Stephen J. Schorr

Laparoscopic surgery during pregnancy

BACKGROUND Animal studies have demonstrated fetal acidosis during carbon dioxide pneumoperitoneum. This finding suggests a potential adverse effect of CO2 pneumoperitoneum on fetal outcome in humans. PATIENTS AND METHODS We reviewed our recent experience with laparoscopic surgery performed under general anesthesia and with the use of CO2 pneumoperitoneum, in pregnant women with appendicitis or cholecystitis. We compared these womens charts and pregnancy outcomes with those of pregnant women who underwent formal laparotomy during the same period of time. RESULTS Seven pregnant patients underwent laparoscopic surgery, and there were 4 fetal deaths among them (3 during the first postoperative week, and another 4 weeks postoperatively). Five pregnant patients underwent formal laparotomy, of whom 4 subsequently progressed to term and 1 was lost to follow-up. CONCLUSIONS Our recent experiences together with the available animal data suggest that caution should be used when considering nonobstetrical laparoscopic surgery in pregnant women. This experience suggests that additional clinical and laboratory investigations may be indicated to evaluate fetal risk associated with such surgery.

The diagnosis and management of breast problems during pregnancy and lactation

BACKGROUND In addition to mastitis, lactational breast abscesses, and several other benign conditions unique to the puerperium, pregnant women may develop any of the other breast problems seen in the nonpregnant female population. This review deals with the diagnosis and management of breast problems during pregnancy and lactation. DATA SOURCES A literature review of the evaluation, technique of biopsy, and treatment of cancer in pregnant women was conducted. CONCLUSIONS The most common problems fall into a spectrum of infectious complications from milk stasis or mastitis to frank abscess formation. Galactoceles, noninfected milk-filled cysts, present as tender masses; aspiration is both diagnostic and curative. Benign fibroadenomas occasionally enlarge significantly or infarct during pregnancy. A physiologic nipple discharge is common during pregnancy, and may be bloody. Rare cases of massive breast hypertrophy during pregnancy have been reported. The mortality of breast cancer during pregnancy is related to delay: compared stage-for-stage with nonpregnant controls, the prognosis is similar. As a general rule, the cancer should be treated surgically and the pregnancy may be allowed to progress.

A randomized trial of two vacuum extraction techniques

Objective To determine whether two techniques of vacuum extraction delivery—continuous vacuum and intermittent vacuum—have different effects on maternal-fetal outcomes. Methods Patients to be delivered by vacuum extraction were randomized to receive continuous or intermittent vacuum. All deliveries were performed using the M-cup. In the continuous group, the level of vacuum was brought to 600 mmHg between contractions and was maintained at that level until delivery of the infant. Active efforts were made to prevent fetal loss-of-station between contractions by maintaining traction. In the intermittent group, the level of vacuum was decreased to 100 mmHg between contractions and no effort was made to prevent fetal loss-of-station. Results A total of 322 patients were randomized: 164 in the continuous arm and 158 in the intermittent group. The continuous method did not effect delivery faster (continuous 167 ± 175 seconds versus intermittent 167 ± 150 seconds;(P = .97), nor did it lead to a reduction in method failures (continuous 12, intermittent nine;(P = .72). The intermittent method did not appear to offer any benefit to the neonate regarding cephalhematoma formation (continuous 20, intermittent 17;(P = .686) or any other measure of neonatal outcome. Maternal lacerations and episiotomy extensions were evenly distributed between the groups. Overall, the efficacy rate of the vacuum cup was 93.5% and the cephalhematoma rate was 11.5%. Conclusion No differences in maternal or fetal outcome could be demonstrated if the level of vacuum was decreased between contractions or if an effort was made to prevent fetal loss-of-station. The clinical results obtained in this trial using the M-cup are similar to the published results with the stainless-steel Malmstrom cup.

Wound Complications Followingcesarean Delivery of Patients with Hellp Syndrome: Pfannenstiel Versus Vertical Skin Incision

Objective: We sought to determine whether vertical or Pfannenstiel skin incision was associated with fewer hemorrhagic and postoperative wound complications following cesarean delivery in patients with HELLP syndrome.Methods: As part of an extensive retrospective analysis of medical records for all patients with HELLP syndrome who delivered between January 1,1980 and June 30,1993, we investigated those delivering abdominally either using a midline or Pfannenstiel skin incision and primary skin closure.Main Outcome Measure: The principal outcome measure was wound complication as hematoma or dehiscence.Results: A total of 215 patients were identified; 185 patients received midline vertical skin incisions and 30 had Pfannenstiel incisions. In the midline group, there were 17 wound separations (17/185, 9%) and 5 other types of wound complication (total 22/185, 12%). Significantly more wound complications, as wound separation, occurred in 8 of the 30 (27%) patients with Pfannenstiel incisions (p = 0.01). The o...