Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / @xirurgi_2025 / @xirurgi_2025 - 674 - файл
.pdf
252
https://t.me/medicina_free
57. Longstreth GF, Yao JF.Diseases and drugs that increase risk of acute large bowel ischemia.
Clin Gastroenterol Hepatol. 2010;8(1):49–54. https://doi.org/10.1016/j.cgh.2009.09.006.
Epub 2009 Sep 16.
58. Gurakar M, Locham S, Alshaikh HN, Malas MB. Risk factors and outcomes for bowel
ischemia after open and endovascular abdominal aortic aneurysm repair. J Vasc Surg.
2019;70(3):869–81. https://doi.org/10.1016/j.jvs.2018.11.047. Epub 2019 Mar 6.
59. Ultee KH, Zettervall SL, Soden PA, Darling J, Bertges DJ, Verhagen HJ, Schermerhorn ML,
Vascular Study Group of New England. Incidence of and risk factors for bowel ischemia after
abdominal aortic aneurysm repair. J Vasc Surg. 2016;64(5):1384–91. https://doi.org/10.1016/j.
jvs.2016.05.045. Epub 2016 Jul 27.
60. Flynn AD, Valentine JF.Update on the diagnosis and management of colon ischemia. Curr
Treat Options Gastroenterol. 2016;14(1):128–39. https://doi.org/10.1007/s11938- 016- 0074- 2.
61. Sun D, Wang C, Yang L, Liu M, Chen F.The predictors of the severity of ischaemic colitis: a
systematic review of 2823 patients from 22 studies. Color Dis. 2016;18:949–58. https://doi.
org/10.1111/codi.13389.
62. Brandt LJ, Boley SJ. AGA technical review on intestinal ischemia. Am Gastrointest Assoc
Gastroenterol. 2000;118(5):954–68. https://doi.org/10.1016/s0016- 5085(00)70183- 1.
63. Theodoropoulou A, Koutroubakis IE.Ischemic colitis: clinical practice in diagnosis and treatment. World J Gastroenterol. 2008;14(48):7302–8. https://doi.org/10.3748/wjg.14.7302.
64. Dignan CR, Greenson JK. Can ischemic colitis be differentiated from C difcile colitis in biopsy specimens? Am J Surg Pathol. 1997;21(6):706–10. https://doi.
org/10.1097/00000478- 199706000- 00011.
65. Screenarasimhaiah J.Diagnosis and managemente of ischemic colitis. Curr Gastroenterol Rep.
2005;7(5):421–6.
66. Montoro MA, Brandt LJ, Santolaria S, et al. Clinical patterns and outcomes of ischaemic
colitis: results of the working Group for the Study of Ischaemic Colitis in Spain (CIE study).
Scand J Gastroenterol. 2011;46:236–46.
67. Brandt LJ, Boley SJ, Sammartano R.Carbon dioxide and room air insufation of the colon.
Effects on colonic blood ow and intraluminal pressure in the dog. Gastrointest Endosc.
1986;32:324–9.
68. Zuckerman GR, Prakash C, Merriman RB, Sawhney MS, DeSchryver-Kecskemeti K, Clouse
RE.The colon single-stripe sign and its relationship to ischemic colitis. Am J Gastroenterol.
2003;98(9):2018–22. https://doi.org/10.1111/j.1572- 0241.2003.07633.x.
69. Rania H, Mériam S, Rym E, Hyafa R, Amine A, Najet BH, Lassad G, Mohamed TK.Ischemic
colitis in ve points: an update 2013. Tunis Med. 2014;92(5):299–303.
70. Reissfelder C, Sweiti H, Antolovic D, et al. Ischemic colitis: who will survive? Surgery.
2011;149:585–92.
71. Urbanavičius L, Pattyn P, de Putte DV, Venskutonis D.How to assess intestinal viability during surgery: a review of techniques. World J Gastrointest Surg. 2011;3(5):59–69. https://doi.
org/10.4240/wjgs.v3.i5.59.
72. Amore Bonapasta S, Lazzaro S, Passaume F, Santoni S, Grassi GB, Longo G.Laparoscopic
management of acute, severe colon ischaemia: demanding emergency extended left hemicolectomy with completely intracorporeal anastomosis—a video vignette. Color Dis.
2019;21(12):1454–5. https://doi.org/10.1111/codi.14812. Epub 2019 Aug 21.
