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Introduction: Vernix caseosa peritonitis (VCP) is a rare peripartum complication secondary to the introduction of fetal vernix into the maternal peritoneal cavity. Vernix caseosa peritonitis typically manifests a few hours to days after a cesarian section and is often initially misdiagnosed as a more common disease process resulting in delayed diagnosis. We report the computed tomography (CT) findings in 2 patients with VCP and reviewed the previously reported CT findings of VCP., Cases: Two patients, aged 17 and 24 years, presented with signs and symptoms of peritonitis within days of undergoing a cesarian section. In both cases, CT scans of the abdomen and pelvis demonstrated ascites and multiple small, well-defined, peripherally enhancing, cystic peritoneal nodules which were most prominent around the liver and became larger and more numerous over time. Antibiotic therapy was not effective, subsequent laparoscopic peritoneal biopsy demonstrated VCP, and patients were successfully treated with lavage and the addition of intravenous steroids., Conclusions: Vernix caseosa peritonitis is an underrecognized disorder that is most often mistaken for other more common causes of peritonitis. In the setting of peripartum peritonitis, the CT findings of ascites with multiple small, well-defined, peripherally enhancing, cystic peritoneal nodules, especially adjacent to the liver, which grow in size and number strongly suggests VCP.

Placenta accreta (PA) is a life-threatening disorder associated with decidual maldevelopment and a thin endometrium. Few cases of systemic lupus erythematosus (SLE) pregnancy complicated by PA have been reported, and the background pathophysiology remains elusive. Here, we report a case of PA in SLE pregnancy treated with hydroxychloroquine. A nulligravida woman with SLE, aged 41 years, visited our hospital because of infertility problems. Her SLE was treated with prednisolone and tacrolimus. We conducted assisted reproductive technology and gained several embryos. An artificial cycle successfully prepared the endometrium for embryo transfer with sufficient thickness. Over time, her SLE exacerbated, and we started hydroxychloroquine administration. Consequently, the endometrium did not respond to hormonal supplementation and remained thin, but we transferred the embryo and managed to achieve pregnancy. On the 38th week of gestation, we conducted labor induction because of elevated blood pressure. Induction was not effective, so we performed cesarean section; PA was observed. We performed compression suturing and were able to stop the hemorrhage. Postoperative uterine infarction and pelvic infection were successfully managed with conservative treatment. The present case highlights the use of hydroxychloroquine during endometrial development and contributes evidence regarding the pathogenesis of PA in pregnancy complicated by SLE.

We report on a rare case of dicavitary twin pregnancy in a woman with a uterine didelphys. Delivery was performed by elective caesarean section, where live female and male infants were born. Twin pregnancies, in women with uterine anomalies, are high risk and require close surveillance in a specialist centre to monitor for complications such as preterm birth and fetal growth restriction., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Adnexal torsion during pregnancy is a gynecological emergency. Delayed diagnosis and treatment can cause ovarian necrosis and fetal loss. This study assessed the clinical characteristics, treatment and outcomes of adnexal torsion in pregnant women., Methods: A retrospective study was conducted at a tertiary center between January 2008 and January 2018. Eighty-two pregnant women with surgically confirmed adnexal torsion were included. The clinical characteristics, ultrasound data, surgical interventions and pregnancy outcomes were analyzed., Results: The median age of the patients was 28 (range, 18-38) years. The median gestational age was 11 (range, 6-31) weeks: 53 (64.6%) were in the first trimester, 21 (25.6%) were in the second trimester, and 8 (9.8%) were in the third trimester. The most common symptoms and signs were sudden pelvic pain (100%) and adnexal or pelvic masses (97.6%), followed by nausea and vomiting (61%). The Doppler blood flow signal disappeared in 62.5% of the patients. Sixty-three (76.8%) patients underwent laparoscopy, and 29 (24.2%) underwent laparotomy. The median gestational age in patients undergoing laparotomy was higher than that in those undergoing laparoscopy (26 weeks vs 10 weeks, p < 0.001). Fifty-three (64.6%) patients underwent conservative surgery, with 48 detorsions and cystectomies, 2 detorsions and cyst fenestrations, 1 detorsion only and 2 salpingectomies only. Twenty-nine (25.4%) patients underwent unilateral salpingo-oophorectomy. There were no cases of postoperative thrombosis, spontaneous abortion or recurrence during the same pregnancy. Seven patients underwent simultaneous artificial abortion. One patient experienced intrauterine fetal death, and 74 patients had live births., Conclusion: Surgical intervention was required as soon as possible. Laparoscopic conservative surgery is safe and may be appropriate to preserve ovarian function.

Competing Interests: Competing interests: None declared.

Acute appendicitis (AA) is the most common nonobstetric surgical emergency during pregnancy. According to the current guidelines and meta-analyses, traditional open appendectomy (OA) is still recommended for pregnant patients over laparoscopic appendectomy (LA), which might be associated with higher rates of fetal loss. Previous studies and experiences indicated that LA might be safe in the second trimester of pregnancy. The current study aimed to evaluate the safety and feasibility of LA in pregnant women during the second trimester.At our institution, a retrospective study was conducted with pregnant patients who underwent LA or OA during the second trimester between January 2016 and August 2018.A total of 48 patients were enrolled. Of them, 12 were managed with laparoscopy and 36 with the open approach. We found that the LA group had higher BMIs than the OA group (4.0 ± 4.3 vs 21.5 ± 2.9, P = .031). The financial results showed that the average daily medical costs for patients who underwent LA was higher than those who underwent OA (444 ± 107 US$ vs 340 ± 115 US$, P = .009), while the total cost of hospitalization was comparable between the 2 approaches. The perioperative and obstetric outcomes were comparable between LA and OA. In each group, only 1 patient had fetal loss. No "Yinao" was found in any of the patients in the LA group.In this study, with the proven advantages of the laparoscopic techniques, LA was found to be safe and feasible for pregnant women during the second trimester.

