Levels of evidence (I–III) and recommendation grades (A–C) are defined at the end of the "Major Recommendations" field.
Diagnosis and Workup
Imaging Techniques
Ultrasound
Guideline 1: Ultrasonographic imaging during pregnancy is safe and useful in identifying the etiology of acute abdominal pain in the pregnant patient (Level II, Grade A).
Risk of Ionizing Radiation
Guideline 2: Expeditious and accurate diagnosis should take precedence over concerns for ionizing radiation. Radiation dosage should be limited to 5-10 rads in the first 25 weeks of pregnancy (Level III, Grade B).
Computed Tomography (CT)
Guideline 3: Contemporary multi-detector CT protocols deliver a radiation dose to the fetus below detrimental levels and may be considered as an appropriate test during pregnancy depending on the clinical situation (Level III, Grade B).
Magnetic Resonance (MR) Imaging
Guideline 4: MR Imaging can be performed at any stage of pregnancy without the use of intravenous Gadolinium (Level III, Grade B).
Nuclear Medicine
Guideline 5: Nuclear Medicine administration of radio nucleotides can generally be accomplished at fetal radiation levels of exposure that are well below any known detrimental levels (Level III, Grade C).
Cholangiography
Guideline 6: Intra-operative and endoscopic cholangiography exposes the mother and fetus to minimal radiation and may be used selectively during pregnancy. The lower abdomen should be shielded when performing cholangiography during pregnancy to decrease the radiation exposure to the fetus (Level III, Grade B).
Surgical Techniques
Guideline 7: Diagnostic laparoscopy is safe and effective when used selectively in the workup and treatment of acute abdominal processes in pregnancy (Level II, Grade B).
Patient Selection
Pre-operative Decision Making
Guideline 8: Laparoscopic treatment of acute abdominal processes has the same indications in pregnant and non-pregnant patients (Level II, Grade B).
Laparoscopy and Trimester of Pregnancy
Guideline 9: Laparoscopy can be safely performed during any trimester of pregnancy (Level II, Grade B).
Treatment
Patient Positioning
Guideline 10: Gravid patients should be placed in the left lateral recumbent position to minimize compression of the vena cava and the aorta (Level II, Grade B).
Initial Port Placement
Guideline 11: Initial access can be safely accomplished with open (Hassan), Verres needle, or optical trocar technique if the location is adjusted according to fundal height, previous incisions, and experience of the surgeon (Level III, Grade B).
Insufflation Pressure
Guideline 12: Carbon dioxide (CO2) insufflation of 10-15 mm Hg can be safely used for laparoscopy in the pregnant patient. Intra-abdominal pressure should be sufficient to allow for adequate visualization (Level III, Grade C).
Intra-operative CO2 Monitoring
Guideline 13: Intra-operative CO2 monitoring by capnography should be used during laparoscopy in the pregnant patient (Level III, Grade C).
Venous Thromboembolic (VTE) Prophylaxis
Guideline 14: Intra-operative and post-operative pneumatic compression devices and early post-operative ambulation are recommended prophylaxis for deep venous thrombosis in the gravid patient (Level III, Grade C).
Gallbladder Disease
Guideline 15: Laparoscopic cholecystectomy is the treatment of choice in the pregnant patient with gallbladder disease regardless of trimester (Level II, Grade B).
Choledocholithiasis
Guideline 16: Choledocholithiasis during pregnancy may be managed with preoperative endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy followed by laparoscopic cholecystectomy, intra-operative laparoscopic transcystic or choledochotomy common bile duct exploration, or post-operative ERCP depending on local resources and clinical scenario (Level III, Grade C).
Laparoscopic Appendectomy
Guideline 17: Laparoscopic appendectomy may be performed safely in pregnant patients with suspicion of appendicitis (Level II, Grade B).
Solid Organ Resection
Guideline 18: Laparoscopic adrenalectomy, nephrectomy and splenectomy are safe procedures in pregnant patients when indicated and standard precautions are taken (Level III, Grade C).
Adnexal Masses
Guideline 19: Laparoscopy is safe and effective treatment in gravid patients with symptomatic cystic masses. Observation is acceptable for all other cystic lesions provided ultrasound is non-worrisome for malignancy and tumor markers are normal. Initial observation is warranted for most cystic lesions <6 cm in size (Level III, Grade C).
Adnexal Torsion
Guideline 20: Laparoscopy is recommended for both diagnosis and treatment of adnexal torsion unless clinical severity warrants laparotomy (Level III, Grade C).
Peri-operative Care
Fetal Heart Monitoring
Guideline 21: Fetal heart monitoring should occur pre- and postoperatively in the setting of urgent abdominal surgery during pregnancy (Level III, Grade B).
Obstetrical Consultation
Guideline 22: Obstetric consultation can be obtained pre- and/or postoperatively based on the acuteness of the patient's disease and availability (Level III, Grade B).
Tocolytics
Guideline 23: Tocolytics should not be used prophylactically, but should be considered peri-operatively when signs of preterm labor are present in coordination with obstetric consultation (Level I, Grade A).
Definitions:
Levels of Evidence
Level I - Evidence from properly conducted randomized, controlled trials
Level II - Evidence from controlled trials without randomization
Or
Cohort or case-control studies
Or
Multiple time series, dramatic uncontrolled experiments
Level III - Descriptive case series, opinions of expert panels
Recommendation Grades
Grade A - Based on high-level (level I or II), well-performed studies with uniform interpretation and conclusions by the expert panel
Grade B - Based on high-level, well-performed studies with varying interpretation and conclusions by the expert panel
Grade C - Based on lower level evidence (level II or less) with inconsistent findings and/or varying interpretations or conclusions by the expert panel
