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Bardakçi O, Bahçecioğlu İB, Tatli F, Özgönül A, Güldür ME, Uzunköy A. Does one of the two most commonly used scoring systems have a decisive advantage over the other in diagnosing acute appendicitis in pregnant women? Medicine (Baltimore) 2023; 102:e33596. [PMID: 37115072 PMCID: PMC10145901 DOI: 10.1097/md.0000000000033596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 03/29/2023] [Accepted: 03/31/2023] [Indexed: 04/29/2023] Open
Abstract
This study aimed to compare the accuracy and reliability of Alvarado Score (AS) and Appendicitis Inflammatory Response Score (AIRS) in pregnant women undergoing surgery for acute appendicitis (AA). The files of 53 pregnant women with a diagnosis of AA who underwent surgery in our clinic between February 2014 and December 2018 were examined retrospectively. The patients were divided into 3 groups as follows: first trimester between 0 and 14 weeks, second trimester between 15 and 28 weeks, and third trimester between 29 and 42 weeks. The AS and AIRS values were calculated according to preoperative physical examination and laboratory results. The mean age of the patients was 28.58 (18-44) years. According to the pathology results, appendicitis was detected in 16 of 23 patients in the first trimester, in 22 of 25 patients in the second trimester, and in 2 of 5 patients in the third trimester. The AIRS was ≥ 9 in 9 patients and the AS was ≥ 7 in 19 of the 23 patients in the 1st trimester, while the AIRS was ≥ 9 in 11 patients and the AS was ≥ 7 in 19 of the 25 patients in the 2nd trimester. However, in the 3rd trimester, the AIRS was ≥ 9 in 2 patients and AS was ≥ 7 in 4 of the 5 patients. In conclusion, when the data obtained from the present study were evaluated, it was determined that both AS and AIRS are effective methods for diagnosing AA in pregnant women.
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Affiliation(s)
- Osman Bardakçi
- Department of Surgical Oncology, Ankara Gülhane Research and Training Hospital, Ankara, Turkey
| | | | - Faik Tatli
- Department of General Surgery, Harran University Faculty of Medicine, Sanliurfa, Turkey
| | - Abdullah Özgönül
- Department of General Surgery, Harran University Faculty of Medicine, Sanliurfa, Turkey
| | - Muhammet Emin Güldür
- Department of Pathology, Harran University Faculty of Medicine, Sanliurfa, Turkey
| | - Ali Uzunköy
- Department of General Surgery, Harran University Faculty of Medicine, Sanliurfa, Turkey
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Stanley AD, Tembelis M, Patlas MN, Moshiri M, Revzin MV, Katz DS. Magnetic Resonance Imaging of Acute Abdominal Pain in the Pregnant Patient. Magn Reson Imaging Clin N Am 2022; 30:515-532. [PMID: 35995477 DOI: 10.1016/j.mric.2022.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Evaluation of a pregnant patient presenting with acute abdominal pain can be challenging to accurately diagnose for a variety of reasons, and particularly late in pregnancy. Noncontrast MR remains a safe and accurate diagnostic imaging modality for the pregnant patient presenting with acute abdominal pain, following often an initially inconclusive ultrasound examination, and can be used in most settings to avoid the ionizing radiation exposure of a computed tomography scan. Pathologic processes discussed in this article include some of the more common gastrointestinal, hepatobiliary, genitourinary, and gynecologic causes of abdominal pain occurring in pregnancy, as well as traumatic injuries.