73. Peris A, Matano S, Manca G, Zagli G, Bonizzoli M, Cianchi G, Pasquini A, Batacchi S, Di
Filippo A, Anichini V, Nicoletti P, Benemei S, Geppetti P. Bedside diagnostic laparoscopy
to diagnose intraabdominal pathology in the intensive care unit. Crit Care. 2009;13(1):R25.
https://doi.org/10.1186/cc7730. Epub 2009 Feb 25.
74. Alemanno G, Prosperi P, Di Bella A, Socci F, Batacchi S, Peris A, Pieri M, Olivo G, Quilghini
P, Fontanari P, Stefàno P, Giordano A, Iacopini V, Bergamini C, Valeri A.Bedside diagnostic laparoscopy for critically ill patients in the intensive care unit: retrospective study and
review of literature. J Minim Access Surg. 2019;15(1):56–62. https://doi.org/10.4103/jmas.
JMAS_232_17.
F. Pata et al.
General Surgery Emergencies
https://t.me/medicina_free
inPregnancy
GoranAugustin
1 General Considerations
The pregnant patient should be placed in a left lateral position to relieve pressure on
the inferior vena cava. This is more important in pregnancy when CO2 pneumoperitoneum puts additional pressure on the inferior vena cava. Pregnancy is a hypercoagulable state. To avoid thromboembolic events, sequential compression stockings
are routinely employed. Some also administer a prophylactically low dose of heparin
or LMWH.However, evidence regarding the optimal perioperative prevention strategy of thromboembolic events during pregnancy is scarce. No incidents of DVT or
PE were documented [1]. Fetal monitoring during laparoscopy in pregnancy is not
necessary. Preoperative and postoperative fetal monitoring is adequate. During operation, fetal well-being is indirectly estimated through maternal CO2 and O2 levels.
2 Acute Appendicitis
2.1 Indications
Conservative management of acute appendicitis (AA) is more commonly employed
in pregnancy and ranges from 5.8 to 19% of cases [2–4]. Nonoperative therapy is
based on broad-spectrum antibiotics [5]. An abdominal MRI should be performed
before the commencement of conservative treatment [6–10]. There is no consensus
on the route, type, and duration of antibiotic therapy, typically lasting 3–10days [7,
9, 11]. The most signicant shortcoming of conservative treatment is a 25% failure
rate even with uncomplicated AA in the rst and second trimesters [5].
G. Augustin (*)
School of Medicine University of Zagreb, University Hospital Centre Zagreb, Croatian
Academy of Medical Sciences, Zagreb, Croatia
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
F. Coccolini et al. (eds.), Mini-invasive Approach in Acute Care Surgery,
Hot Topics in Acute Care Surgery and Trauma,
https://doi.org/10.1007/978-3-031-39001-2_19
253
254
https://t.me/medicina_free
G. Augustin
2.2 Treatment
Appendectomy is the most common non-obstetric surgical procedure performed in
pregnancy [12]. However, several uncertainties regarding the optimal abdominal
wall approach for suspected AA in pregnancy exist [13]. There is no consensus
regarding the specic abdominal wall approach used for suspected AA in pregnancy. Four systematic reviews (SRs) comparing open appendectomy (OA) versus
laparoscopic appendectomy (LA) for suspected AA reported inconsistent ndings
[14–17]. There were signicant differences in included studies, analyzed outcomes,
and reported magnitude and direction of effect sizes from meta-analyses (MAs). All
SRs included observational studies and had critically low methodological quality
[18]. OA and LA are equally safe and effective with similar obstetric outcomes. LA
is preferred due to less uterine manipulation, faster recovery, less pain, and better
cosmesis. Single-port laparoscopy is also used. The method is feasible, but with (1)
a high (33%) rate of conversion to standard or reduced-port laparoscopic appendectomy and (2) an increased rate of wound complications (8%) [19].
2.3 Prognosis
Fetal loss is arguably the most important obstetric outcome considering the effect of
different approaches to appendectomy in pregnancy. All four SRs [14–17] reported
a signicantly higher fetal loss rate after LA than OA, although all included a different number of studies. The study by McGory etal. [20] predominantly affected
the result because it included more than half of the total number of participants in
all studies within analyzed SRs. Only McGory etal. [20] have shown that LA is
signicantly worse than OA for fetal loss. There are many limitations of that study,
and their ndings should be interpreted cautiously [18]. The remaining studies
reported no signicant difference in fetal loss between LA and OA.
