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Cusimano MC, Liu J, Azizi P, Zipursky J, Sajewycz K, Sussman J, Kishibe T, Wong E, Ferguson SE, D'Souza R, Baxter NN. Adverse Fetal Outcomes and Maternal Mortality Following Nonobstetric Abdominopelvic Surgery in Pregnancy: A Systematic Review and Meta-analysis. Ann Surg 2023; 278:e147-e157. [PMID: 34966066 DOI: 10.1097/sla.0000000000005362] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To quantify the absolute risks of adverse fetal outcomes and maternal mortality following nonobstetric abdominopelvic surgery in pregnancy. SUMMARY BACKGROUND DATA Surgery is often necessary in pregnancy, but absolute measures of risk required to guide perioperative management are lacking. METHODS We systematically searched MEDLINE, EMBASE, and EvidenceBased Medicine Reviews from January 1, 2000, to December 9, 2020, for observational studies and randomized trials of pregnant patients undergoing nonobstetric abdominopelvic surgery. We determined the pooled proportions of fetal loss, preterm birth, and maternal mortality using a generalized linear random/mixed effects model with a logit link. RESULTS We identified 114 observational studies (52 [46%] appendectomy, 34 [30%] adnexal, 8 [7%] cholecystectomy, 20 [17%] mixed types) reporting on 67,111 pregnant patients. Overall pooled proportions of fetal loss, preterm birth, and maternal mortality were 2.8% (95% CI 2.2-3.6), 9.7% (95% CI 8.3-11.4), and 0.04% (95% CI 0.02-0.09; 4/10,000), respectively. Rates of fetal loss and preterm birth were higher for pelvic inflammatory conditions (eg, appendectomy, adnexal torsion) than for abdominal or nonurgent conditions (eg, cholecystectomy, adnexal mass). Surgery in the second and third trimesters was associated with lower rates of fetal loss (0.1%) and higher rates of preterm birth (13.5%) than surgery in the first and second trimesters (fetal loss 2.9%, preterm birth 5.6%). CONCLUSIONS Absolute risks of adverse fetal outcomes after nonobstetric abdom- inopelvic surgery vary with gestational age, indication, and acuity. Pooled estimates derived here identify high-risk clinical scenarios, and can inform implementation of mitigation strategies and improve preoperative counselling.
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Affiliation(s)
- Maria C Cusimano
- Department of Obstetrics & Gynecology, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, Dalla Lana School ofPublic Health, University of Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Jessica Liu
- Department of Obstetrics & Gynecology, University of Toronto, Toronto, ON, Canada
| | - Paymon Azizi
- Institute of Health Policy, Management, and Evaluation, Dalla Lana School ofPublic Health, University of Toronto, Toronto, ON, Canada
| | - Jonathan Zipursky
- Institute of Health Policy, Management, and Evaluation, Dalla Lana School ofPublic Health, University of Toronto, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Katrina Sajewycz
- School of Medicine, Faculty ofHealth Sciences, Queen's University, Kingston, ON, Canada
| | - Jess Sussman
- School of Medicine, Faculty ofMedicine, University of Toronto, Toronto, ON, Canada
| | - Teruko Kishibe
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
- Health Sciences Library, St. Michael's Hospital, Toronto, ON, Canada
| | - Eric Wong
- Institute of Health Policy, Management, and Evaluation, Dalla Lana School ofPublic Health, University of Toronto, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Sarah E Ferguson
- Department of Obstetrics & Gynecology, University of Toronto, Toronto, ON, Canada
- Division of Gynecologic Oncology, Princess Margaret Cancer Centre/Sinai Health Systems, Toronto, ON, Canada
| | - Rohan D'Souza
- Department of Obstetrics & Gynecology, University of Toronto, Toronto, ON, Canada
- Division of Maternal Fetal Medicine, Mount Sinai Hospital/Sinai Health Systems, Toronto, ON, Canada
| | - Nancy N Baxter
- Institute of Health Policy, Management, and Evaluation, Dalla Lana School ofPublic Health, University of Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
- Melbourne School of Population and Global Health, University of Melbourne, Melbourne ViC, Australia
