed This amnioreduction reduces the risk of

port - site leaking and amniotic fl uid irritation of the peritoneal

is based on contraction activity Frequently no further medica-tion is necessary Maternal vital signs should be followed carefully

as direct observation of the uterine puncture is not possible to determine hemostasis, because of the percutaneous approach One benefi t of not needing tocolysis is that the hemostatic mech-anism of the uterus in response to a puncture is a localized contraction

In summary, the fact that many fetal and particularly placental procedures can now be performed using microendo-scopes and that hysterotomy is infrequently needed except for a few rare indications, has improved the rate and severity of mater-nal complications Nevertheless none of these procedures are risk free There have been intraoperative maternal deaths reported and this must be discussed with a patient and her family in balancing the risks and benefi ts of a prospective intervention

References

1 Golombeck K , Ball RH , Lee H , et al Maternal morbidity after

mater-nal - fetal surgery Am J Obstet Gynecol 2006 ; 194 ( 3 ): 834 – 839

2 DiFederico EM , Burlingame JM , Kilpatrick SJ , Harrison MR , Matthay

MA Pulmonary edema in obstetric patients is rapidly resolved except

in the presence of infection or of nitroglycerin tocolysis after open

fetal surgery Am J Obstet Gynecol 1998 ; 179 : 925 – 933

3 Wilson RD , Johnson MP , Crombleholme TM , et al Chorioamniotic membrane separation following open fetal surgery: pregnancy

outcome Fetal Diagn Ther 2003 ; 18 ( 5 ): 314 – 320

4 Bruner JP , Tulipan NB , Richards WO , Walsh WF , Boehm FH , Vrabcak EK In utero repair of myelomeningocele: a comparison

of endoscopy and hysterotomy Fetal Diagn Ther 2000 ; 15 ( 2 ):

83 – 88

5 Johnson MP , Gerdes M , Rintoul N , et al Maternal - fetal surgery for myelomeningocele: neurodevelopmental outcomes at 2 years of age

Am J Obstet Gynecol 2006 ; 194 ( 4 ): 1145 – 1150

6 Farrell JA , Albanese CT , Jennings RW , Kilpatrick SJ , Bratton BJ ,

Harrison MR Maternal fertility is not affected by fetal surgery Fetal

Diagn Ther 1999 ; 14 : 190 – 192

7 Wilson RD , Johnson MP , Flake AW , et al Reproductive outcomes

after pregnancy complicated by maternal - fetal surgery Am J Obstet

Gynecol 2004 ; 191 ( 4 ): 1430 – 1436

8 Macones GA , Peipert J , Nelson DB , et al Maternal complications with

vaginal birth after cesarean delivery: a multicenter study Am J Obstet

Gynecol 2005 ; 193 ( 5 ): 1656 – 1662

9 McMahon MJ Vaginal birth after cesarean Clin Obstet Gynecol 1998 ;

41 ( 2 ): 369 – 381

10 Yamamoto M , El Murr L , Robyr R , et al Incidence and impact of perioperative complications in 175 fetoscopy - guided laser coagula-tions of chorionic plate anastomoses in fetofetal transfusion

syn-drome before 26 weeks of gestation Am J Obstet Gynecol 2005 ; 193 ( 3

Pt 2 ): 1110 – 1116

11 Gratacos E , Deprest J Current experience with fetoscopy and the

Eurofoetus registry for fetoscopic procedures Eur J Obstet Gynecol

Reprod Biol 2000 ; 92 : 151 – 160

12 Robyr R , Boulvain M , Lewi L , et al Cervical length as a prognostic factor for preterm delivery in twin - to - twin transfusion syndrome