3 Acute Cholecystitis
3.1 Indications
Recurrence rates after conservative treatment are 31–92%, decreasing as pregnancy advances [21–25]. Also, the disease is often more severe at the time of
relapse [26]. Compared with patients managed surgically, nonoperative management is associated with a signicantly higher rate of labor induction and preterm
delivery requiring neonatal intensive care [26], fetal death [24], and a spontaneous
abortion rate of 12% in the rst trimester [27]. Therefore, conservative treatment
of acute cholecystitis during pregnancy is not recommended, except until the late
third trimester. There are difculties in performing laparoscopic cholecystectomy
(LC) after 35weeks of gestation. After conservative therapy, as bridge therapy, LC
is performed postpartum.
General Surgery Emergencies inPregnancy
https://t.me/medicina_free
255
3.2 Treatment
There have been no published randomized controlled trials (RCTs) comparing open
(OC) and laparoscopic cholecystectomy (LC) in pregnancy. LC carries a decreased
risk of spontaneous abortion in the rst trimester and premature contractions [28,
29] or preterm delivery [29, 30] in the third trimester. Previously, LC was mainly
performed in the puerperium, while OC during pregnancy [31].
The only signicant differences between LC and OC were that patients underwent LC on average 5weeks of gestation earlier than those with OC.The serum
alkaline phosphatase was signicantly higher with the OC.No PTDs occurred after
rst-trimester LC in many studies [30, 32, 33]. 10.7% of pregnant patients with
acute cholecystitis underwent OC in the USA between 1999 and 2006 [34]. The
conversion rate to OC in pregnancy in Australia was 13% [35], while meta-analysis
found only 3.8% [36]. LC is the treatment of choice in pregnant patients with gallbladder disease, regardless of the trimester [37].
3.3 Prognosis
LC is associated with decreased risks for fetal, maternal, and surgical complications. The average length of hospital stay is 3.2days after LC and 6.0days after
OC [36].
4 Acute Pancreatitis
4.1 Indications
In pregnancy, as in the general population, initial management is mainly medical.
Surgical treatment of acute pancreatitis (AP) has two aspects—operative intervention for the AP itself and management of local (biliary tract disease, pancreatic
tumor) or distant (primary hyperparathyroidism, hypertriglyceridemia, etc.) cause
of the AP.
Surgery for necrotizing AP in pregnancy should be delayed as long as possible
[38]. Resolution is achieved in most patients (78.9%) with conservative treatment.
Therefore, the indications for surgery and antibiotics are [38–42] (a) pancreatic
necrosis and infection (3–4weeks after the onset of symptoms), (b) extensive intraabdominal exudates, and (c) clinical deterioration. In pregnancy, there are no published series relating to the laparoscopic management of necrotizing pancreatitis.
4.2 Treatment
Percutaneous drainage, endoscopic drainage, or minimally invasive surgical techniques are gaining wider acceptance. Decompression and percutaneous drainage
256
https://t.me/medicina_free
avoid or delay surgery in most patients with severe AP [38, 41]. For patients with
pancreatic abscess, drainage is recommended [40]. Necrosectomy is deferred as late
as possible, and it can be performed during the CS through midline laparotomy.
The only indication for laparoscopy in the general population is biliary
AP.Patients with common bile duct stones should undergo LC within 24–48h after
ERCP to shorten the hospitalization, avoid readmission, and reduce the possibility
of recurrent biliary events in the interval between ERCP and LC [43, 44]. ERCP for
treating CBD stones and acute cholangitis in pregnancy is preferred to the surgical
approach [45–52]. For biliary AP, the principles are the same as in the nonpregnant
population. With mild AP, LC is recommended during the same hospitalization and
with severe AP when the inammation subsides.
G. Augustin
4.3 Prognosis
Due to the lack of performance of laparoscopy for AP in pregnancy, no studies compare maternal and obstetric/fetal outcomes between methods. LC for indications
other than AP during pregnancy shows better outcomes for both the mother and
fetus. Maternal and fetal outcomes depend primarily on the severity and cause of AP.
5 Visceral Perforation
5.1 Perforated Peptic Ulcer
5.1.1 Treatment
A perforated peptic ulcer is extremely rare during pregnancy, with less than 100
cases published. Diffuse peritonitis from perforated peptic ulcers commonly results
in preterm labor or spontaneous abortion even before treatment. All reported cases
were treated with midline laparotomy, despite many cases in the general population
now being treated by laparoscopy.