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Topcu A, Ozturk A, Deniz E, Duman Ozturk S, Arpa M, Atak M. The effects of amiodarone in ovarian injury due to oxidative stress and inflammation caused by ischemia-reperfusion. Immunopharmacol Immunotoxicol 2022; 44:1022-1031. [PMID: 35838634 DOI: 10.1080/08923973.2022.2102991] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Ovarian ischemia constitutes 2-3% of all gynecological emergencies. New-generation therapeutic agents need to be discovered, in addition to invasive interventions capable of reducing the risk of potential ovarian ischemia to a minimum and protecting against potential adverse outcomes. AIMS To investigate the effects of amiodarone (AMD) on ischemia-reperfusion-induced oxidative stress and inflammation-induced ovarian damage. METHODS The control group, received intraperitoneal (i.p.) injection of saline solution. The ischemia group (I-Group), was subjected to ischemia-induced injury without drug administration. The ischemia + AMD (50 mg/kg) group was subjected to ischemia injury and also received i.p. 50 mg/kg AMD prior to induction of ovarian ischemia. The ischemia-reperfusion (I/R group) was exposed to ischemia and reperfusion-induced injury without drug administration. The I/R + AMD (50 mg/kg) group underwent I/R injury together with i.p. administration of 50 mg/kg AMD prior to induction of ovarian I/R. The Sham + AMD group received intraperitoneal (i.p.) injection of 50 mg/kg AMD alone. In this study performed thiobarbituric acid reactive substances (TBARS), thiol (-SH), interleukin 1 Beta (IL-1β), interleukin 6 (IL-6), toll-like receptor 4 (TLR4) and nuclear factor-kappa B(NF-κβ). RESULTS Increased oxidative stress and inflammation as a result of ovarian I and I/R application activated the cascade. AMD was not sufficient to reduce the oxidative stress and inflammation. TLR4 and NF-kβ, which were up-regulated by triggering oxidative stress and inflammation, were not regressed by the effects of AMD. CONCLUSIONS AMD, used as an antiarrhythmic agent, was found to be insufficient, despite its antioxidant and anti-inflammatory properties, to reduce the experimentally induced ovarian tissue damage.
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Affiliation(s)
- Atilla Topcu
- Department of Pharmacology, Faculty of Medicine, Recep Tayyip Erdogan University, Rize, Turkey
| | - Aykut Ozturk
- Department of Pharmacology, Faculty of Medicine, Recep Tayyip Erdogan University, Rize, Turkey
| | - Esra Deniz
- Department of Pharmacology, Faculty of Medicine, Recep Tayyip Erdogan University, Rize, Turkey
| | - Seda Duman Ozturk
- Department of Pathology, Recep Tayyip Erdogan University Education and Research Hospital, Rize, Turkey
| | - Medeni Arpa
- Department of Medical Biochemistry, Faculty of Medicine, Recep Tayyip Erdogan University, Rize, Turkey
| | - Mehtap Atak
- Department of Medical Biochemistry, Faculty of Medicine, Recep Tayyip Erdogan University, Rize, Turkey
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Cathcart AM, Nezhat FR, Emerson J, Pejovic T, Nezhat CH, Nezhat CR. Adnexal masses during pregnancy: diagnosis, treatment, and prognosis. Am J Obstet Gynecol 2022:S0002-9378(22)02179-2. [PMID: 36410423 DOI: 10.1016/j.ajog.2022.11.1291] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 11/15/2022] [Accepted: 11/15/2022] [Indexed: 11/21/2022]
Abstract
Adnexal masses are identified in pregnant patients at a rate of 2 to 20 in 1000, approximately 2 to 20 times more frequently than in the age-matched general population. The most common types of adnexal masses in pregnancy requiring surgical management are dermoid cysts (32%), endometriomas (15%), functional cysts (12%), serous cystadenomas (11%), and mucinous cystadenomas (8%). Approximately 2% of adnexal masses in pregnancy are malignant. Although most adnexal masses in pregnancy can be safely observed and approximately 70% spontaneously resolve, a minority of cases warrant surgical intervention because of symptoms, risk of torsion, or suspicion of malignancy. Ultrasound is the mainstay of evaluation of adnexal masses in pregnancy because of accuracy, safety, and availability. Several ultrasound mass scoring systems, including the Sassone, Lerner, International Ovarian Tumor Analysis Simple Rules, and International Ovarian Tumor Analysis Assessment of Different NEoplasias in the adneXa scoring systems have been validated specifically in pregnant populations. Decisions regarding expectant