There is strong consensus that all women hospitalized Diagnostic considerations Perioperative considerations with moderate OHSS should receive thromboprophylaxis while in the hospital (22). The Simultaneous (ruptured) ectopic/heterotopic Thromboprophylaxis patient with severe OHSS is started on subcutaneous pregnancy and acute appendicitis heparin (5000 U twice daily) immediately on hospital General pregnant population admission and this regimen is continued throughout the In cases of IVF-ET techniques, the complication of The risk of deep vein thrombosis (DVT) or pulmonary hospital stay. Since these patients are likely to be very ectopic (EP) / heterotopic pregnancy (HP) is present in embolism (PE) is 10-fold higher with puerperium inactive, thigh-high intermittent pneumatic compression 1 – 3 %,(1,2) while HP in non-IVF pregnancies is carrying the highest VTE risk, up to 25-fold higher than stockings for the duration of hospitalization should be present in 1 in 30,000.(3,4) Transfer of ≥4 embryos in nonpregnant women. SAGES guidelines for placed. Otherwise, the patient is encouraged to poses an additional risk for HP(5). EP has been rarely pregnant population in general state that prophylaxis ambulate frequently and avoid prolonged sedentary reported in conjunction with appendicitis; there are 24 with pneumatic compression devices both positions. Furthermore, all OHSS patients with such cases in the medical literature since 1960 (6-9). intraoperatively and postoperatively and early thromboembolism should be treated with full There are five cases in IVF-ET pregnant patients which postoperative ambulation are recommended. There are heparinization throughout their entire pregnancy, while is significant in comparison to the incidence of non-IVF no data regarding use of unfractionated or low others suggested treatment for a minimum of 6 months pregnancies. Of these, 3 represent spontaneous acute molecular weight heparin (LMWH) for prophylaxis in (23). appendicitis (10-12) and the remaining two iatrogenic pregnant patients undergoing laparoscopy, though its There is one case of OHSS with perforated apendiceal punctuations with the needle for oocyte use has been suggested in patients undergoing appendicitis but there is no mention of perioperative retrieval and subsequent development of perforated extended major operations (14). In patients with risk care except antibiotics and no mention of any appendicitis(11,12). Beta–HCG in HP is elevated due to factors who require anticoagulation during pregnancy, complications of prolonged (37 days) postoperative normal intrauterine pregnancy and is not diagnostic for LMWH or unfractioned heparin should be adimistered course (24). HP. Therefore the recommendation is: (15). General pregnancy During emergent diagnostic laparoscopy both IVF-ET no risk 1) pneumatic compression devices intra- and postoperatively appendix and adnexa should be always examined 2) early postoperative ambulation The risk of PE in women in IVF-ET pregnancy is risk 1) thromboprophylaxis according to risk severity in IVF pregnant patient despite proven normal increased (Fig.1) almost sevenfold during the first intrauterine pregnancy, especially if appendicitis is trimester, although the absolute risk is low (2-3 IVF pregnacy as in general pregnancy proven intraoperatively with fresh blood in the pelvis additional cases of PE per 10 000 pregnancies)(16) or around adnexa. and thromboembolism in women has been estimated to OHSS be 0.08 – 0.11% of treatment cycles (17,18). Therefore, mild/moderate 1) and 2) as in general pregnancy 3) thromboprophylaxis (enoxaparin 40mg or uncomplicated IVF-ET pregnancy should be dalteparin 5000IU) considered as spontaneous pregnancy in terms of Therapeutic considerations severe 1) and 2) as in general pregnancy thromboembolic incidents. 3) sc. heparin 2 x 5000 U during hospitalization thromboemb. 1) and 2) as in general pregnancy Simultaneous (ruptured) ectopic/heterotopic 3) full heparinization throughout entire pregnancy pregnancy and acute appendicitis Appendectomy for acute appendicitis is mandatory in Tocolytics all cases and therapetic approach for simultaneous EP / HP depend if ruptured or unruptured variant is IVF singletons have 2-3 times higher incidence of early present: and spontaneous preterm delivery (PD) (16,25) and they weigh less at birth than they should according to Ruptured HP 1) intrauterine pregnancy preserved their gestational age (16). Administration of 400 mg 2) salpingectomy / salpingotomy vaginal natural progesterone from mid third trimester Severe damaged single tube Damaged both tubes Contralateral tube healthy Further pregnancies reduced the incidence of PD in IVF singleton Live intrauterine pregnancy pregnancies (26). Ruptured EP 1) salpingectomy / salpingotomy In IVF twins in comparison to spontaneous twin pregnancies risks of