5.1.2 Prognosis
There are two important predictors of fetal outcome from perforated peptic ulcers
during pregnancy. The rst predictor is related to long-standing peptic ulcer disease
with its treatment during pregnancy. The second predictor is the presence of peritonitis. The diagnosis is often made late in pregnancy resulting in peritonitis with
severe obstetric consequences.
5.2 Bowel Perforation
5.2.1 Treatment
There are different causes of bowel perforation, including ischemia, colon cancer,
and intestinal endometriosis. The appropriate management of these patients may be
challenging, and for good outcomes, a multidisciplinary approach is mandatory.
General Surgery Emergencies inPregnancy
https://t.me/medicina_free
The best approach is en bloc resection of endometriosis and associated segment of
a perforated bowel. For small bowel perforation, resection with anastomosis or ileostomy when prolonged peritonitis is present is recommended. With sigmoid colon
perforation, Hartmann’s operation is the procedure of choice [53]. For obstructive
colon cancer, treatment is surgical. The resection of the diseased segment with proximal colostomy and closure of the rectal stump or mucous stula are the procedures
with the lowest reported mortality rates [54–56].
Surgical management of perforated intra-abdominal viscus is usually complex
due to diffuse peritonitis and enlarged gravid uterus. Therefore, when encountered,
a midline laparotomy is often required. Due to the high incidence of preterm labor,
this is also the incision of choice to deliver a viable fetus.
257
5.2.2 Prognosis
Endometriosis as a cause of bowel perforation should always be conrmed histologically; decidualized endometriosis involving the entire intestinal wall was found
in 88% of cases. Fetal survival is 100%, with a mean gestational age near term [57,
58] in patients with intestinal perforation. Maternal survival is also 100%.
Of four pregnant patients with obstructed colon carcinoma [54–56, 59], one died
(maternal mortality of 25%). Perinatal mortality is 50%, probably due to prolonged
peritonitis.
6 Symptomatic Abdominal Wall Hernia
6.1 Treatment
During pregnancy, even symptomatic hernias are not operatively repaired. There are
no reported cases of incarceration during pregnancy or delivery caused by a groin
hernia with a rst symptomatic manifestation during pregnancy [60].
Many authors claim that mesh hernioplasties should not be performed in women
who plan future pregnancies. The rationale is that the abdominal wall becomes more
rigid, with less compliance which is essential for the normal abdominal wall distension to accommodate the growing uterus. Moreover, the prerequisite for laparoscopic
hernia repair, in most cases, is mesh. Therefore, laparoscopic mesh hernioplasty can
be safely performed only after the last pregnancy. Another advantage of open umbilical or inguinal hernia repair is the simultaneous operation when CS is indicated.
Through the (extended) skin incision for CS, both umbilical (vertical midline skin
incision) and inguinal (Pfannenstiel incision) hernias can be repaired.
6.2 Prognosis
Results have shown an increased risk of recurrence if abdominal wall hernias are
operatively repaired during pregnancy. The risk is twofold higher if the patient
becomes pregnant after surgical repair. Therefore, the recommendation is to perform hernioplasty after the last pregnancy.
258
https://t.me/medicina_free
G. Augustin
7 Symptomatic Diaphragmatic Hernia
7.1 Indications
There is no strict consensus about indications for the operative treatment of diaphragmatic hernia (DH) during pregnancy. For asymptomatic patients, some recommend CS after fetal lung maturity with simultaneous hernia repair always before the
onset of labor. The recommendation is based upon maternal and fetal morbidity
being 55% and 27%, respectively, when vaginal delivery was attempted before the
DH repair [61]. Others [62] recommend vaginal delivery with (1) planned induction
of labor (to avoid precipitous labor at a remote site), (2) regional anesthesia to help
prevent the urge to bear down, and (3) the use of instrumentation to shorten the
second stage of labor.
7.2 Treatment
7.2.1 Open Approach
The open approach may be transabdominal, thoracoabdominal, or transthoracic.
The transthoracic approach is indicated for previously operated DH by the
transabdominal approach due to dense intra-abdominal adhesions [63–65]. Under
normal circumstances, the best surgical approach is lateral thoracotomy at the level
of the seventh or eighth rib [66] because it provides a better view of the diaphragm
while it requires one-lung ventilation. If strangulation has occurred, the incision
should be planned as a thoracoabdominal approach for adequate exposure and eas-
ier access to the bowel, particularly if the colon is involved. Also, a separate laparotomy is an option. Some prefer the transthoracic approach due to the limited
intra-abdominal space from the gravid uterus [67].