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Affiliation(s)
- Abigail D Stanley
- NYIT College of Osteopathic Medicine, Old Westbury, 101 Northern Boulvard, Glen Head, NY 11545, USA.
| | - Miltiadis Tembelis
- Department of Radiology, NYU Langone Hospital, 222 Station Plaza North, Suite 501, Mineola, NY 11501, USA
| | - Michael N Patlas
- Department of Radiology, McMaster University, Hamilton General Hospital, 237 Barton Street, East Hamilton, ON L8L 2X2, Canada
| | - Mariam Moshiri
- Department of Radiology, Vanderbilt University Medical Center, 1161-21st Avenue, South Medical Center North CCC-117, Nashville, TN 37232, USA
| | - Margarita V Revzin
- Department of Radiology and Biomedical Imaging, Yale University, 330 Cedar Street, New Haven, CT 06520, USA
| | - Douglas S Katz
- Department of Radiology, NYU Langone Hospital, 222 Station Plaza North, Suite 501, Mineola, NY 11501, USA
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Body mass index as an indicator of the likelihood of ultrasound visualization of the appendix in pregnant women with suspicion of appendicitis. Abdom Radiol (NY) 2020; 45:2637-2646. [PMID: 32514628 DOI: 10.1007/s00261-020-02610-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 05/23/2020] [Accepted: 05/29/2020] [Indexed: 12/26/2022]
Abstract
PURPOSE To determine if clinical characteristics of pregnant women are associated with the likelihood of ultrasound (US) visualization of the appendix in cases where there is a clinical suspicion of appendicitis. MATERIALS AND METHODS A retrospective study of 471 pregnant patients with suspicion of appendicitis from 2009 to 2018 were studied. Patients underwent sonography of the appendix as their initial imaging study. The association of body mass index (BMI) and gestational age with sonographic visualization of the appendix was analyzed using logistic regression. Cut-off values were determined for BMI to predict visualization of the appendix. RESULTS The rate of visualization of the appendix on US was 16% (95% CI 12% to 19%). When stratified by trimester of pregnancy, rebound pain on compression US examination in the 1st trimester and BMI in the 2nd and 3rd trimesters were identified as predictors of US visualization. Applying BMI cut-off values rounded to the nearest whole number, 36, 30, and 26 in the 1st, 2nd, and 3rd trimesters, non-visualization rates would be reduced by 16% (95% CI 10% to 25%), 35% (95% CI 29% to 42%), and 67% (95% CI 58% to 74%). Using BMI index cut-off values would reduce the number of primary US examinations by 35% (95% CI 30% to 39%) and increase the rate of visualization by 6% (95% CI 0.02% to 12%, P = 0.04). CONCLUSION Using BMI cut-off values for determining the efficaciousness of US visualization of the appendix in pregnant women with suspicion of appendicitis could significantly reduce the non-visualization rate.
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Kave M, Parooie F, Salarzaei M. Pregnancy and appendicitis: a systematic review and meta-analysis on the clinical use of MRI in diagnosis of appendicitis in pregnant women. World J Emerg Surg 2019; 14:37. [PMID: 31367227 PMCID: PMC6647167 DOI: 10.1186/s13017-019-0254-1] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 07/04/2019] [Indexed: 02/07/2023] Open
Abstract
Background The aim of this systematic review and meta-analysis was to evaluate the clinical use of MRI for the evaluation of acute appendicitis during pregnancy. Methods The searches were conducted by two independent researchers (MK, MS) to find the relevant studies published from 1/1/2009 until end of 30/12/2018. We searched for published literature in the English language in MEDLINE via PubMed, EMBASETM via Ovid, The Cochrane Library, and Trip database. For literature published in other languages, we searched national databases (Magiran and SID), KoreaMed, and LILACS. The keywords used in the search strategy are Pregnancy [MeSH], Pregnant [MeSH] OR-Magnetic resonance imaging [MeSH] OR-Appendicitis [MeSH] OR-Ultrasound, [MeSH] OR, imaging, MRI [MeSH] OR"،" and Right lower quadrant pain [MeSH]. The risk of bias of every article was evaluated by using QUADAS-2. On the basis of the results from the 2 × 2 tables, pooled measures for sensitivity, specificity, diagnostic odds ratio (DOR), and area under the curves (AUC) along with their 95% confidence intervals (CIs) were calculated using the DerSimonian Lair methodology. Results As many as 1164 studies were selected. After analyzing the correspondence of the studies with the required criteria, 19 studies were selected for the final review. For appendicitis in pregnancy, the MRI sensitivity was 91.8% at the 95% confidence interval of (95% CI 87.7-94.9%). At the confidence interval of 95%, the specificity was 97.9% (95% CI 0.97.2-100%). The risk of bias in the studies conducted was measured using the QUADAS-2 tool. Conclusion MRI has high sensitivity and specificity (91.8%, 97.9% respectively) for the diagnosis of acute appendicitis in pregnant patients with clinically suspected appendicitis. It is an excellent imaging technique in many instances, which does not expose a fetus, or the mother, to ionizing radiation, making it an excellent option for pregnant patients with suspected acute appendicitis.