vs surgical management of adnexal masses in pregnancy must balance the risks of torsion or malignancy with the likelihood of spontaneous resolution and the risks of surgery. Laparoscopic surgery is preferred over open surgery when possible because of consistently demonstrated shorter hospital length of stay and less postoperative pain and some data demonstrating shorter operative time, lower blood loss, and lower risks of fetal loss, preterm birth, and low birthweight. The best practices for laparoscopic surgery during pregnancy include left lateral decubitus positioning after the first trimester of pregnancy, port placement with respect to uterine size and pathology location, insufflation pressure of less than 12 to 15 mm Hg, intraoperative maternal capnography, pre- and postoperative fetal heart rate and contraction monitoring, and appropriate mechanical and chemical thromboprophylaxes. Although planning surgery for the second trimester of pregnancy generally affords time for mass resolution while optimizing visualization with regards to uterine size and pathology location, necessary surgery should not be delayed because of gestational age. When performed at a facility with appropriate obstetrical, anesthetic, and neonatal support, adnexal surgery in pregnancy generally results in excellent outcomes for pregnant patients and fetuses.
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Affiliation(s)
- Ann M Cathcart
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, OR
| | - Farr R Nezhat
- Weill Cornell Medical College, Cornell University, New York, NY; New York University Long Island School of Medicine, Mineola, NY.
| | - Jenna Emerson
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, OR; Division of Gynecologic Oncology, Oregon Health & Science University, Portland, OR
| | - Tanja Pejovic
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, OR; Division of Gynecologic Oncology, Oregon Health & Science University, Portland, OR
| | - Ceana H Nezhat
- Atlanta Center for Minimally Invasive Surgery and Reproductive Medicine, Atlanta, GA
| | - Camran R Nezhat
- Center for Special Minimally Invasive and Robotic Surgery, Palo Alto, CA; University of California San Francisco, San Francisco, CA; Stanford University Medical Center, Palo Alto, CA
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Effect of Two-Port Laparoscopic Surgery on Pregnancy Outcomes of Patients with Concurrent Adnexal Masses. J Clin Med 2022; 11:jcm11164697. [PMID: 36012938 PMCID: PMC9409682 DOI: 10.3390/jcm11164697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 07/29/2022] [Accepted: 08/09/2022] [Indexed: 11/25/2022] Open
Abstract
Adnexal masses are common in pregnancy, with 2–10% of pregnancies presenting with an ovarian mass and approximately 1–6% of these masses being malignant. For suspected malignancy or masses with symptoms, surgery must be performed as early as possible. We retrospectively investigated the effect of two-port laparoscopic surgery on the outcomes of patients with concurrent adnexal masses between 2012 and 2019 (including large mucinous tumor, large teratoma, serous borderline tumor, and heterotopic pregnancy). Laparoscopic right partial oophorectomy was performed for a 27 cm ovarian mucinous tumor at a gestational age (GA) of 21 weeks, laparoscopic right oophorocystectomy for an 18 cm teratoma at a GA of 10 weeks, and laparoscopic left salpingo-oophorectomy for a 7 cm serous borderline tumor at a GA of 7 weeks after ultrasonographic confirmation of an intrauterine gestational sac with a fetal heartbeat. Laparoscopic excision of a tubal pregnancy was performed in a heterotopic pregnancy at a GA of 12 weeks with massive internal bleeding. Laparoscopic surgery is easier and safe to perform during early pregnancy because a smaller uterus allows for superior visualization. All of these patients had optimal postoperative recovery and normal spontaneous delivery at term. We discussed several aspects of treatment and delivery, namely treatment option (expectant management or surgery), surgery timing (early or advanced pregnancy), surgery type (laparoscopy or laparotomy), and delivery route (normal spontaneous delivery or cesarean section), in patients with concurrent adnexal tumors and their effects on pregnancy outcomes.
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