fetus and the wall of the uterus during this procedure to prevent

the outer end of the shunt from being left in the myometrium or

maternal abdominal wall In the case of the shunt penetrating the

uterus there is the risk of an amnioperitoneal shunt Shunt

place-ment procedures may be the most frequently performed fetal

surgical intervention

Complications from shunt placement include maternal and

fetal bleeding, placental abruption, amniotic – peritoneal shunt,

and infection

Radiofrequency ablation (RFA) is most commonly used for

destruction of tumor tissue in solid organs such as the liver This

technique was fi rst used for localized cautery of fetal vascular

communications Additionally it has been used for ablating the

feeding vessels to the anomalous fetus in twin reversed arterial

perfusion (TRAP) sequence [15,16] Further applications include

selective reduction in monochorionic twin gestations discordant

for severe anomalies, and in severe twin – twin transfusion without

hope for salvage of one of the twins

The RFA device that we currently use is a 17G needle device

(Rita Medical, USA) The perioperative management is identical

to that discussed above with shunts except that local anesthesia

alone is usually suffi cient In the case of TRAP, the instrument is

guided into the tissue of the acardiac twin at the level of the cord

insertion The prongs are deployed and energy transmission to

the device initiated Because of the heat generation there is

out-gassing that is readily visible with ultrasound The procedure is

considered completed when there is no evidence of fl ow in the

acardiac twin (or in the cord leading to it) as evidenced by color

and pulse Doppler ultrasound The prongs are then retracted and

the device withdrawn Postoperative monitoring is similar to that

used in shunt placement cases and further tocolytic management

is rarely necessary The patients can generally be discharged

within hours of the procedure

The risks of complications following shunt placement and RFA

are lower than for the more invasive fetal surgical interventions

requiring hysterotomy Obviously, by defi nition, all invasive

pro-cedures involve a risk of hemorrhage and infection (Table 49.1 )

[1] The triggering of preterm delivery by these procedures is also

quite unusual, although the risk of PPROM remains There is also

the risk of fetal injury, which in cases of monochorionic twins

generally is related to hypotension from acute hypovolemia in the

normal cotwin secondary to exsanguination into the placental

vascular bed and the other fetus

Over time, as teams have become more comfortable with

feto-scopic procedures, the length of hospitalization, complexity of

perioperative management and type of anesthesia have changed

In many cases these operations can be performed under

ultra-sound guidance as an outpatient procedure (23 - hour admission)

with a single dose of indomethacin for tocolysis Routine

preop-erative antibiotic prophylaxis is given For most procedures spinal

or local anesthesia is suffi cient

Postoperative management involves maternal and fetal

moni-toring (in cases of fetal viability) Further tocolytic management

15 Tsao K , Feldstein VA , Albanese CT , et al Selective reduction of

acar-diac twin by radiofrequency ablation Am J Obstet Gynecol 2002 ;

187 ( 3 ): 635 – 640

16 Lee H , Wagner AJ , Sy E , et al Effi cacy of radiofrequency ablation for

twin - reversed arterial perfusion sequence Am J Obstet Gynecol 2007 ;

196 ( 5 ): 459

treated by fetoscopic laser coagulation of chorionic plate

anastomo-ses Ultrasound Obstet Gynecol 2005 ; 25 : 37 – 41

13 Harrison MR , Golbus MS , Filly RA , et al Management of the fetus

with congenital hydronephrosis J Pediatr Surg 1982 ; 17 ( 6 ): 728 –

742

14 Nicolini U , Rodeck CH , Fisk NM Shunt treatment for fetal

obstruc-tive uropathy Lancet 1987 ; 2 ( 8571 ): 1338 – 1339

Critical Care Obstetrics, 5th edition Edited by M Belfort, G Saade,

M Foley, J Phelan and G Dildy © 2010 Blackwell Publishing Ltd.

Kenneth H Kim , David M O ’ Malley & Jeffrey M Fowler

Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, James Cancer Hospital and Solove Research Institute, The Ohio State University, Columbus, OH, USA

Introduction

The diagnosis of cancer in pregnancy complicates anywhere

between 1 in 1000 and 1 in 2000 live births According to the 2004

Annual National Vitals Statistics Report Provisional Data,

malig-nancy is the second most common cause of mortality in

repro-ductive - age women aged 25 – 44 years; however, it is a rare cause

of maternal death in pregnancy [1,2] As the trend continues

toward delaying childbearing, the incidence of malignancy

occur-ring in pregnancy is expected to increase The most common type

of cancer diagnosed during pregnancy is melanoma

(complicat-ing approximately 1 in 350 pregnancies), followed by cervical

cancer (1 in 2250), Hodgkin ’ s lymphoma (1 in 3000), breast

cancer (1 in 7500), ovarian cancer (1 in 18 000), and leukemia

(1 in 75 000) [3]