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Affiliation(s)
- Mania Kave
- 1Gynecology and Obstetrics Institution, Faculty of Medicine, Zabol University of Medical Sciences, Zabol, Islamic Republic of Iran
| | - Fateme Parooie
- 2Student Research Committee, Faculty of Medicine, Zabol University of Medical Sciences, Zabol, Islamic Republic of Iran
| | - Morteza Salarzaei
- 2Student Research Committee, Faculty of Medicine, Zabol University of Medical Sciences, Zabol, Islamic Republic of Iran
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Sazhin AV, Kirienko AI, Kurtser MA, Konoplyannikov AG, Panin AV, Son DA, Shulyak GD. [Acute appendicitis during pregnancy]. Khirurgiia (Mosk) 2019:70-77. [PMID: 30789612 DOI: 10.17116/hirurgia201901170] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Acute appendicitis is the most frequent surgical disease complicating pregnancy. Accurate diagnosis is difficult due to atypical and misleading clinical manifestations. Surgeons frequently do not know about advantages and disadvantages of different diagnostic methods applied during pregnancy. Treatment of acute appendicitis in pregnant women remains the real challenge for surgeons. There are enough researches indicating on benefits and risks of both open and laparoscopic operations. The main risk is due to fetal loss after laparoscopic procedure. Safety of diagnostic techniques and laparoscopic procedures, surgical tactics and independent risk factors of pregnancy loss are touched in the article.
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Affiliation(s)
- A V Sazhin
- Pirogov Russian National Research Medical University of Healthcare Ministry of Russia, Moscow, Russia
| | - A I Kirienko
- Pirogov Russian National Research Medical University of Healthcare Ministry of Russia, Moscow, Russia
| | - M A Kurtser
- Pirogov Russian National Research Medical University of Healthcare Ministry of Russia, Moscow, Russia; Clinical Hospital Lapino 'Mother and Child', Moscow region, Russia
| | - A G Konoplyannikov
- Pirogov Russian National Research Medical University of Healthcare Ministry of Russia, Moscow, Russia
| | - A V Panin
- Clinical Hospital Lapino 'Mother and Child', Moscow region, Russia
| | - D A Son
- Pirogov Russian National Research Medical University of Healthcare Ministry of Russia, Moscow, Russia
| | - G D Shulyak
- Pirogov Russian National Research Medical University of Healthcare Ministry of Russia, Moscow, Russia
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Suspicion of appendicitis in pregnant women: emergency evaluation by sonography and low-dose CT with oral contrast. Eur Radiol 2018; 29:345-352. [PMID: 29948087 DOI: 10.1007/s00330-018-5573-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 05/07/2018] [Accepted: 05/29/2018] [Indexed: 02/06/2023]
Abstract
OBJECTIVES To evaluate non-intravenously enhanced low-dose computed tomography with oral contrast (LDCT) for the assessment of pregnant women with right lower quadrant pain, when magnetic resonance imaging (MRI) is not immediately available. METHODS One hundred and thirty-eight consecutive pregnant women with acute abdominal pain were admitted in our emergency centre. Thirty-seven (27%) of them, with clinical suspicion of acute appendicitis, underwent abdominal ultrasonography (US). No further examination was recommended when US was positive for appendicitis, negative with low clinical suspicion or showed an alternative diagnosis