Background: To study the cesarean section (c-section) practices in the French Centre-Val de Loire region: incidence of planned c-section and rate variations between maternities, incidence of potentially avoidable cesarean sections., Methods: The data were extracted from the 2016 regional birth register, which permitted classification of each planned c-section according to the pre-existing risk of c-section (high or low) as defined by the Robson classification. To enhance the data, especially the indications for c-section, which are not included in the register, a survey was conducted from September 2016 to February 2017 in all of the 20 maternities in the region., Results: In 2016, nearly 26,000 women gave birth in the CVL region, of whom 19.2% by c-section (7.0% planned c-sections). The planned c-section rate was higher for breech presentation and scarred uterus, and decreased according to level of the maternity (I 41% - II 35% - III 32%). Concerning the c-section indications, 1,979 c-sections were studied during the period (18.6% of births), including 762 planned c-sections (7.1% of births). Among them, 246 (32%) were potentially avoidable, mainly isolated indications of scarred uterus with only one previous c-section or breech presentation, and 17 due to unfavorable radiologic pelvimetry in nulliparous women., Conclusion: Specific actions were identified: targeted use of radiologic pelvimetry, targeted c-section on scarred uterus with only one previous cesarean section or breech presentation, as recommended by the national guidelines. The Robson classification should be widely used to evaluate and enhance practices, in particularly through painstakingly interpreted inter-maternity comparisons., (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

Objective: To define current national practice patterns of imaging modalities and urologic procedures in pregnant women with urinary stone disease., Methods: Using the IBM MarketScan national insurance claims database, we identified pregnant women with urinary stone disease and their corresponding gestational age between 2011 and 2016 using administrative claims data. We then assessed each encounter for urinary stone disease or stone-related urologic procedure during their pregnancy. We abstracted demographic information as well as codes for stone procedures and imaging., Results: We identified 14,298 pregnant women with urinary stone disease during the study period. Of the 12,315 undergoing abdominal imaging (86.1%), magnetic resonance imaging was used in 2.8%, x-ray in 9%, and ultrasound in 74.3%. Computed tomography was not used as a diagnostic modality during pregnancy. Procedural intervention was performed in 749 women (5.2%): 476 (3.3%) ureteral stent placement without definitive stone treatment, 93 (0.6%) percutaneous nephrostomy placement, and 180 (1.3%) ureteroscopy (URS) for definitive stone treatment. URS was most commonly performed before 34 weeks gestation with only 27 cases (15%) performed after., Conclusion: This large national cohort reveals the current imaging and procedural practice patterns for urinary stone disease during pregnancy and provides a critical baseline as these practice patterns evolve in the future., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Adrenal lesions diagnosed during pregnancy remain rare, and their management is challenging because of maternal physiologic modifications, restricted imaging investigations, and contraindications to several treatments. Surgical issues of adrenalectomy during pregnancy and consequences on perinatal outcomes are poorly described. We therefore aimed to report maternal and fetal outcomes after adrenalectomy during pregnancy., Methods: All pregnant women who underwent adrenalectomy over a 15-year inclusion period were identified from a prospectively maintained database. Surgical management and maternal and fetal outcomes were reviewed., Results: From January 2003 to July 2018, a total of 12 women underwent adrenalectomy at a median gestation of 20 weeks. Of these women, 11 had hyper-secreting lesions, including 8 with cortisol oversecretion, and 11 had benign lesions, including cortisol-secreting adenoma (n = 5), pheochromocytoma (n = 2), primary pigmented, nodular adrenal disease (n = 1), severe Cushing's disease (n = 2), and hematoma (n = 1). A total of 3 patients with severe Cushing's disease (n = 2) and primary pigmented, nodular adrenal disease (n = 1) required bilateral adrenalectomy. One patient presented with a malignant adrenal Ewing sarcoma. Adrenalectomy during pregnancy was performed by the lateral laparoscopic transabdominal laparoscopic route in 9 patients. Postoperative morbidity occurred in 3 women. Maternal mortality was nil, but preterm birth occurred in 7 cases and intrauterine growth retardation was observed in 3 cases. Finally, among the 12 women, 10 had a child in good health., Conclusion: During pregnancy, a lateral laparoscopic transabdominal approach is a feasible procedure. Maternal outcome is acceptable but fetal outcome is determined by the underlying disease, with a worse outcome when the adrenalectomy is indicated for malignant lesions or Cushing's syndrome., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Previous studies indicate a low incidence of appendicitis in third-trimester pregnancy, suggesting a protecting effect of pregnancy. This large population-based cohort study analyzes the association of appendicitis with pregnancy in more detail. The aim of the study was to investigate the incidence of appendicitis and negative appendectomy before, during and after pregnancy., Methods: Cross-linking between two Swedish health registries provided data on appendectomy for all women in Sweden giving birth between 1973 and 2013. We analyzed the incidence rates (IR) of perforated and non-perforated appendicitis and negative appendectomy before, during and after pregnancy, and secular trends during the study period. Standardized incidence ratios (SIR) were estimated using age-, sex- and period-specific IR from the background population in Sweden., Results: Some 3,888,452 pregnancies resulted in birth during the study period. An appendectomy was registered for 27,575 women in the interval starting one year before and ending two years after pregnancy. The incidence of appendicitis varied substantially during and after pregnancy. SIR for perforated appendicitis was 0.47 (95% CI 0.38-0.59) in the third trimester, 3.89 (2.92-5.18) peripartum, 2.20 (1.89-2.55) in the puerperium and 1.27 (1.19-1.36) in the year postpartum. The pattern was similar for non-perforated appendicitis. Negative appendectomy decreased postpartum. Incidence rate of non-perforated appendicitis and negative appendectomy decreased for both pregnant and non-pregnant women during the study period., Conclusions: The findings in this study suggest a protecting effect of pregnancy on the development of appendicitis, which is followed by a rebound effect after birth.

