Quality of evidence (high, moderate, low, and very low) and grades of recommendations (strong and weak) are defined at the end of the "Major Recommendations" field.
Diagnosis and Workup
Guideline 1: Ultrasonographic imaging during pregnancy is safe and useful in identifying the etiology of acute abdominal pain in the pregnant patient (Moderate; Strong).
Risk of Ionizing Radiation
Guideline 2: Expeditious and accurate diagnosis should take precedence over concerns for ionizing radiation. Cumulative radiation dosage should be limited to 5-10 rads during pregnancy (Moderate; Strong).
Computed Tomography (CT)
Guideline 3: Contemporary multidetector CT protocols deliver a low radiation dose and may be used judiciously during pregnancy (Moderate; Weak).
Magnetic Resonance (MR) Imaging
Guideline 4: MR imaging without the use of intravenous gadolinium can be performed at any stage of pregnancy (Low; Strong).
Guideline 5: Administration of radionucleotides for diagnostic studies is generally safe for mother and fetus (Low; Weak).
Guideline 6: Intraoperative and endoscopic cholangiography exposes the mother and fetus to minimal radiation and may be used selectively during pregnancy. The lower abdomen should be shielded when performing cholangiography during pregnancy to decrease the radiation exposure to the fetus (Low; Weak).
Guideline 7: Diagnostic laparoscopy is safe and effective when used selectively in the workup and treatment of acute abdominal processes in pregnancy (Moderate; Strong).
Pre-operative Decision Making
Guideline 8: Laparoscopic treatment of acute abdominal disease has the same indications in pregnant and non-pregnant patients (Moderate; Strong).
Laparoscopy and Trimester of Pregnancy
Guideline 9: Laparoscopy can be safely performed during any trimester of pregnancy (Moderate; Strong).
Guideline 10: Gravid patients should be placed in the left lateral decubitus position to minimize compression of the vena cava (Moderate; Strong).
Initial Port Placement
Guideline 11: Initial abdominal access can be safely accomplished with an open (Hasson) technique, Verres needle, or optical trocar, if the location is adjusted according to fundal height and previous incisions (Moderate; Strong).
Guideline 12: Carbon dioxide (CO2) insufflation of 10-15 mm Hg can be safely used for laparoscopy in the pregnant patient. (Moderate; Strong).
Intraoperative CO2 Monitoring
Guideline 13: Intraoperative CO2 monitoring by capnography should be used during laparoscopy in the pregnant patient (Moderate; Strong).
Venous Thromboembolic (VTE) Prophylaxis
Guideline 14: Intraoperative and postoperative pneumatic compression devices and early postoperative ambulation are recommended prophylaxis for deep venous thrombosis in the gravid patient (Moderate; Strong).
Guideline 15: Laparoscopic cholecystectomy is the treatment of choice in the pregnant patient with gallbladder disease regardless of trimester (Moderate; Strong).
Guideline 16: Choledocholithiasis during pregnancy may be managed with preoperative endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy followed by laparoscopic cholecystectomy, laparoscopic common bile duct exploration, or post-operative ERCP (Moderate; Strong).
Guideline 17: Laparoscopic appendectomy may be performed safely in pregnant patients with appendicitis (Moderate; Strong).
Solid Organ Resection
Guideline 18: Laparoscopic adrenalectomy, nephrectomy and splenectomy are safe procedures in pregnant patients (Low; Weak).
Guideline 19: Laparoscopy is safe and effective treatment in gravid patients with symptomatic ovarian cystic masses. Observation is acceptable for all other cystic lesions provided ultrasound is not concerning for malignancy and tumor markers are normal. Initial observation is warranted for most cystic lesions <6 cm in size (Low; Strong).
Guideline 20: Laparoscopy is recommended for both diagnosis and treatment of adnexal torsion unless clinical severity warrants laparotomy (Low; Strong).
Fetal Heart Monitoring
Guideline 21: Fetal heart monitoring should occur preoperatively and postoperatively in the setting of urgent abdominal surgery during pregnancy (Moderate; Strong).
Guideline 22: Obstetric consultation can be obtained pre- and/or postoperatively based on the severity of the patient's disease, gestational age, and availability of the consultant (Moderate; Strong).
Guideline 23: Tocolytics should not be used prophylactically in pregnant women undergoing surgery but should be considered perioperatively when signs of preterm labor are present (High; Strong).
Grading of Recommendations Assessment, Development and Evaluation (GRADE) System for Rating the Quality of Evidence
High quality - Further research is very unlikely to alter confidence in the estimate of impact
Moderate quality - Further research is likely to alter confidence in the estimate of impact and may change the estimate
Low quality - Further research is very likely to alter confidence in the estimate of impact and is likely to change the estimate
Very low quality - Any estimate of impact is uncertain
GRADE System for Recommendations Based on the Quality of Evidence
Strong - It is very certain that benefit exceeds risk for the option considered
Weak - Risk and benefit well balanced, patients in differing clinical situations would make different choices, or benefits available but not certain
Adapted from Guyatt GH, Oxman AD, Vist GE, et al; GRADE Working Group. GRADE: An emerging consensus on rating quality of evidence and strength of recommendations. BMJ 2008;336:924-6.