which explained the clinical presentation. All other patients underwent LDCT (<2.5 mSv). Standard intravenously enhanced CT or MRI was performed when LDCT was indeterminate. RESULTS Eight (22%) of 37 US exams were reported normal, 25 (67%) indeterminate, 1 (3%) positive for appendicitis, 3 (8%) positive for an alternative diagnosis. LDCT was obtained in 29 (78%) patients. It was reported positive for appendicitis in 9 (31%), for alternative diagnosis in 2 (7%), normal in 13 (45%) and indeterminate in 5 (17%). Further imaging (standard CT or MRI) showed appendicitis in 2 of these 5 patients, was truly negative in 1, indeterminate in 1 and falsely positive in 1. An appendicitis was confirmed at surgery in 12 (32%) of the 37 patients. The sensitivity and the specificity of the algorithm for appendicitis were 100% (12/12) and 92% (23/25), respectively. CONCLUSIONS The proposed algorithm is very sensitive and specific for detection of acute appendicitis in pregnant women; it reduces the need of standard CTs when MRI is not available as second-line imaging. KEY POINTS • In pregnant women, US is limited by an important number of indeterminate results • Low-dose CT can be used after an inconclusive US for the diagnosis of appendicitis in pregnant women • An algorithm integrating US and low-dose CT is highly sensitive and specific for appendicitis in pregnant women.
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Accuracy of ultrasonography in diagnosing acute appendicitis during pregnancy based on surgical findings. Med J Islam Repub Iran 2018; 31:48. [PMID: 29445677 PMCID: PMC5804447 DOI: 10.14196/mjiri.31.48] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Indexed: 12/29/2022] Open
Abstract
Background: Acute appendicitis is the most common nonobstetric surgical problem in pregnancy. Common signs and symptoms of appendicitis are less reliable during pregnancy due to physiological changes; thus, the role of imaging becomes prominent. Thus, in the present study, we aimed at assessing the accuracy of sonography in diagnosing acute appendicitis during pregnancy. Methods: In this prospective analytic study, among 1000 patients diagnosed and treated as acute appendicitis, clinical and sonographic findings of 58 consecutive pregnant patients, who underwent appendectomy, were recorded and analyzed. All surgically resected samples were evaluated and confirmed through histological evaluation. Sonographic criteria were utilized to judge the results for appendicitis. Diagnostic test performance characteristics (sensitivity, specificity, predictive values, and likelihood ratios) were calculated. Results: The mean age of the patients was 27.1±4.9 years, and the most common clinical symptom was right lower quadrant pain. There was no significant difference in the mean leukocyte count between the appendicitis group and normal appendix group (p=0.768). Left shift was also unrelated with the appendix pathology (p= 0.549). The sensitivity, specificity, predictive values (positive and negative), and likelihood ratios (positive and negative) were 80%, 75%, 91.4%, 52.9%, 3.2, and 0.26, respectively during all trimesters of pregnancy. Conclusion: Ultrasonography is the initially preferred imaging modality in pregnant women suspected of having acute appendicitis with an acceptable sensitivity; however, application of other imaging modalities such as CT scan or MRI is recommended after inconclusive ultrasonography results.