very PD is 5-fold higher (27) and a The benefits of salpingectomy over salpingotomy are 10-fold before 37 weeks and 7.4-fold before 32 weeks uncertain. Salpingectomy is easier and safer, especially as compared with singleton pregnancy (28). in the presence of a live intrauterine pregnancy. It Administration of 400 mg vaginal natural progesterone reduces the risk of complications such as the persistent from mid trimester did not reduced the incidence of PD bleeding or retention of trophoblastic tissue that can in IVF twin pregnancy (26). occur after salpingotomy (3). Also, if fallopian tubes are Maternal use of benzodiazepines during pregnancy significantly damaged and not functional salpingectomy was associated with a significantly increased risk of PD is recommended. Salpingectomy should be considered (OR=6.79) and increased risks of low birth weight, low also if contralateral fallopian tube is healthy as this Apgar score, admission to NICU, and RDS. Selective treatment does not preclude future fertility. serotonin receptor inhibitors were associated with PD Figure 1. Comparison of incidence of PE and venous thromboembolism in normal and IVF pregnancies (16) and low birth weight, but not with other adverse Unruptured HP 1) intrauterine pregnancy preserved outcomes, only among women who started taking 2) salpingectomy / salpingotomy Ovarian hyperstimulation syndrome Severe damaged single tube Damaged both tubes these medications during the second or third trimesters Contralateral tube healthy Further pregnancies The ovarian hyperstimulation syndrome (OHSS) is (29). It just confirms that PD is thought to be associated Live intrauterine pregnancy typically associated with regimens of exogenous Unruptured EP 1) methotrexate with infection and inflammation (30). Despite previous gonadotropins during ovarian stimulation for assisted clinical trials failing to demonstrate the effectiveness of reproduction. OHSS is significant risk factor for antibiotic therapy at reducing PD incidence, strong thromboembolism (19). There is 10-fold increased risk Acute cholecystitis in IVF pregnancy evidence suggested that infections could contribute to of first-trimester VTE and a 2.8-fold increased risk of 25% of PD (30). antepartum VTE (20) and approximately 4-12% risk of There is only one case published and PE (21). recommendations cannot be made (13). Despite this, General pregnancy →uterine contractions (SAGES and EAES guidelines) we recommend laparoscopic cholecystectomy early in If non-obstetrical acute abdomen is suspected or IVF singletons the course of the disease in all IVF pregnant patients proven, (until proven otherwise) is that all medications →400 mg vaginal progesterone from mid third trimester due to known higher all-perioperative-complication rate for assisted reproduction should be withdrawn to IVF multiple in such patients and known increased rate of recurrent →uterine contractions (benefit questionable) eliminate or minimize perioperative complications along cholecystitis in pregnancy due to hormonal changes. with possible complications of acute abdomen itself and medications used for the specific cause of acute Early laparoscopic cholecystectomy for acute abdomen. cholecystitis in all IVF pregnant patients Are additional perioperative considerations needed in non-obstetrical emergency laparoscopy in in vitro fertilization pregnancy Augustin G, Matosevic P, Kinda E, Kekez T, Majerovic M, Silovski H Department of Surgery, University Hospital Center Zagreb and School of Medicine University of Zagreb, Zagreb, Croatia Abstract In vitro fertilization and embryo transfer (IVF-ET) techniques are prone to some serious obstetric and gynecologic complications during pregnancy, especially heterotopic pregnancy, injury of adjacent pelvic organs and ovarian hyperstimulation syndrome. On the other hand, acute surgical conditions in normal pregnancy increase maternal and fetal morbidity and mortality. Due to the rare occurence of surgical acute abdomen in IVF-ET pregnant patients there are no recommendations and guidelines for such situations. Current guidelines do not recommend prophylactic tocolysis in pregnant population with acute abdomen but there is no mention of the IVF-ET subpopulation of patients which is prone to obstetric complications such as abortion and preterm labor. Also, there are no guidelines for thromboprophylaxis in such patients especially with some of its complications prone to thromboembolism due to hormonal changes caused by hormonal load during the IVF process. We present several topics for further discussion and possible consensus for recommendations of IVF-ET pregnant patients with non-obstetrical acute abdomen diagnosed and treated by laparoscopy. References 13 Augustin G et al. J Postgrad Med 2012;58:298-300 25 Jackson RA et al. 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