The transabdominal approach enables good access to (1) herniated parenchymal
organs such as the liver and spleen [68] when mobile cecum is present or (2) anterior (Morgagni) DH.The transabdominal approach is preferred because it is less
invasive [69]. However, some prefer the transthoracic approach in longer-lasting
hernias to treat pleuroperitoneal adhesions. On the other hand, the transabdominal
approach is better in pregnancy if CS is indicated or other intra-abdominal pathologic ndings are removed, such as gallbladder stones. Most cases are explored
through midline laparotomy, although a subcostal incision can be performed [70].
Midline laparotomy is better if abdominal organ resection is anticipated.
7.2.2 Laparoscopic Approach
Recently, the laparoscopic approach has gained popularity [71–78]. The advantages
are avoiding laparotomy, which increases the rate of abdominal wall disruption during and after delivery and postoperative hernia. The disadvantage is that CS requires
a separate incision. Simultaneous Pfannenstiel incision for CS, when the laparoscopic procedure is completed, results in excellent cosmetic results. Also, the
General Surgery Emergencies inPregnancy
https://t.me/medicina_free
laparoscopic operation can be undertaken after vaginal delivery [77, 78] or CS [79]
as a secondary procedure.
With a lateral approach, the patient is positioned in frank right lateral decubitus
with double-lumen endotracheal intubation. An electronic fetal monitoring device is
placed on the right lower part of the abdomen. The lateral position has many advantages over the more traditional supine position. First, it permits a complete view of
the diaphragm, the subdiaphragmatic space, and the thorax. In this position, gravity
helps retract the spleen, the stomach, and the uterus without manipulation. This
reduces the risk of iatrogenic injury, especially to the gravid uterus. Also, if needed,
a thoracoscopy could be easily accomplished without any repositioning. A more
pronounced right lateral decubitus reduces the risk of inferior vena cava compression by a posterolateral displacement of the uterus. This position could be tried
preoperatively with fetal and maternal monitoring (for 1 h) to ensure maternal
hemodynamic stability and fetal well-being [71].
259
8 Intestinal Obstruction
8.1 Treatment
8.1.1 Intussusception
Most patients are explored by laparotomy, but laparoscopy is more frequently used
to minimize abdominal wall trauma and shorten postoperative hospital stay [80, 81].
After exploration, the further procedure depends on the viability of the intestine and
the presence of the lead point. The manual reduction can be attempted in small
bowel intussusception if the segment involved is viable and if malignancy is not
suspected (palpated or checked with intraoperative enteroscopy) [80]. The manual
reduction should be performed to push the intussuscipiens rather than pulling the
bowel due to a lower risk of bowel wall tearing. Resection of the bowel segment is
indicated in the presence of [82] (1) gangrenous bowel, (2) recurrent intussusceptions, and (3) the leading point is present. The leading point should be resected, and
additional procedures depend on the histopathological diagnosis.
Maternal prognosis, both after resection for ischemic bowel or without bowel
resection, is excellent [80–84]. Higher rates of spontaneous abortion and preterm
labor are present [83], particularly if perforation with peritonitis occurs. If intussusception presents during the puerperium, it is easier to indicate diagnostic imaging modalities with radiation; therefore, the diagnosis could be made earlier. The
problem is that intussusception is sometimes mistaken for postdelivery ileus delaying the diagnostic workup.
8.1.2 Small Bowel Volvulus
All cases of small bowel volvulus were treated by laparotomy. Laparoscopy could
be used in the early stages because detorsion leads to restitution, without additional
more complex laparoscopic procedures such as intestinal resection.
260
https://t.me/medicina_free
Early diagnosis and management are essential to avoid infarction of the bowel.
The rate of bowel resection is still high, around 68%, over the last 20years [85].
Maternal and fetal mortality decreased from 6–20% and 22–50% [86] to 3–15% and
22%, respectively (another 14% of newborns with proven asphyxia) [85, 87].
G. Augustin
8.1.3 Sigmoid Volvulus
In the absence of peritonitis and during the second trimester of gestation, early studies recommend detorsion by mini-laparotomy to shorten the operating time. In contrast, sigmoid resection with anastomosis may be performed after puerperium [88,
89]. Sigmoid resection is recommended due to the high incidence of recurrence [90,
91]. Such management could be performed by laparoscopy. Others recommend
anastomosis after sigmoidectomy during the rst and second trimesters [92].
