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Non-Obstetric
Surgery During
Pregnancy
A Comprehensive Guide

Ceana H. Nezhat Editor

Michael S. Kavic
Raymond J. Lanzafame
Michael K. Lindsay
Travis M. Polk Associate Editors

123
Non-Obstetric Surgery During
Pregnancy
Ceana H. Nezhat
Editor

Michael S. Kavic
Raymond J. Lanzafame
Michael K. Lindsay • Travis M. Polk
Associate Editors

Non-Obstetric Surgery
During Pregnancy
A Comprehensive Guide
Editor
Ceana H. Nezhat Department of Gynecology and Obstetrics
Nezhat Medical Center Emory University
Atlanta, GA Atlanta, GA
USA USA
Minimally Invasive Surgery and
Robotics Northside Hospital
Atlanta, GA
USA

Associate Editors
Michael S. Kavic Michael K. Lindsay
Department of Surgery Department of Gynecology and
Northeast Ohio Medical University Obstetrics
Youngstown, OH Emory University
USA Atlanta, GA
USA
Raymond J. Lanzafame
School of Dental Medicine Travis M. Polk
State University of New York at Buffalo Division of Trauma and Surgical Critical
Buffalo, NY Care
USA LAC+USC Medical Center
Keck School of Medicine
Society of Laparoendoscopic Surgeons
University of Southern California
Rochester, NY
Los Angeles, CA
USA
USA

ISBN 978-3-319-90751-2    ISBN 978-3-319-90752-9 (eBook)

https://doi.org/10.1007/978-3-319-90752-9

Library of Congress Control Number: 2018951633

© Springer International Publishing AG, part of Springer Nature 2019

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or
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To the mother and twins whose story planted the first seed
of this project years ago and to all mothers and infants
worldwide, past, present, and future.
Foreword I

“She’s Pregnant”

No two words create more doubt, angst, and heartburn for a surgical
consultant.
Every surgeon has been there. After hearing about a case from an ER doctor
or a trainee and formulating a mental model and plan, the conversation closes
with “by the way, she’s pregnant.”
Suddenly a twinge, perhaps a jolt, or maybe even a cold sweat ensues. The
consultant surgeon’s mind kicks into overdrive churn. The clinical problem
and solution, previously obvious, is now in question! There is an agonizing
reappraisal. Do the fundamental principles of care for a general surgical or
specialty surgical problem remain valid, or do they “go out the window”?
Now every intervention holds the possibility of a 200% morbidity or 200%
mortality.
While concurrent surgical disease arises infrequently during pregnancy,
pregnancy is common. Thus, this is a nontrivial problem, usually arising at
the worst possible time.

“What to Do?”

Enter Nezhat’s volume Non-obstetric Surgery During Pregnancy: A

Comprehensive Guide. More than just a “how to do cookbook” this book
provides a rational framework of thinking about the health of both the fetus
and the pregnant mother. Dr. Nezhat brings three decades of deep experience
and expertise in obstetrics and gynecology to us all in this superb book. Ceana
is recognized as a leading authority and he does not disappoint.
In crisp clean sequence, the fundamental groundwork is laid; preferred
imaging strategies, anesthesia considerations, and OR setup are wonderfully
outlined. Subsequent sections target general surgical and specialty surgical
conditions often arising during pregnancy. Each, in turn, is methodically cov-
ered. Treatment options, risks, and benefits are all carefully and thoroughly
described. Finally, gynecological conditions, obstetric complications, and in
utero operative approaches to spinal bifida round out this exceptional book.

vii
viii Foreword I

Forearmed with the knowledge gained from this book, the general surgeon
or the specialty surgeon will no longer quake when they hear the words,
“She’s pregnant!”