Background: Trauma in pregnancy poses a unique challenge to clinicians. Literature on this topic is limited in South Africa (SA)., Objectives: To review our institution's experience with the management of trauma in pregnancy in a developing-world setting., Methods: This study was based at Grey's Hospital, Pietermaritzburg, SA. All pregnant patients who were admitted to our institution following trauma between December 2012 and December 2018 were identified from the Hybrid Electronic Medical Registry (HEMR)., Results: During the 6-year study period, 2 990 female patients were admitted by the Pietermaritzburg Metropolitan Trauma Service (PMTS), of whom 89 were pregnant. The mean age of these patients was 25.64 (range 17 - 43) years. The mechanism of injury was road traffic crash (RTC) in 39, stab wounds (SW) in 19, assault other than SW or gunshot wounds (GSW) in 19, GSW in 8, snake bite in 5, impalement in 1, dog bite in 1, hanging in 1, sexual assault in 1 and a single case of a patient being hit by a falling object. A subset of patients sustained &gt;1 mechanism of injury. Thirty patients were managed operatively. The mean time of gestation was 19.16 (5 - 36) weeks. Three patients died, and there were 16 fetal deaths (including 3 lost after the mother's death). Forty-five fetuses were recorded as surviving at discharge, while 25 fetal outcomes were not specifically recorded. There were 2 threatened miscarriages and/or patients with vaginal bleeding, 1 positive pregnancy test with no recorded outcome and no premature births as a result of trauma., Conclusions: Trauma in pregnancy is relatively uncommon and mostly due to a RTC or deliberately inflicted trauma. Fetal outcome is largely dependent on the severity of the maternal injury, with injuries requiring laparotomy leading to a high fetal mortality rate.

Background and Aims: Crohn's disease (CD) frequently affects young women and may require surgery during pregnancy. Data regarding operation for CD in expectant mothers are scare., Materials and Methods: This was a retrospective nationwide survey from the GETAID Chirurgie. Any woman with CD undergoing surgery during pregnancy was eligible., Results: A total of 15 cases were collected between 1992 and 2015. Most operations were performed due to penetrating or stricturing complications. Mean gestational age at delivery was 34 weeks, with a mean birth weight of 2507 g. Maternal post-operative complications occurred in two-thirds of cases. Maternal mortality rate was 6.7% and neonatal mortality rate 9.1%., Conclusions: This is the largest case series of surgery for CD during pregnancy. This operation may have significant morbidity and mortality for mother, fetus, and newborn. Indication needs to be tailored to maternal status, disease severity, and gestational age. Surgery should be managed by experienced gynecologists, physicians, and surgeons. Active CD may be associated with a greater risk to the fetus than the surgical procedure itself.

Background: Low back pain is a common complaint during pregnancy. However, spinal pathologies, which manifest with severe pain, radiculopathy, and acute neurologic deficits because of disk herniation or mass lesions require special attention. Here, we present our interdisciplinary experience in the surgical management of spinal emergencies during pregnancy., Methods: The data of pregnant women who underwent surgery for spinal pathologies over a 10-year period were collected. Patient-related characteristics such as maternal age, gestational age, preoperative workup, signs and symptoms of mothers, and diagnostic procedures were evaluated. After an interdisciplinary conference, individualized treatment plans regarding available options were developed. Fetal Doppler and cardiotocography were obtained before and after surgery., Results: Nine pregnant women presented with spinal disorders and underwent spinal emergency surgery within the study period. The mean maternal age was 32.2 years. Six women presented with lumbar disk herniations manifesting as severe sciatica or foot drop and 3 patients had thoracic mass lesions resulting in cauda equine syndrome and/or ataxia. The mean gestational age at the time of presentation was 26.5 weeks. Caesarean sections were performed in 3 women prior to the neurosurgical procedure, whereas the pregnancies were maintained in the 6 other patients. Eight infants who were healthy at birth had an unremarkable development., Conclusions: Surgery for spinal emergencies in pregnancy can be performed safely according to individual treatment plans developed by an interdisciplinary team taking into account the expectant mother's decision. Maintenance of pregnancy is possible and feasible in most patients., (Copyright © 2020 Elsevier Inc. All rights reserved.)

The aim of our study was to compare the clinical and surgical characteristics of pregnant and nonpregnant women with surgically verified ovarian torsion, as well as the differences among 3 trimesters during pregnancy.We conducted a retrospective study of patients diagnosed with surgically proven ovarian torsion in our hospital from January 2012 to June 2018. The clinical characteristics, surgical procedure, pathologic outcomes, and trimesters of pregnancy were analyzed.Thirty-three pregnant and 72 nonpregnant patients diagnosed with surgically proven ovarian torsion were assessed during the study period. The most common presenting symptom in both groups was abdominal pain (90.2% and 99.0%, respectively). The median time from admission to surgery was shorter in pregnant patients than nonpregnant patients (5.3 compared with 47.7 hours, P < .001). Pregnant patients had a higher number of twists than nonpregnant patients (median of 2 compared with 1, P < .01). Benign cyst was the most common cyst causing ovarian torsion in both groups, and luteum cyst was more common in the pregnant group. The mean size of ovarian cyst in pregnant patients was much smaller in the third trimester than the first and the second trimesters (6.6 ± 2.0, 8.4 ± 2.1and 8.1 ± 1.5 cm, respectively; P = .097). Cystectomy performed in the third trimester was more frequent compared with the other 2 trimesters (77.8%, 26.7%, and 22.2%, respectively; P = .021).Abdominal pain is the most common feature of ovarian torsion. Clinical presentation of ovarian torsion is relatively similar between pregnant and nonpregnant women, and among different trimesters. The tumor size was smaller in the third trimester of pregnancy than the other 2 trimesters of pregnancy. Cystectomy performed in pregnant patients is more during the third trimester compared with the other 2 trimesters.