Cancer in pregnancy can be categorized into those discovered

during the antenatal period, those discovered at the time of

deliv-ery, and those discovered up to 1 year postpartum In over 50%

of cases, cancers complicating pregnancy are found in the

post-partum period, within 1 year of delivery At least one - quarter of

cancers are found in the antenatal period, and a small minority

are found at the time of delivery [4]

When the diagnosis of a malignant neoplasm is made in

preg-nancy, particular care must be taken to balance both maternal

and fetal well - being This often leads to an extremely challenging

therapeutic dilemma In the antenatal period, the clinical picture

is simplifi ed if the fetus is mature and can be delivered prior to

any treatment initiation, or if the pregnancy is unwanted and the

fetus is not viable When cancer is diagnosed in a desired

preg-nancy, and the fetus has not achieved maturity, the clinical

situ-ation is more complex If prognosis is such that delaying treatment

will not affect or worsen maternal outcome, treatment may be

deferred until the fetus has achieved maturity However, if the prognosis will deteriorate with a delay in treatment, the risks and benefi ts of more immediate treatment must be weighed against the risks to the pregnancy and the fetus

Certainly, a patient should not be penalized for being pregnant and the necessary steps required to assure appropriate manage-ment and therapy should be taken Treatmanage-ment should be indi-vidualized with emphasis on the parents ’ participation in the decision - making process In addition, a multidisciplinary team must be utilized to ensure that the patient, the physicians, and all else who are involved are well informed of the risks, benefi ts, and alternatives to the treatment choices It is important to not only consider the medical aspects of the condition but also to consider ethical, moral, spiritual, and cultural issues of the patients Physicians may be faced with unique psychosocial challenges in addition to the clinical diagnosis of cancer, or fi ndings that are suspicious for cancer in pregnancy Examples of this may include those patients who are carrying their fi rst, and potentially only pregnancy, or those who have had diffi culties with conception and have undergone assisted reproductive technologies to achieve pregnancy, both cases in which the pregnancy is truly desired There are also patients that may be opposed to terminating the pregnancy regardless of gestational age for various personal, reli-gious or ethical reasons The patient ’ s goal may not necessarily

be to undergo curative therapy for their malignancy, but to give birth to a healthy infant, no matter what the risk Some patients may not believe in cesarean delivery for cultural or other reasons and choose to defer any surgery until after delivering vaginally

A small subset may also refuse not only cesarean delivery, but any labor - inducing agents as well, preferring to go into “ natural labor ” There may be those who refuse blood products of any sort

on the basis of religion or culture and may also choose to deliver vaginally, deferring surgery to the postpartum period to reduce the risk of blood loss In these cases, the patient must be thor-oughly informed of the risks, benefi ts, and alternatives of therapy for their specifi c clinical scenario while heeding their cultural, ethical, religious, and moral beliefs

Surgical risks inherent to minimally invasive surgery do not appear to be increased in pregnancy Laparoscopic techniques in pregnant patients should not differ greatly from that of open procedures As with open procedures, fetal heart tones should be obtained before and after the procedure In those cases where the fetus is viable continuous monitoring of the fetal heart rate is advised so that intervention can be undertaken in the event of fetal decompensation Naso/orogastric decompression should be utilized, and the patient should be placed in a leftward tilt to minimize aortocaval compression The primary port should be inserted via the open technique or the left upper quadrant direct technique to decrease the risk of uterine perforation or laceration There has been one reported case of incorrect placement of the Verres needle, leading to pneumoamnion that contributed to fetal loss [15] Ancillary ports should be placed under direct visu-alization in the cephalad direction, and then rotated carefully Due to an intra - abdominal space that is progressively compro-mised, laparoscopy should generally not be attempted after 26 – 28 weeks gestation [14] ; however, this should be evaluated on a case

by - case basis Promising reports of robotic gynecologic surgery are now appearing in the literature but there is no information yet on the use of this novel technique in a pregnant patient to date