Thomas M. Krummel
Stanford Byers Center for Biodesign
Stanford University
Stanford, CA
USA
Foreword II

I congratulate Dr. Ceana H. Nezhat and his associate editors Drs. Michael
S.Kavic, Raymond J. Lanzafame, Michael K. Lindsay, and Travis M. Polk on
highlighting the much ignored topic of non-obstetrical surgery during preg-
nancy. In addition to the surgical procedures themselves, it is imperative the
surgeon is knowledgeable about the pathophysiology of pregnancy and its
impact on both the mother and fetus. Hypertension and diabetes during preg-
nancy can result in increased morbidity and mortality when compared to
women who are not pregnant. A 50% increase in blood volume, as well as
changes in renal function, can impact the procedures being performed. This
book provides the reader with an in-depth knowledge of surgical procedures
and anesthesia challenges in the gravid patient. Procedures reviewed range
from establishing a pneumoperitoneum in pregnancy to exploratory
laparotomy.
Abdominal surgery is presently the most common surgical procedure for the
pregnant patient. Unfortunately, even if done by the most experienced sur-
geon, the procedure can result in a miscarriage and loss of pregnancy. The
authors recommend surgical procedures be delayed when possible and elec-
tive procedures avoided until completion of the pregnancy. However, there
are many conditions that require emergent surgery, such as appendicitis. The
authors have provided their readers with a road map to perform these proce-
dures. The ultimate goal is to protect both the mother and the unborn fetus.
This book provides an evaluative review of the surgical management of
urgent and emergent procedures during pregnancy as well as a thorough anal-
ysis of gynecologic surgery and the surgical management of obstetrical com-
plications. This comprehensive guide is a must-read not only for obstetrician
gynecologists but also for any clinician involved in the management of a
pregnant patient.

ix
x Foreword II

Dr. Nezhat has brought together both national and international experts to
contribute their years of experience for this book. It is through knowledge we
will be able to decrease the unacceptable morbidity and mortality of the preg-
nant and postpartum patient observed throughout the world today.

Ira R. Horowitz
Department of Gynecology and Obstetrics
Emory University School of Medicine
Atlanta, GA
USA
Emory Clinic, Atlanta, GA
USA
Emory Healthcare, Atlanta, GA
USA
Emory University School of Medicine
Atlanta, GA
USA
Preface

Non-obstetrics Surgery During Pregnancy: A Comprehensive Guide was

conceptualized from an identified gap in education and fills a major void as
one of a few texts which provides a comprehensive evidence-based approach
to the management of major non-obstetric surgical procedures. Surgery for
non-­obstetric causes during pregnancy is not uncommon and a timely topic.
The book is written in “cookbook style” and geared towards most specialties.
It is my intention that this book provides a compendium that will assist clini-
cians by guiding their management of pregnant patients and hopefully
improving outcomes for both mother and baby.
The text flows logically with introductory chapters, such as history of lap-
aroscopy, instrumentation, room setup, and patient positioning, laying the
groundwork for performing non-obstetric surgery in a pregnant patient.
Moreover, there will be individual chapters covering various specialties and
detailing surgical complications that may arise specific to each field. The
book concludes with an overview of various obstetrics-related complications
that require surgical management. I trust the readers will find this to be a use-
ful, well-rounded, and educative resource.
Ideally, every child is “well-born,” physically, mentally, and emotionally
which is fundamental to human dignity. The contributors to this book repre-
sent the vanguard in their respective specialties. They highlight critical fac-
tors for consideration while caring for the pregnant woman and her unborn
child, aspiring to build human dignity one birth at a time. I greatly appreciate
the editorial assistance/review provided by my associate editors whose exten-
sive experience in varying disciplines brought expert-level evaluation to the
review process. Special thanks to Ms. Sarah Kyle McClellan, MPH, who con-
tributed greatly to the review process and preparation of the book. We are
very proud of the depth of information we are providing to our readers owing
to the knowledge and experience of our contributors.

Atlanta, GA, USA Ceana H. Nezhat

Youngstown, OH, USA  Michael S. Kavic
Rochester, NY, USA  Raymond J. Lanzafame
Atlanta, GA, USA  Michael K. Lindsay
Los Angeles, CA, USA  Travis M. Polk

xi
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