Background: Albeit rarely, different spinal pathologies may require surgical treatment during pregnancy. The management of such cases poses a series of challenges, starting with adequate body positioning., Objective: To illustrate limits and indications of the different surgical positioning strategies for pregnant women undergoing spine surgery., Methods: We performed a systematic review of literature about the described surgical positioning strategies used for spinal surgery during pregnancy, discussing advantages, indications, and limits. We also describe of a novel three-quarters prone positioning for dorsal pathology., Results: The surgical strategy may vary according to several factors, such as the location and the nature of the underlying pathology, the stage of the pregnancy, and the clinical condition of mother and fetus. During the second trimester, the habitus begins to raise issues about both the abdominal and the aortocaval compressions. The third trimester implies neonatal and ethical challenges: both fetal monitoring and the possibility of urgently proceeding to delivery should be guaranteed. The prone position is feasible during the second trimester provided an adequate frame is supplied. The lateral or three-quarters prone positioning may offer the safest option in the last stages of pregnancy, whereas both supine and sitting positionings are anecdotal., Conclusions: Gestational age, surgical comfort and maternofetal safety should be balanced by a multidisciplinary team to tailor an adequate positioning plan for each individual case. The early third trimester is the more limiting period because of the womb hindrance favoring lateral or three-quarters positionings., (Copyright © 2020 Elsevier Inc. All rights reserved.)

This study was performed to describe the clinical features, risk factors, and treatment methods of uterine torsion in pregnancy. The most common symptoms are abdominal pain, fetal heart rate changes, and failure of cervical dilatation and are often accompanied by complete or partial placental abruption. Preoperative diagnosis is challenging even with the use of ultrasound. Uterine torsion in the third trimester is correlated with the presence of multiple uterine fibroids. The causes of gravid uterine torsion vary and the clinical manifestations are nonspecific. Early diagnosis and improved detection approaches are the keys to treatment of patients with uterine torsion. However, the preoperative diagnosis remains difficult and the diagnosis is often made during cesarean section.

If it is medically necessary to perform nonobstetrical abdominal surgery in pregnancy, a minimally invasive approach should be considered. The benefits of laparoscopy are well known and current studies promote the safety of laparoscopy in pregnancy, when certain guidelines are followed. This article will review the safety of surgery in pregnancy, maternal physiology, fetal considerations, maternal obesity, laparoscopic cerclage, large adnexal mass, and complications. Guidelines for surgery will be reviewed as well.

A surgical disease occurring during pregnancy can present a diagnostic dilemma due to the desire to make a timely and accurate diagnosis within the constraints of limiting radiation exposure to the fetus. However, required diagnostic imaging should be pursued when indicated and attempts made to minimize the radiation dose by utilizing abdominal shielding and low-dose protocols when feasible. When surgery is indicated due to disease processes, treatment should not be altered or delayed due to pregnancy as the evidence for adverse pregnancy outcomes including early pregnancy loss and preterm delivery are overall of low quality due to substantial confounding by the disease process itself.

Necessary nonobstetric surgical procedures should not be withheld from pregnant women for fear of risks to the women and their pregnancies; however, careful preoperative planning should be undertaken to mitigate risks that may be present. Fetal monitoring recommendations will be dependent on the woman's preferences, gestational age of the pregnancy, and situational-specific risks (including anticipated risk of cardiovascular instability). Some fetal heart rate changes (lower baseline, less variability) can be anticipated, depending on anesthetic agents utilized during the procedure, and should not routinely prompt delivery.

This chapter reviews issues which complicate surgery in obese pregnant patients. Maternal obesity is prevalent in the United States and is associated with numerous adverse health outcomes. When surgery is indicated during pregnancy, the presence of maternal obesity increases surgical risks for both the fetus and mother. Specific risks are identified and strategies to avoid them are evaluated. The prognosis and management of pregnant women who have undergone bariatric surgery is also discussed, and practical guidelines for obstetric management of these patients are presented.

Introduction: Stroke is a leading cause of adult death and disability. Although acute ischemic stroke (AIS) in pregnancy is rare, it has devastating consequences on the life of the mother and fetus. Pregnancy was an exclusion criterion in endovascular thrombectomy (EVT) trials and so there are no evidence-based treatment recommendations in this subgroup. The objective of this study was to evaluate the safety and feasibility of mechanical thrombectomy in large vessel occlusion (LVO) stroke in pregnancy., Methods: Patients with AIS due to LVO treated with EVT during pregnancy between 2000 and 2019 were identified at seven tertiary care centers. After IRB approval, retrospective analysis of prospectively maintained stroke/endovascular databases was performed., Results: A total of seven subjects were identified. The average age was 33.2 years (range 25-38 years) and the average initial National Institutes of Health Stroke Scale (NIHSS) score at presentation was 15 (range 9-28). Three patients received IV tissue plasminogen activator. Techniques of EVT included stent retriever thrombectomy, stent retriever-assisted continuous aspiration, direct contact aspiration, and multimodal techniques including a rescue balloon mounted coronary stent placement. While one patient was noted to have petechial hemorrhage, no individuals developed parenchymal hematoma. Mean discharge NIHSS score was 1.7 (range 0-5)., Conclusion: EVT is a safe and effective treatment for acute stroke secondary to LVO in this series of pregnant patients. While EVT for acute stroke is standard of care in select patient populations, our study suggests that treatment should be considered in the gravid population., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Gestational gigantomastia (GGM) is a rare complication of pregnancy. The etiology of GGM is yet to be fully established. Treatment methods for GGM include medical therapy and surgery. If medical treatment is unsuccessful, surgery may be required. Currently available surgical interventions are either breast reduction or mastectomy with delayed reconstruction. We report a case of a 25-year-old woman (G1P1) who presented with massive enlargement of both breasts during puerperium. Because of the limited effect of medical therapy, surgical intervention was considered to be the first choice. Bilateral mastectomies with grafting of the nipple-areola complex and immediate bilateral tissue expander implantation were performed. Reconstruction was fully completed 8 months after the initial procedure by replacing tissue expanders with definitive implants. Despite being a benign condition, GGM can turn into a serious problem. GGM can be successfully reconstructed by mastectomy with delayed reconstruction and grafting of the nipple-areola complex.