Hartmann’s procedure is safer, eliminating the risk of anastomotic dehiscence with
its deleterious consequences on the mother and fetus. The growing uterus could
compress the anastomosis, causing ischemia, or compress the colon distal to the
anastomosis, increasing the risk of anastomotic dehiscence. In the third trimester, if
sufcient intestinal exposure cannot be obtained due to the enlarged uterus, a CS is
required [93]. After detorsion, the deated loop could be on the left side of the abdomen and should be replaced. This can be done by slipping the loop of the bowel over
the fundus of the uterus. Compression by the uterus may be a contributing factor in
obstruction when the volvulus is partial. The entire bowel should be examined for
other areas of obstruction. Intestinal viability should be assessed cautiously. If viable, the bowel can be derotated and left in situ [94, 95], but recurrent sigmoid volvulus in the general population is around 50%; therefore, resection during the index
operation with or without anastomosis is recommended [93].
9 Acute Crohn’s Disease
9.1 Indications
The indications for surgery in pregnant women with Crohn’s disease (CD) are not
different from the general population and include intestinal obstruction or perforation, bleeding, or abscess. Only 2–2.7% of CD pregnant patients require surgery
[96, 97]. The approach should be multidisciplinary, and surgery should be performed at a tertiary center with neonatal, pediatric, and obstetric departments.
9.2 Treatment
The most common location for surgical intervention is terminal ileum, including
free or contained small bowel perforation [98] or terminal ileitis with abscesses and
stula or stenosis [99]. Half of the patients present in the second trimester, with a
similar incidence in the rst and less than 10% in the third [98, 99]. Ileocecal resection is the most common procedure performed (66.7%), followed by small bowel
General Surgery Emergencies inPregnancy
https://t.me/medicina_free
resection (20%), subtotal colectomy (6.7%), and restoration of bowel continuity
(6.7%) [99]. A laparoscopic approach is preferred but completed in only 20% of
patients [98, 99]. Only several cases of image-guided percutaneous drainage of an
intra-abdominal abscess are published [98].
261
9.2.1 Terminal Ileitis/Acute Appendicitis
If acute appendicitis is suspected, laparoscopic exploration is recommended. If an
indication for bowel resection exists (abscess adjacent to active ileocecal disease,
bowel perforation, bowel obstruction), ileocolic resection can be completed by laparoscopy or conversion to midline laparotomy. There is an issue with bowel resection
when the active ileocecal CD is present without perforation, obstruction, or adjacent
abscess [100]. During exploration, when the active disease is found, resection is
preferable to prevent exacerbation later in pregnancy. The severity of the CD, not
the operation itself, is the leading cause of the poor fetal outcome.
9.3 Prognosis
Intra-abdominal surgery performed during the rst trimester is associated with an
increased risk of miscarriage; for planned procedures in the second trimester, the
risk is lower. In the third trimester, a laparotomy may be complicated by premature
delivery and technical difculties. However, the severity of the CD, not the operation, determines the maternal and fetal risk.
9.3.1 Maternal Outcome
Increased maternal morbidity is due to the consequences of acute abdominal conditions requiring emergency surgery and the underlying chronic inammatory condition itself and all comorbid conditions related to it. There is a threefold increase in
the incidence of gestational diabetes in patients with IBD compared to healthy controls, regardless of gestational corticosteroid use [101]. There is a signicantly
higher rate of gestational diabetes among UC patients using ART than CD patients
(29.4% vs. 6.1%) [102]. Higher maternal thromboembolic complications and malnutrition/poor weight gain in pregnant IBD patients are conrmed [103, 104].
Perioperative complications depend mainly on the severity of CD. There are no
comparisons between open or laparoscopic procedures.
9.3.2 Fetal Outcome
Active disease at conception is associated with a higher rate of fetal loss, preterm
birth (twofold), LBW (threefold), and small for gestational age infants [105–115].
Women with CD have 1.9 times the risk of fetal abdominal wall defects [116]. The
association between CD and abdominal wall defects was found and is declining. It
is unlikely that the introduction of biologics increased the risk of wall defects and
that folic acid food fortication could have been benecial [116]. Preterm delivery
is further associated with disease ares during pregnancy [108, 117]. The overall
preterm delivery rate among surgically treated patients is 79% [98].
Соседние файлы в папке @xirurgi_2025