Another theoretical risk of laparoscopy is that the developing fetus could potentially be susceptible to acidosis caused by mater-nal absorption of the carbon dioxide gas with subsequent hyper-carbia and serum conversion to carbonic acid There have been two studies performed in pregnant ewes to evaluate the response

in fetal sheep to the use of CO 2 insuffl ation In the fi rst study [16] , one fetus that was compromised prior to the study succumbed during the pneumoperitoneum The second study [17] had no such complications There have been no subsequent reports of fetal loss attributable to acidosis secondary to pneumoperito-neum, and this risk appears to be theoretical Notwithstanding,

if the duration of the case is anticipated to be rather lengthy, it may be prudent to employ traditional open methods of surgery Until randomized trials are available, the decision of surgical approach should be individualized and made in consultation with the perinatologist and the surgeon, ensuring that the risks, ben-efi ts, and alternatives are discussed at great length with the patient

Cervix

In 2007 there will be approximately 11 000 new cases of cervical cancer in the United States with an estimated 3600 deaths from the disease according to the National Cancer Institute The inci-dence of invasive cervical cancer in pregnancy is low, comprising only approximately 1% of total cervical cancers diagnosed; however, preinvasive cervical neoplasia is quite common in reproductive age women, occurring in 5 – 50 cases per 1000 preg-nancies [18 – 20] The recent downward trend in the incidence of cervical neoplasia in pregnancy coincides with the general

Surgical p rinciples d uring p regnancy

While every pregnancy comes with inherent risk such as stillbirth

or preterm labor, patients generally never expect to require

surgery during this time It is clear that pregnant patients are

not immune to processes that require surgical intervention,

whether it be gallbladder disease, appendicitis or invasive

cancer Pregnant patients generally tolerate surgical procedures

well, depending on the nature and complexity of the surgery

performed Moreover, the risks of adverse pregnancy outcomes

appear to be small when uncomplicated, non - emergent surgical

procedures are performed Nevertheless, the ramifi cations

can be grave if the surgery becomes complicated secondary to

the clinical scenario (e.g ruptured viscera) or the procedure

itself (e.g postoperative bleeding, infection or anesthetic

complications)

Various non - obstetric surgical procedures have been

per-formed and reported in the literature The largest study involves

5405 patients undergoing a large variety of procedures

through-out pregnancy, with the majority occurring in the second

trimes-ter [5] This study, which employed the Swedish Birth Registry,

observed that the difference in rate of stillbirth and congenital

anomalies was insignifi cant, although an increase in the rate

of low birth weight and preterm delivery was noted Factors

associated with an increased risk of pregnancy loss include fi rst

trimester surgery, peritonitis, and longer procedure times [6]

Thus if the surgery is needed, recommendations for timing of

surgery have generally been to electively defer procedures until

the second trimester under controlled circumstances The use of

prophylactic tocolytics at the time of surgery in the second

tri-mester has not been shown to decrease the risk of preterm labor

or preterm delivery in these patients, but may be benefi cial in the

third trimester [7] However, there are no randomized or

pro-spective trials to address this specifi c issue Clearly, these

deci-sions must be individualized for each patient If the patient is

unstable, or requires emergent surgery, this should be carried out

in an effi cient, timely manner When counseling patients it is

important to note that intra - abdominal surgery, as opposed to

extra - abdominal sites, is associated with a higher risk of

preg-nancy - related complications

With advancing technology, the use of minimally invasive

laparoscopic and robotic techniques have entered the surgeon ’ s

armamentarium The complexity of the decision to proceed with

surgery during the gestation is therefore further layered with what

surgical approach to employ Abundant case reports and studies

are present in the literature regarding the well - tolerated nature of

laparoscopic surgery during pregnancy [8 – 12] Benefi ts of the

minimally invasive approach include less pain in the

postopera-tive period, less use of analgesics, less use of tocolytics, and overall

shorter length of bedrest and hospitalization as compared to

lapa-rotomy The most common indications for laparoscopic surgery

during pregnancy are cholecystectomy, evaluation of an adnexal

mass, and appendectomy [13,14]