Nonobstetric surgery during pregnancy occurs in 1% to 2% of pregnant women. Physiologic changes during pregnancy may have an impact when anesthesia is needed. Anesthetic agents commonly used during pregnancy are not associated with teratogenic effects in clinical doses. Surgery-related risks of miscarriage and prematurity need to be elucidated with well-designed studies. Recommended practices include individualized use of intraoperative fetal monitoring and multidisciplinary planning to address the timing and type of surgery, anesthetic technique, pain management, and thromboprophylaxis. Emergency procedures should be performed immediately and elective surgery should be deferred during pregnancy.

Up to 2% of pregnant women develop a disease that requires nonobstetrical operative intervention during pregnancy. We discuss the issues unique to pregnant patients as they pertain to the presentation, diagnosis, and management of nonobstetric surgical disease, with an emphasis on 2 of the most common diseases that affect pregnant women: appendicitis and cholecystitis. Surgery has been demonstrated to be safe and effective during pregnancy, provided proper precautions are taken into account. It is the consensus of multiple professional committees and societies that no pregnant women should be delayed or denied a necessary surgery because of pregnancy.

The management principles of non-obstetric surgery during pregnancy are important concepts for all health care providers to be cognizant of. The goals of non-obstetric surgery are to ensure maternal safety, maintain the pregnancy, and ensure fetal well-being. In this regard, organogenesis occurs roughly between days 7-57 and thus, certain medications have a higher incidence of fetal teratogenicity in this first trimester. Some examples of common surgeries performed urgently or emergently include appendectomies, ovarian detorsions, bowel obstruction, trauma, and cholecystectomies. The choice of anesthetic technique and the selection of appropriate anesthetic drugs should be guided by indication for surgery, the nature of the surgery, and the site of the surgical procedure. Many of the concerns for any patients undergoing urgent or emergent surgery must be considered by anesthesia providers along with steps to ensure the fetus has the best outcome., Competing Interests: Declaration of Competing Interest None., (Published by Elsevier Ltd.)

Midgut volvulus complicating congenital malrotation is a rare but life-threatening condition that can occur in pregnancy. We present a case of intestinal infarction resulting from midgut volvulus in a healthy 32-week pregnant woman who underwent emergency laparotomy and small bowel resection in the setting of fetal death in utero. This case highlights several challenging issues in diagnosing and managing this uncommon condition which leads to increased adverse perinatal outcomes. Prompt investigation and definitive surgical treatment are required when pregnant women present with bilious vomiting and new-onset abdominal or back pain especially beyond the first trimester., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Primary splenic cysts are very rarely diagnosed in pregnancy, with only thirteen cases described in the literature. We examine the approach towards diagnosing and managing uniquely large abdominal masses that significantly complicate obstetric care., Case Presentation: A 37-year-old primigravida woman presented with abdominal distension and discomfort, yet otherwise asymptomatic. On ultrasound, an incidental pregnancy at 25 weeks of gestation and a large pelvic lesion were discovered. MRI defined a 28 × 29 cm lobulated, complex cystic mass in the upper abdomen. The patient underwent two ascitic drainages throughout her pregnancy. At 34 weeks of gestation, she had a classical caesarean section. Then at five-weeks postpartum, she underwent a laparotomy and total splenectomy with 16 L of fluid drained. Histopathological analysis revealed an epithelial cyst of the spleen. Her recovery was complicated by complete portal vein thrombosis., Conclusion: This case describes the largest splenic cyst ever reported in pregnancy and explores the diagnostic dilemmas and treatment challenges associated. We introduce the utility of serial ascitic drainages in prolonging the pregnancy and emphasise the reliance on imaging for surveillance of splenic size and fetal wellbeing.

Background: Peritoneal leiomyomatosis disseminate (LPD) is a rare disease characterized by widespread dissemination of leiomyomas nodules throughout the peritoneal and omental surfaces. Reports of pregnancy with LPD are even rarer. Therefore, there is no clear consensus on the treatment of LPD on pregnancy, and the pathogenesis is still unclear., Case Presentation: We reported a case of LPD patient who developed during pregnancy. The patient underwent a cesarean section at 32 weeks of gestation while removing all visible tumors, and no LPD lesions were seen in the subsequent cesarean section at full term. NGS of LPD lesions detected 4 mutations with focal high-level amplifications of CDK4 (cyclin-dependent kinases 4), NBN (Nibrin), DAXX (death domain associated protein), and MYC (myelocytomatosis oncogene). Immunohistochemistry staining analysis among benign leiomyoma, LPD, and leiomyosarcoma verified that LPD was an unusual intermediate between benign and malignant uterine smooth muscle tumors. Besides, LPD is a hormonal-dependent leiomyoma. After a detailed literature search, we summarized the detailed clinical features and follow-up information of patients with LPD during pregnancy., Conclusions: This is the first reported LPD case of successful term pregnancy without recurrence, following resection of all visible lesions in a prior pregnancy. LPD is an unusual intermediate between benign and malignant uterine smooth muscle tumors.

Background: The abdomen is a common donor site in autologous breast reconstruction. The authors aimed to determine whether pregnancy following autologous breast reconstruction increases the risk of incisional hernia repair., Methods: All women younger than 50 years who underwent abdominally based autologous breast reconstruction between 2005 and 2016 were identified. Patients with less than 20 months of follow-up were excluded. Demographics, operative details, outcomes, incisional hernia repair occurrence, and pregnancy history were analyzed., Results: Five hundred nineteen patients underwent autologous breast reconstruction with 890 free flaps [free transverse rectus abdominis musculocutaneous, n = 645 (72.5 percent); deep inferior epigastric perforator, n = 214 (24.0 percent); pedicled transverse rectus abdominis musculocutaneous, n = 18 (2.0 percent); and superficial inferior epigastric artery, n = 13 (1.5 percent)]. Average follow-up was 57.2 months (range, 9.5 to 312.8 months). Fourteen women became pregnant, with mean postpregnancy follow-up of 31.2 months (range, 5.4 to 70.8 months; pregnancies, n = 18). Age of nonpregnant patients (mean, 43.1 years; range, 20.6 to 50.0 years) was higher than that of pregnant patients (mean, 32.1 years; range, 27.1 to 37.9 years) (p < 0.0001); in univariate analysis, age was not associated with incisional hernia repair. Twelve pregnant patients (66.7 percent) underwent cesarean delivery. No statistically significant differences existed between groups regarding flap type and closure technique. Zero pregnant patients underwent incisional hernia repair, compared with a 6.1 percent incisional hernia repair rate in nonpregnant patients (p = 0.339). In multivariate analysis, prior incisional hernia, hematoma, fascial dehiscence, and reoperation predicted incisional hernia repair., Conclusion: The authors' results demonstrate that there may not be an increased risk of incisional hernia repair associated with pregnancy following autologous breast reconstruction despite additional weakening of the abdominal wall., Clinical Question/level of Evidence: Risk, II.

