Preoperative Gynecologic Evaluation

The pregnancy status should be determined in all females of reproductive age undergoing surgery. Any suspicion of a pelvic mass, abdominal enlargement, or enlarged uterus should prompt the discussion of the patient's pregnancy status. This is the most common form of pelvic mass in a reproductive age female.

Pelvic masses including pregnancy, enlarged uteri due to leiomyoma or sarcoma, or adnexal masses are clinically sized using the weeks of gestational age scale. This provides clinicians with a standardized range to use while communicating about clinical assessment of a pelvic mass. The 12-week sized mass is palpated at the level of the pubic symphysis while a 20-week sized mass is palpated at the level of the patient's umbilicus. These sizes are typical for normal pregnancies.

It is not uncommon to perform laparoscopy in the pregnant patient. Although the effects to the fetus during laparoscopic surgery are currently unclear, it is generally agreed upon to closely monitor insufflation pressure.

Lachman et al. reported on 518 procedures performed during pregnancy. Forty-five percent were cholecystectomy, 34% adnexal surgery, and 15% appendectomy (1). Barnard et al. found that pressures greater than 15 mmHg seemed to decrease uteroplacental blood flow (2). Despite several series reporting that laparoscopy can be successfully performed during pregnancy, it is imperative upon the physician to appropriately assess and counsel the gravid patient regarding increased risks to both her and her fetus. Minimal gynecologic parameters to be assessed preoperatively are:

■ Pregnancy status

■ Menstrual cycle history

■ Pap smear history

■ Patient's interest in future fertility

■ Pelvic examination

The most important information is a history of irregular periods or post-menopausal bleeding. This should not be ignored, and if present an evaluation and/or appropriate consultation should be initiated. Typically, an ultrasound evaluation of the endometrium and an endometrial biopsy are performed.

If the patient has not yet completed her family, a discussion of the potential impact of the surgery on her future fertility is recommended. The general principle in modern gynecologic surgery is to be as conservative as possible, especially in women of reproductive age.

It is not uncommon to perform laparoscopy in the pregnant patient. Although the effects to the fetus during laparoscopic surgery are currently unclear, it is generally agreed upon to closely monitor insufflation pressure.

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