Biopsies should be taken of the most suspicious lesions seen at the time of colposcopic evaluation Multiple biopsies at one examination and use of the endocervical curettage should be avoided [26] Colposcopic diagnostic accuracy, with or without biopsy, is 95 – 99% and complications rarely arise [27] The most common complication associated with colposcopically directed biopsy is hemorrhage secondary to the hyperemic state of the cervix during pregnancy Should this problem present itself, a number of methods can stop the bleeding including direct pres-sure to the site, Monsel solution, silver nitrate, vaginal packing, and/or rarely suture

When the possibility of invasive disease has been excluded, con-servative management with close observation of cervical intraepi-thelial neoplasia is reasonable and acceptable [27 – 32] While an inadequate colposcopic evaluation is indication for loop electrical excisional procedure (LEEP) or cone biopsy in the non - pregnant patient, this approach can be modifi ed during pregnancy Pregnant patients with unsatisfactory colposcopic evaluation may undergo repeat colposcopic examination 6 – 12 weeks from the initial col-poscopy As the transformation zone undergoes further eversion through the gestation, a repeated colposcopy may subsequently yield a satisfactory examination In pregnancy, the biopsy - proven progression rate from lower - grade to higher - grade dysplasia was found to be approximately 7%, and there was no progression to invasive disease [31] However, it has also been demonstrated that regression rates of moderate and even severe dysplasia 6 months after delivery appear higher than regression rates in the non - preg-nant population [31,33] Regression rates in these studies were found to be 68% in patients with CIN 2, and 70% in CIN 3 [31] Therefore, biopsy - proven dysplasia may be followed with serial colposcopic examinations during pregnancy The patient may be allowed to have a vaginal delivery, and then followed up 6 – 8 weeks postpartum for defi nitive management

In the pregnant state, LEEP and cone biopsy should be reserved for excluding invasive disease Risks of these procedures in preg-nancy include cramping, bleeding, infection, preterm premature rupture of membranes, spontaneous abortion and/or preterm labor, and subsequent loss of the pregnancy Comparatively, the rates of complication with LEEP and cone biopsy are similar [34] Cold knife cone biopsy may be favored over LEEP to allow for adequate assessment of the margins If a LEEP or cone biopsy is indicated, this can be performed any time during the fi rst trimes-ter and up to 20 weeks gestational age If fetal maturity is attain-able in a reasonattain-able amount of time, these procedures can also

be deferred until after delivery Alternatively, cone cerclage, where a McDonald cerclage is placed at the time of conization, has been proposed to try and prevent hemorrhage, preterm labor, and pregnancy loss While there were no complications in the study, it was quite underpowered, involving only 17 patients [35]

Cervical c arcinoma

The occurrence of cervical carcinoma in pregnancy is rare, com-prising only 1% of all cervical cancers diagnosed per year Presentation will usually be postcoital bleeding or persistent