Study Objective: To evaluate the reproductive outcomes in women treated for retained products of conception (RPOC) by hysteroscopy (morcellation vs loop resection)., Design: Cohort study., Setting: A teaching and university hospital., Patients: Patients included in a previous randomized controlled trial on hysteroscopic removal of RPOC comparing morcellation (n = 46) with loop resection (n = 40)., Interventions: Hysteroscopic morcellation versus loop resection., Measurements and Main Results: The primary outcome measures were live birth and pregnancy complications (including abnormal placentation [placenta accreta/increta/percreta], placenta previa, vasa previa, retained placenta after delivery or incomplete expulsion with the need for manual removal or curettage, and RPOC), uterine rupture, and other complications (blood loss, preterm labor, preterm premature rupture of membranes, hypertensive disorders of pregnancy, and intrauterine growth restriction). The live birth rate was 88.9% in the morcellation group and 68.2% in the loop resection group (p = .09). Uterine rupture occurred in 1 patient in the morcellation group (4.2%) (p = 1.00). Placental complications were found in 20.8% and 22.2% of the hysteroscopic morcellation and loop resection groups, respectively (p = .33), and other pregnancy complications were seen in 33.3% and 16.6% of the 2 groups (p = .33). The secondary outcome was time to pregnancy. The median time to pregnancy was 14 weeks (interquartile range [IQR], 5-33 weeks) in the morcellation group and 15 weeks (IQR, 6-37 weeks) in the loop resection group (p = .96)., Conclusion: Hysteroscopic removal of RPOC seems to have no detrimental effect on reproductive outcome and no significant effect on pregnancy rate., (Copyright © 2019 AAGL. Published by Elsevier Inc. All rights reserved.)

Cushing's syndrome (CS) during pregnancy is rare. It causes the clinical disorder by overproduction of cortisol. Hypercortisolemia in pregnancy can lead to severe complications, both for the mother and the fetus, including spontaneous abortion, perinatal death, prematurity, maternal hypertension, heart failure, diabetes and opportunistic infections. The most common cause of hypercortisolemia in pregnancy is a cortisol-secreting adrenal tumor. Herein we present a 31 year-old female patient, at 20 weeks' gestation, with CS secondary to a left adrenal tumor. A brief review of reported similar cases is included.

Study Objective: Laparoscopic management of nonobstetric acute abdominal pain in the third trimester of pregnancy remains controversial with limited data regarding procedure safety and feasibility. This study aimed to investigate the feasibility, immediate complications, and short-term outcomes of laparoscopic surgery at an advanced gestational age., Design: Case-series., Setting: Sheba Medical Center, a tertiary referral center., Patients: Pregnant women who underwent urgent laparoscopic surgery at 27 weeks of gestation and above., Intervention: Emergent laparoscopic surgery., Measurements and Main Results: Clinical data were retrospectively collected and analyzed. A telephone questionnaire was administered in cases of missing data. Clinical information obtained included detailed medical and obstetric history; preoperative, intraoperative, and postoperative data; complications; and pregnancy outcomes. Between January 2010 and July 2017, 12 patients underwent emergent laparoscopic surgeries during the third trimester of pregnancy. The gestational age at the time of the surgery ranged between 27 and 38 weeks. All women had singleton pregnancies. Laparoscopic surgeries included 7 appendectomies, 4 adnexal surgeries, and 1 diagnostic laparoscopy. No complications related to the access route for any of the 12 laparoscopic surgeries occurred. The laparoscopic surgical procedure was successfully completed in 11 patients; only 1 laparoscopic appendectomy for perforated acute appendicitis with purulent peritonitis at 30 weeks of gestation was converted to laparotomy because of a limited operative field. Two patients had preterm labor at 35 and 36 weeks of gestation, respectively. None of the women was complicated with intrauterine fetal demise or low Apgar scores., Conclusion: Our results demonstrate that urgent laparoscopic surgeries in the third trimester of pregnancy are feasible and can be safely performed with minimal risk for the patient and fetus. Larger prospective studies are required to validate these recommendations., (Copyright © 2019 AAGL. Published by Elsevier Inc. All rights reserved.)

Purpose: We compared the efficacy of modified Shirodkar and McDonald rescue cerclage techniques in women with singleton pregnancies. Methods: The study sample included 47 women who presented at two tertiary hospitals in Turkey from 2008 to 2017 and underwent rescue cerclage due to cervical incompetence and cervical dilatation with fetal membranes prolapsed into the vagina. The outcomes were compared by cerclage technique used, Shirodkar or McDonald. Results: The McDonald cerclage was applied in 27 cases, and modified Shirodkar cerclage in 20 cases. A longer cerclage-to-birth interval (83.8 ± 37.6 vs. 63.7 ± 38.9 days) and later gestational age at delivery (33 vs. 31 weeks) were observed with the Shirodkar cerclage, although these differences were not statistically significant ( p  = .08 and .63, respectively). Both groups had similar delivery rates after 28, 32, and 37 weeks ( p  = .20, .15, and .25, respectively), whereas the modified Shirodkar technique resulted in a higher rate of live births although these differences were not statistically significant (85% vs. 63%, p  = .09). Conclusion: The effects of the McDonald and modified Shirodkar cerclage procedures on prolonging pregnancy and improving the live birth rate were similar. Therefore, either technique can be applied to prevent neonatal loss due to advanced prematurity.

