Low insufflation key to laparoscopy in pregnancy: try to avoid surgery in first trimester.(Obstetrics)

LAS VEGAS -- When performing laparoscopic surgery on a pregnant patient, try to keep the pneumoperitoneum insufflation pressure between 7 and 12 mm Hg, and never exceed 15 mm Hg, speakers advised at an international congress of the Society of Laparoendoscopic Surgeons.

Higher insufflation pressures increase in traabdominal pressure and affect cardiac and respiratory physiology, said Dr. Tommaso Falcone, a reproductive endocrinologist at the Cleveland Clinic.

The C[O.sub.2] gas used for pneumoperitoneum also can be absorbed across the peritoneum, increasing the maternal partial pressure of C[O.sub.2]. Anesthesiologists can compensate for this by increasing the tidal volume to maintain the plasma partial pressure of C[O.sub.2] and avoid acidosis.

Patient positioning is critical in pregnancy. When a pregnant woman lies supine during laparoscopy, her uterus rests on the inferior vena cava, which can lower cardiac output, decreasing uterine perfusion and causing fetal hypoxemia. To avoid this scenario, keep the patient in a 15-degree left lateral tilt position, he advised.

Studies of laparoscopic surgery in pregnant animals have raised concerns about the safety of the procedure in women. Indeed, a report published in 1996 noted that after seven pregnant women underwent laparoscopic surgery for appendicitis or gall bladder disease, four of their fetuses died. The investigators did not measure maternal or fetal blood gases but attributed the deaths to acidosis.

In three of these cases, however, the mothers had significant comorbid conditions that probably contributed to the deaths--a perforated appendix in one woman and pancreatitis in the other two. "The most important determinant of fetal well being is maternal status," he said.

Since then, several small case-control studies and a survey conducted by the Society of ...