decreasing incidence of cervical cancer Therefore the practicing

obstetrician/gynecologist is more likely to encounter the issue of

evaluation and management of an abnormal pap smear rather

than management of a pregnant woman with invasive cervical

cancer While Pap smears and routine screening are readily

avail-able in developed countries, most patients diagnosed with

cervi-cal cancer have not had appropriate screening Pregnancy and

prenatal care affords an opportunity to screen and appropriately

treat many patients who would otherwise not seek healthcare

Thus, at the antenatal visit, it is important to stress the

impor-tance of cervical neoplasia screening and appropriate follow - up

of any abnormal Pap results with colposcopic evaluation, in

addi-tion to routine obstetric care

Intraepithelial n eoplasia

As many as 5% of pregnancies are complicated by an abnormal

Pap smear [20] Cervical cytology and physical examination,

com-plemented with colposcopy, are the mainstay for cervical cancer

screening during pregnancy Studies have shown that use of either

spatula - or liquid - based smear methods result in similar detection

rates While an endocervical curettage should be avoided during

pregnancy, an endocervical cytology brush should be employed as

it improves the adequacy of the smear Use of the brush may

increase the incidence of post - collection spotting, but appears to

have no effect on increasing the risk of serious adverse outcomes

related to the pregnancy [21] During pregnancy the emphasis is

on evaluation and diagnosis of the extent of neoplasia while defi

ni-tive therapeutic management is usually delayed until after delivery

This evaluation of an abnormal Pap smear in the pregnant patient

mirrors the management in the non - pregnant state

The Bethesda system remains the standard for classifi cation

and management of abnormal cervical cytology Atypical

squa-mous cells of uncertain signifi cance (ASCUS) should be managed

in the same manner as in the non - pregnant state with high - risk

human papilloma virus (HPV) type testing and colposcopy when

indicated, immediate colposcopy, or colposcopy after a repeated

abnormal Pap result Pap smears revealing atypical glandular cells

(AGC) of any variety, however rare in pregnancy, warrant further

evaluation with colposcopic examination In the case of AGC,

pregnancy complicates the cytologic interpretation with sloughed

decidual cells, endocervical gland hyperplasia, and/or cells

dem-onstrating an Arias – Stella reaction, all of which are benign

changes occurring in normal pregnancy Compared to non -

pregnant counterparts, AGC found in pregnancy may have

decreased probability of being associated with malignancy, but

should still be followed closely [22 – 25] Patients who are found

to have low - or high - grade intraepithelial lesions, or any other

results that cannot exclude high - grade disease, must also undergo

colposcopic evaluation

Colposcopic evaluation, which is facilitated in pregnancy by

the fact that the transformation zone is everted, should be

per-formed when indicated by the Pap cytology Colposcopy should

be performed by clinicians who are familiar with the cervical

cytological and colposcopic changes associated with pregnancy

demonstrated relative success with delivery once fetal maturity is obtained and delaying cancer therapy until that time or until the postpartum period, even if the cancer is diagnosed at an early gestational age [40,45,46] Although the risk of recurrence is low

in these relatively small case series, the recurrence rate of cervical cancer after intentional delay of treatment to optimize fetal matu-rity cannot be quantifi ed Thus, if the pregnancy is desired, the patient must be thoroughly counseled on this unquantifi able but likely low risk of recurrence if therapy were to be delayed If the malignancy is diagnosed in the latter half of the pregnancy, treat-ment can likely be delayed with only slight risk of progression and worsened outcome With advancing neonatal intensive care technology, the threshold for fetal maturity will continue to decrease, and patients who present at less than 20 weeks will likely have improved risk/benefi t ratio with delay of treatment In those patients who are diagnosed in the fi rst half of the gestation, and wish to terminate the pregnancy and future fertility, immediate treatment may be offered and recommended The majority of patients diagnosed with invasive disease in pregnancy will be stage Ia2 to Ib1; in these patients, and those with up to stage IIA disease, standard treatment is usually radical hysterectomy with pelvic lymphadenectomy Care must be taken in evaluating pelvic lymph nodes as they may contain decidual reaction from the pregnancy which can be confused with metastatic cells Depending

on the size of the uterus at the time of surgery, hysterectomy can

be performed with the fetus in utero , or a hysterotomy may be

performed immediately preceding hysterectomy Defi nitive radi-ation therapy offers similar cure rates in these stages of disease; however, this has been avoided mainly secondary to the potential adverse effects of therapeutic radiation Defi nitive surgical man-agement is associated with baseline perioperative morbidity but offers the advantage of surgical staging and preservation of ovarian function Use of defi nitive radiation therapy exposes the ovaries, vagina, gastrointestinal and urinary tracts to high doses

of radiation, leading to loss of ovarian function and risk of long term chronic toxicity [47]

Mode of delivery with concomitant cervical cancer remains a controversial topic There appears to be a slight trend toward worsening prognosis in vaginal deliveries through a cancerous cervix yet this is not well established [36,37,48] A bulky, friable cervix is at risk for signifi cant complications with life - threatening intrapartum and/or postpartum hemorrhage that may lead to emergent hysterectomy in a less than ideal, uncontrolled and acute situation In addition, case reports describe recurrence at the episiotomy site, most of which occurred within 6 months of delivery [49,50] Thus close follow - up with careful palpation and inspection of any laceration or episiotomy site is recommended;

if recurrence at this site is noted, management should entail exci-sion followed by radiation therapy Vaginal delivery should likely

be reserved for intraepithelial lesions and potentially early stage

I candidates who wish to preserve pregnancy and fertility Consequently, most clinicians favor abdominal delivery, espe-cially if radical hysterectomy with lymphadenectomy is indicated and can be performed at the time of cesarean delivery

