Charlie C. Kilpatrick

Management of the acute abdomen in pregnancy: a review

Purpose of review The acute abdomen remains a challenge for all physicians who take part in the care of women in pregnancy. Obstetricians must be abreast of current topics, especially critical when having to consult other specialties for assistance in managing these conditions. Recent findings We will highlight recent observations in the literature concerning the ability to perform laparoscopy safely in pregnancy, the accuracy of diagnosing appendicitis, and new methods to accurately diagnose urolithiasis with less ionizing radiation effect on the fetus. Finally, with the proficiency of laparoscopy and choledochoscopy improving, we will review several articles underlining their safety. Summary Laparoscopy appears to be well tolerated in pregnancy, but larger multicenter prospective studies are required to make better recommendations concerning its use, with a registry needed to facilitate this endeavor. Conservative management of gallstone pancreatitis may fall out of favor, and choledochoscopy for symptomatic gallstones in the biliary tree may become the treatment of choice. Most cases of urolithiasis resolve with conservative management, but the possibility of preterm labor in these patients must be recognized and newer imaging techniques for diagnosis containing less radiation be used. Adnexal torsion in pregnancy may be another condition that is managed through the laparoscope as the gynecologic communitys laparoscopic skills improve.

Laparoscopy in pregnancy: a literature review.

The first laparoscopic surgery in pregnancy was a cholecystectomy in 1991. Since that time, a number of articles and case series have been published addressing laparoscopy in pregnancy. Current recommendations are on the basis of these findings, such as operating during any trimester in pregnancy can be safely performed, fetal heart monitoring should be made preoperatively and postoperatively, prophylactic tocolytics should not be used, and multiple entry techniques (Veress needle, Hasson trocar, or optical trocar) can be safely performed. This article will review anesthesia, fetal effects, obesity, complications, adnexal masses, and gastrointestinal issues.

Intraoperative fetal heart rate monitoring during nonobstetric surgery in pregnancy: a practice survey.

Objective: To assess practice patterns concerning intraoperative fetal heart rate monitoring during nonobstetric surgery in pregnancy among members of the Association of Professors of Gynecology and Obstetrics (APGO). Study Design: A 16-question survey regarding intraoperative fetal heart rate monitoring during nonobstetric surgery was delivered to the 1300 APGO members via email. Descriptive statistics were used to determine the reasons for fetal monitoring during nonobstetric surgery in pregnancy. Results: Concerning intraoperative monitoring during nonobstetric surgery, 98% of respondents recorded the fetal heart rate pre-and post-surgery, and 43% of respondents reported they usually monitor intraoperatively. Of the 1151 physicians surveyed, 16% completed the survey. Conclusion: The majority of APGO members surveyed do not employ intraoperative fetal heart rate monitoring during nonobstetric surgery in pregnancy.

Vaginal myomectomy in pregnancy: A report of two cases

Prolapsed fibroids presenting in pregnancy are rare. Two cases of bleeding prolapsed fibroids, one cervical and the other submucosal, are presented to demonstrate the clinical features and outcomes following surgical treatment during pregnancy. While vaginal myomectomy of a prolapsed cervical fibroid in pregnancy appears safe, prolapse of a submucosal fibroid in pregnancy necessitating excision may be associated with rupture of the membranes.

Cervical and prolapsed submucosal leiomyomas complicating pregnancy.

Cervical and prolapsed submucosal leiomyomas are rarely seen in pregnancy. Depending on the size threshold used to diagnose a leiomyoma, the prevalence of uterine leiomyomas in pregnancy is approximately 3% to 10%. The prevalence of clinically evident cervical leiomyomas in pregnancy is less than 1%. Contrary to prior thought, the majority of uterine leiomyomas in pregnancy do not usually lead to complications. Indications for surgical intervention in pregnancy for cervical leiomyomas include bleeding, infection, degeneration, pain, and urinary stasis. Preoperative imaging with ultrasound and magnetic resonance imaging may help to delineate the location and nature (e.g., pedunculated) of the cervical leiomyoma when clinical examination is inconclusive. We reviewed the current literature in regard to cervical leiomyomas in pregnancy and summarize the major findings. After completing this CME activity, readers should be better able to evaluate the prevalence and natural history of uterine and cervical leiomyomas in pregnancy, assess indications for surgical intervention in pregnant patients, manage surgical complications, and select imaging modalities that may determine their origin. Target Audience: Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this educational activity, the reader should be better able to evaluate the prevalence and natural history of uterine leiomyomas in pregnancy; assess indications for surgical intervention in pregnant patients; manage surgical complications; and select imaging modalities that may determine their origin.

Chronic nonpuerperal uterine inversion and necrosis: a case report

IntroductionInversion of the non-pregnant uterus is rare.Case presentationA 56-year-old African American woman presented to our emergency center with complaints of a mass protruding from her vagina. She subsequently underwent vaginal myomectomy, abdominal hysterectomy and bilateral salpingo-oophorectomy. Pathologic examination revealed a necrotic fibroid and endometrium. At the time of laparotomy an inverted uterus was diagnosed when a 3 cm dimple containing bilateral round ligaments, infundibulopelvic ligaments and bladder was observed.ConclusionChronic nonpuerperal inversion of the uterus is rare. Infection should be suspected and appropriate broad spectrum antibiotics begun while planning surgery. An attempt at vaginal restoration and removal is difficult. Abdominal hysterectomy may be necessary taking care to locate the distal urinary collecting system.

Laparoscopy in the Morbidly Obese Pregnant Patient Using a Modified Foley Lap-Lift Technique: Case Report

Obesity in women of reproductive age is increasing. Gynecologic laparoscopy in the morbidly obese pregnant patient presents challenges, and is not often attempted. Herein is reported a successful case using a modified Foley lap-lift technique, which improved visualization and facilitated mechanical ventilation.