Introduction: The implantation of a gestational sac within the scar of a previous caesarean delivery is defined as caesarean scar pregnancy (CSP), which is classified into two types: CSP I and CSP II. CSP II is life threatening, and no clear consensus for CSP II management exists., Patient Concerns: A 31-year-old woman, gravida 1, para 1, with a previous caesarean delivery due to macrosomia, presented with an estimated 45 days of amenorrhea. The patient presented to the emergency department with vaginal bleeding for 1 day and no abdominal pain., Diagnoses: An ultrasound examination was performed demonstrating a viable fetus that was embedded in the caesarean scar area and was bulging through the wall of the uterus into the bladder without contact with the uterine cavity or cervical canal. A diagnosis of type II caesarean scar pregnancy was made., Interventions: Local lauromacrogol was used to reduce the gestational sac blood supply. Suction curettage was performed under the guidance of abdominal ultrasound 24 h later, and the amount of bleeding was 20 mL. The response to the treatment was monitored by serial beta-human chorionic gonadotropin (β-hCG)., Outcomes: Patient was followed up with β-hCG weekly levels which became <10 mIU/mL after 4 weeks of treatment., Conclusion: Ultrasound-guided local lauromacrogol injection combined with suction curettage may be a safer and novel therapeutic method.

Anterior myelomeningocele manifesting as a posterior mediastinal mass has rarely been described. These anomalies, characterized by protrusion of meninges and spinal cord through open vertebral arches, manifest with devastating spinal or neurologic problems. This report describes the case of a young woman with a long-term history of right upper abdominal pain and low-grade fever but no associated neurologic or spinal defects. Relevant investigations showed a posterior mediastinal mass in the right paraspinal region. Through a right posterolateral thoracotomy, complete excision of the growth with preservation of major surrounding structures was performed. Histopathologic examination revealed myelomeningocele. This report discusses a rare case of anterior myelomeningocele at the thoracic level without neurospinal involvement., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Several recent randomised control trials have shown adjunctive endovascular mechanical thrombectomy to be an effective and safe treatment for acute stroke superior to medical therapy alone. Despite this, questions remain over certain groups of patients that have been excluded from these studies, such as pregnant women. We believe this is a topic of increasing clinical significance with minimal data in the literature. In this article we discuss stroke in pregnancy and highlight the important technical considerations of endovascular mechanical thrombectomy, including minimising radiation exposure to the mother and fetus.

Objective: Every year 0.5-2% of women undergo non-obstetric surgery in pregnancy. Hypoxic events with short-term and long-term consequences are one of the most frequent complications in surgery. There is only limited data available regarding the impact of these events. This review aims to analyze the current literature on hypoxic events occurring in non-obstetric abdominal surgery in pregnant women, focused on maternal and fetal outcomes., Materials and Methods: We performed a non-systematic review of the literature, through a PubMed search using the key words "hypoxemia", "non-obstetric surgery", "surgical procedures", "pregnancy", "pregnant women" and "outcome"., Results: There is little data available regarding maternal and fetal outcomes after hypoxic episodes during non-obstetric surgery in pregnancy. In these cases, conservative intrauterine resuscitation maneuvers or immediate delivery should be taken into account. Perimortem cesarean section can be lifesaving for both mother and fetus when maternal collapse is non responsive to resuscitation procedures. Inaccurate information regarding maternal and fetal outcomes is due to the lack of robust data and the heterogeneity of the causes underlying maternal respiratory complications during surgery., Conclusions: Non-obstetric surgery during pregnancy must be performed when indicated. An expert multidisciplinary team, composed of obstetricians, surgeons, and anesthesiologists need to be included, giving appropriate attention to the physiological changes of respiratory, cardiovascular, and gastrointestinal system that occur during pregnancy. The shortest operative time and peri-operative assistance should be ensured. Complications, such as hypoxic events in pregnant patients need adequate assistance. Multidisciplinary cooperation, continuous training and simulation for anesthesiology and resuscitative procedures can guarantee this.

Introduction : Twin-twin transfusion syndrome (TTTS) is a devastating complication of monochorionic twin pregnancy and remains a major challenge for worldwide fetal medicine specialists. In TTTS, intertwin transfusion through vascular anastomoses in the shared placenta leads to severe hemodynamic imbalance. This review summarizes the current knowledge of TTTS. Areas covered : The most recent insights concerning the management of TTTS, as well as fetal and neonatal complications are described. Relevant articles were selected based on a Pubmed search using the keywords below. Understanding of the underlying pathophysiology has improved greatly as a result of placental injection studies. Advancements in antenatal management have led to increased perinatal survival and a decreased incidence of neonatal complications, including brain injury and neurodevelopmental impairment. Expert opinion : Further opportunities for improvement comprise technological innovations in laser procedures and the prevention of preterm rupture of membranes with subsequent prematurity. A noninvasive treatment such as high-intensity focused ultrasound (HIFU) seems to hold promise for the future treatment of TTTS. Fetal MRI studies are important to improve our understanding of fetal brain injury and should relate their findings to long-term neurodevelopment. International collaboration and centralization of care are of paramount importance to ensure the best care for our patients.