bleeding during pregnancy, but many patients will be

asymptom-atic The vast majority of patients with cervical cancer found in

pregnancy will be diagnosed with stage I disease In the past it

was thought that pregnancy altered the course of cervical cancer

compared with non - pregnant cohorts However, it has been

dem-onstrated that there is no difference in survival outcomes when

matched cohorts were studied [33,36,37] When compared with

non - pregnant counterparts, pregnant patients with cervical

cancer are over three times more likely to be stage I, the majority

having stage IB disease [36,38 – 41] Because of the physiologic and

anatomic changes that develop with pregnancy, indurations or

nodularities at the base of the broad ligament will be less

promi-nent during pregnancy, thus risking underestimation of the

degree of involvement during staging of the tumor Regardless,

studies have shown that pregnancy does not affect overall survival

rate when compared to non - pregnant women, with survival rates

of 80% in pregnant subjects compared with 82% in non - pregnant

control cohorts [42]

Cervical cancer is primarily staged by physical examination,

but disease extent may be diffi cult to determine in the pregnant

state Ancillary studies that may aid in the evaluation of the extent

of tumor involvement include limited CT scans of the lower

abdomen and pelvis Sigmoidoscopy and cystoscopy are safe in

pregnancy for the evaluation of mucosal involvement, and, in

some cases, MRI has been utilized to help determine the extent

of urinary tract involvement [43,44]

Once staging has been determined, management must be

indi-vidualized for each patient A multidisciplinary team, which

includes perinatologist, neonatologist, and gynecologic

oncolo-gist, should be recruited to extensively counsel the patient on all

of the treatment options available to her These should take into

account the tumor stage, her prognosis with immediate treatment

versus delayed treatment, and the fetal issues including timing of

delivery The patient ’ s desire to continue or terminate the

preg-nancy may impact treatment decisions In most instances of

inva-sive cancer, relatively prompt treatment is expected and ideal

During pregnancy, effecting defi nitive treatment will depend on

the stage of disease and the gestational age of the fetus

Microinvasive disease may be suspected after colposcopy;

however, the diagnosis is formally made only after cervical

con-ization If it is determined the patients has International

Federation of Gynecology and Obstetrics (FIGO) stage Ia1

disease, she can be followed closely and delivered as obstetrically

indicated with defi nitive management deferred to the postpartum

period However, if there is evidence of frank invasion (FIGO

stage Ia2 or higher), further options must be discussed with the

patient regarding defi nitive management, particularly if the

patient desires to continue the pregnancy Standard management

for the non - pregnant patient would be prompt defi nitive therapy

However, with informed consent, the pregnant patient can be

followed with close observation with defi nitive therapy deferred

until after delivery once fetal maturity is attained

Fortunately, most pregnant patients diagnosed with cervical

cancer have early stage disease Case reports and small series have

rics Prior to routine ultrasonography, these masses were usually found at the time of abdominal delivery, during the postpartum period, or during the gestation when associated symptoms prompted a physical exam Currently, many asymptomatic masses that would otherwise be unrecognized are incidentally found at the time of fi rst - trimester sonogram The actual dence is not well documented since many masses that are inci-dentally discovered in pregnancy undergo regression, are not reported, or may not require/receive any intervention It has been estimated that 0.2 – 2% of pregnancies are complicated by an adnexal mass, and that approximately 1 – 3% of these are malig-nant [56 – 63] While a signifi cant portion of these masses are benign corpus luteum and other cysts that will undergo sponta-neous regression by the second trimester, a proportion of these masses will be neoplastic and persist through the second trimester and beyond, potentially causing major complications during the pregnancy Some of these will need extensive surgical intervention

It has been demonstrated that approximately three - quarters of adnexal masses found in pregnancy are simple - appearing cysts measuring less than 5 cm in diameter The remaining one - quarter

of adnexal masses discovered in pregnancy are either simple or complex, and measure greater than 5 cm in diameter Of all adnexal masses found in pregnancy, 70% will spontaneously resolve by the early middle trimester, becoming undetectable by

14 – 15 weeks gestational age [59,64] Functional cysts, including theca lutein cysts, are the most common masses detected, while dermoid cysts are the most common neoplasm encountered in pregnancy Other common benign fi ndings are cystadenomas, paraovarian cysts, endometriomas, and leiomyomas [64 – 66] Adnexal masses measuring greater than 8 cm are at risk of complications, including pain, torsion, rupture, and hemorrhage

A minority of pregnant women with an adnexal mass will have

an acute presentation where surgery is clearly indicated [67 – 69] Rarely a mass can be associated with preterm labor, preterm premature rupture of membranes, pregnancy loss, obstruction of labor, and/or fetal/neonatal death [66,68,69] The risk of torsion peaks in two periods during the pregnancy: the fi rst trimester or early second trimester, when the uterus is growing out of the true pelvis; and the puerperium, when the uterus undergoes rapid involution If a patient develops clinical signs or symptoms con-sistent with torsion, emergent surgery is indicated and should not

be delayed, regardless of gestational age

In the non - emergent setting, ultrasound, occasionally supple-mented with other imaging modalities, has been traditionally used to guide management decisions Generally, if the mass appears benign on ultrasonographic evaluation, it is extremely unlikely to be malignant Tumor markers including AFP, LDH, hCG, and CA - 125 levels may be elevated with pregnancy and are generally not reliable or useful If the origin of the mass is not clear, occasionally, magnetic resonance imaging can be employed

to differentiate between ovarian versus other possible sources Masses that are simple and cystic in nature and which measure less than 6 cm have a low risk of malignancy (less than 1%) and

For the subset of patients with early - stage tumors who wish to

defer defi nitive treatment until the postpartum period and who

wish to conserve fertility, radical trachelectomy performed

vagi-nally or abdomivagi-nally may be a viable option [51] A total of 212

patients collected from six studies were evaluated for survival,

fertility and pregnancy outcomes after radical trachelectomy Of

these 212 patients, 2% developed recurrence, and 56% delivered

a viable pregnancy with 28% being full term, and 28% being

preterm [52,53]

Advanced - stage cervical cancer is rare in pregnancy and there

is a paucity of data in the literature regarding management For

higher - stage disease and those few patients who are medically

unfi t for surgery, radiation therapy with concurrent

chemother-apy is indicated If this occurs in the third trimester, delay of

therapy until after delivery is reasonable [46] If the patient

chooses not to continue the pregnancy, external - beam radiation

with concomitant chemotherapy can be given in the fi rst

trimes-ter, and if spontaneous miscarriage does not occur, dilation and

curettage or extraction can be performed In the middle

trimes-ter, abortion may be induced or delayed, depending on spiritual/

religious, moral, and ethical considerations If delayed,

telether-apy may be administered; however, hysterotomy may be required

for up to one - fourth of cases [45] One week post - abortion, after

uterine involution, external radiation can be administered,

fol-lowed by brachytherapy In general, the anatomic distortion that

occurs in pregnancy must be taken into consideration to ensure

that the radiation fi eld includes all targeted regions The use of

neoadjuvant chemotherapy without radiation may be helpful in

the pregnant patient [54] The most important factor in

admin-istration of the chemotherapy during pregnancy is the gestational

age of the fetus If the fetus is exposed to chemotherapeutic agents

within 2 weeks postconception, it will either spontaneously abort

or develop normally Organogenesis occurs in the fi rst trimester;

thus, chemotherapy should be avoided during this period, as this

is the most likely time that the fetus will develop a malformation

Though limited, reports have shown relative success with

admin-istration of chemotherapy during the second and third trimesters,

with very low risk of fetal malformations; however, there has been

increased tendency toward interuterine growth restriction, low

birth weight, spontaneous abortion, and/or preterm labor

Timing of chemotherapy administration with relation to the

planned delivery date is also important Chemotherapy given

within 3 weeks of delivery may lead to maternal

myelosuppres-sion with resultant neutropenia, thrombocytopenia, and/or

anemia Furthermore, the neonate may be incapable of handling

such high levels of chemotherapeutic agents and metabolites

because of its immature hepatorenal excretion mechanisms [55]

Management of a dnexal m asses o ccurring

in p regnancy

The fi nding of an adnexal mass during pregnancy has increased

as ultrasound has become commonplace in the practice of