Over the past 30 years, maternal mortality has increased in the United States to 18 deaths per 100,000 live births. Obstetric emergencies, including hemorrhage, hypertensive disorders in pregnancy, HELLP syndrome, and amniotic fluid embolism, and anesthesia complications, including high neuraxial blockade, local anesthetic systemic toxicity, and the difficult obstetric airway, contribute to maternal cardiac arrest and maternal and fetal morbidity and mortality. Expeditious intervention by the obstetric anesthesiologist is critical in these emergent scenarios, and knowledge of best practices is essential to improve maternal and fetal outcomes., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: The torsion of normal adnexa is rare during pregnancy, especially in the third trimester. Nonspecific symptoms and signs as well as the limitations of ultrasound (US) make the diagnosis difficult, resulting in the loss of adnexa and fetal compromise. The magnetic resonance imaging (MRI) features of the torsion of normal adnexa are not classically described during pregnancy and only reported in a few cases. We find some different MRI features of the torsion of normal adnexa in late pregnancy and its diagnosis and treatment values are discussed in our report., Case Presentation: A 27-year-old woman at 31 + 5 weeks' gestation presented to the emergency department with a three-day history of the left lower abdominal pain. US discovered a mass of 87 × 61 mm in the left abdomen, but did not show whether the mass originated from the left ovary or the uterus. MRI showed the left ovary was increased in size to 82 × 42 × 85 mm with peripheral follicles. On fat-suppressed T2-weighted images, the signal intensity of the lesion was significantly decreased compared with the right ovary. The adjacent fallopian tube was found to be thickened. The radiologists diagnosed ovary infarction secondary to adnexal torsion. With the provisional diagnosis of adnexal torsion, the patient was taken to surgery. The left adnexal torsion was found during surgery. There was extensive hemorrhage and necrosis, so a left salpingo-oophorectomy was performed. The histopathology confirmed an extensively hemorrhagic fallopian tube and ovary with partial necrosis., Conclusion: We believe MRI is helpful where US is indeterminate in diagnosis of the torsion of normal adnexa in advanced pregnancy. We found that aside from hyperintensity on fat-saturated T1-weighted images, the low signal intensity on T2-weighted images can also reflect adnexal hemorrhage in conjunction with the torsion of normal adnexa.

Hyperparathyroidism is a rare disease during pregnancy, which has increased risks, including miscarriage and fetal growth restriction. However, the diagnosis of hyperparathyroidism is frequently not recognised or delayed as symptoms are non-specific and calcium is not routinely measured. With a thorough medical history and clinical suspicion, early diagnosis and treatment can reduce the risk of some pregnancy complications. A 35-year-old woman presented at 13/40 with hyperemesis gravidarum. She had elevated serum calcium and a parathyroid lesion on ultrasound. She underwent a parathyroidectomy with rapid normalisation of her calcium. Histopathology confirmed a parafibromin-deficient parathyroid tumour, suggestive of hyperparathyroidism jaw tumour syndrome. At 30/40, she presented with pre-eclampsia (hypertension, hyper-reflexia, proteinuria and intrauterine growth restriction) and had a caesarean section at 30+1/40, delivering a male infant, 897 g (fifth percentile). She had a prior 12-month history of chronic constipation and nephrolithiasis but was not investigated further despite elevated calcium (2.82 mmol/L)., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Aims of the Study: Based on an incidental observation made in the context of the Swiss National Science Foundation (SNSF) Project 67 &ldquo;End-of-life decision-making in extremely low birth weight infants in Switzerland&rdquo;, this retrospective multicentre observational study aimed to analyse circumstances of delivery room deaths after late termination of pregnancy (LTOP) in Switzerland over a 3-year period., Methods: All delivery room deaths (including live and stillbirths) following LTOP among infants with a gestational age between 22 0/7 and 27 6/7 weeks at the nine Swiss level III perinatal centres between 1 July 2012 and 30 June 2015 were analysed. Indications for LTOP were classified as either (a) maternal emergencies or (b) fetal anomalies severe enough to cause significant maternal psychological distress. Whenever possible, specific diagnoses were recorded. Spontaneous intrapartum death and fetal death caused by injection of a cardioplegic drug were distinguished for stillborn infants., Results: A total of 465 delivery room deaths among extremely low gestational age newborns (ELGANs) were identified over the 3-year study period of the SNSF project. Of these, 195 (42%) occurred in the context of LTOP. Central nervous system malformations, chromosomal anomalies, severe congenital heart disease, multiple malformations and maternal emergencies accounted for 70% of all LTOPs. LTOPs resulted in live births in 76 (39%) cases. No correlation between gestational age and rate of live births was observed. Fetal death caused by injection of a cardioplegic drug was documented in only three cases. All infants born alive after LTOP died in the delivery room without resuscitation attempts. The use of drugs for palliative care in these patients was either rare or, alternatively, incompletely documented., Conclusion: LTOPs contribute significantly to mortality rates among ELGANs and should therefore be included in perinatal registries. Uniform reporting of LTOPs should be established. Infants born alive after LTOP are entitled to comprehensive palliative care like any other infant born under different circumstances. Development of national guidelines for LTOPs (including the role of fetal death caused by injection of a cardioplegic drug and palliative birth as an alternative to induced abortion) would be highly desirable to guarantee acceptable standards of care.

Background: Patients deciding to undergo dilation and evacuation (D&E) or induction abortion for fetal anomalies or complications may be greatly influenced by the counseling they receive. We sought to compare maternal-fetal medicine (MFM) and family planning (FP) physicians' attitudes and practice patterns around second-trimester abortion for abnormal pregnancies., Methods: We surveyed members of the Society for Maternal-Fetal Medicine and Family Planning subspecialists in 2010-2011 regarding provider recommendations between D&E or induction termination for various case scenarios. We assessed provider beliefs about patient preferences and method safety regarding D&E or induction for various indications. We compared responses by specialty using descriptive statistics and conducted unadjusted and adjusted analyses of factors associated with recommending a D&E., Results: Seven hundred ninety-four (35%) physicians completed the survey (689 MFMs, 105 FPs). We found that FPs had 3.9 to 5.5 times higher odds of recommending D&E for all case scenarios (e.g. 80% of FPs and 41% of MFMs recommended D&E for trisomy 21). MFMs with exposure to family planning had greater odds of recommending D&E for all case scenarios (p < 0.01 for all). MFMs were less likely than FPs to believe that patients prefer D&E and less likely to feel that D&E was a safer method for different indications., Conclusion: Recommendations for D&E or induction vary significantly depending on the type of physician providing the counseling. The decision to undergo D&E or induction is one of clinical equipoise, and physicians should provide unbiased counseling. Further work is needed to understand optimal approaches to shared decision making for this clinical decision.