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Severe Complications of Laparoscopic and Conventional Appendectomy Reported to the Finnish Patient Insurance Centre. World J Surg 2016; 40:277-83. [PMID: 26482363 DOI: 10.1007/s00268-015-3282-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Appendectomy is considered a safe operation, the related complications being minor. Negative exploration is an accepted procedure to avoid complications of appendicitis. Treatment with antibiotics is under debate as a primary treatment for appendicitis. The aim of this study was to collect and analyze detailed information on complications and morbidity related to appendectomy using the information of the nationwide Patient Insurance Association (PIA) database and to study the incidence of patient claims and compensated injuries related to appendectomy in Finland. METHODS Patients' claims from 1990 to 2010 were collected from the PIA register. Complications were classified using the accordion severity grading system. Severe complications were selected for more detailed analyses. Laparoscopic and open surgeries were compared. Factors related to compensated claims were assessed. For statistical analysis, Fisher's exact test, logistic multivariate regression, and the Mann-Kendall function were used. RESULTS Appendectomy complications leading to a patient insurance claim in Finland are rare (0.2 %). The rate of patients' claims after laparoscopic surgery was higher than after open surgery (p < 0.001), but the rate of compensated claims was equal. During the study period, complications after laparoscopic procedures more often led to additional surgery or organ failure (p = 0.03). Of the patients with a compensated injury, only 57 % had appendicitis. Preoperative computed tomography was used in only 6 % of these cases. CONCLUSIONS Patient injuries and claims regarding severe complications after appendectomy are rare. The complications related to laparoscopic appendectomy were more severe than those of open surgery.
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Aggenbach L, Zeeman GG, Cantineau AEP, Gordijn SJ, Hofker HS. Impact of appendicitis during pregnancy: no delay in accurate diagnosis and treatment. Int J Surg 2015; 15:84-9. [PMID: 25638737 DOI: 10.1016/j.ijsu.2015.01.025] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Revised: 01/10/2015] [Accepted: 01/26/2015] [Indexed: 12/21/2022]
Abstract
BACKGROUND Acute appendicitis during pregnancy may be associated with serious maternal and/or fetal complications. To date, the optimal clinical approach to the management of pregnant women suspected of having acute appendicitis is subject to debate. The purpose of this retrospective study was to provide recommendations for prospective clinical management of pregnant patients with suspected appendicitis. METHOD Case records of all pregnant patients suspected of having appendicitis whom underwent appendectomy at our hospital between 1990 and 2010 were reviewed. RESULTS Appendicitis was histologically verified in fifteen of twenty-one pregnant women, of whom six were diagnosed with perforated appendicitis. Maternal morbidity was seen in two cases. Premature delivery occurred in two out of six cases with perforated appendicitis cases and two out of six cases following a negative appendectomy. Perinatal mortality did not occur. CONCLUSION Both (perforated) appendicitis and negative appendectomy during pregnancy are associated with a high risk of premature delivery. Clinical presentation and imaging remains vital in deciding whether surgical intervention is indicated. We recommend to cautiously weigh the risks of delay until correct diagnosis with associated increased risk of appendiceal perforation and the risk of unnecessary surgical intervention. Based upon current literature, we recommend clinicians to consider an MRI following an inconclusive or negative abdominal ultrasound aiming to improve diagnostic accuracy to reduce the rate of negative appendectomies. Accurate and prompt diagnosis of acute appendicitis should be strived for to avoid unnecessary exploration and to aim for timely surgical intervention in pregnant women suspected of having appendicitis.
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Affiliation(s)
- L Aggenbach
- Department of Surgery, University Medical Center Groningen (UMCG), Hanzeplein 1, 9700 RB Groningen, The Netherlands.
| | - G G Zeeman
- Department of Gynaecology and Obstetrics, University Medical Center Groningen (UMCG), Hanzeplein 1, 9700 RB Groningen, The Netherlands
| | - A E P Cantineau
- Department of Gynaecology and Obstetrics, University Medical Center Groningen (UMCG), Hanzeplein 1, 9700 RB Groningen, The Netherlands
| | - S J Gordijn
- Department of Gynaecology and Obstetrics, University Medical Center Groningen (UMCG), Hanzeplein 1, 9700 RB Groningen, The Netherlands
| | - H S Hofker
- Department of Surgery, University Medical Center Groningen (UMCG), Hanzeplein 1, 9700 RB Groningen, The Netherlands
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Ramalingam V, LeBedis C, Kelly JR, Uyeda J, Soto JA, Anderson SW. Evaluation of a sequential multi-modality imaging algorithm for the diagnosis of acute appendicitis in the pregnant female. Emerg Radiol 2014; 22:125-32. [DOI: 10.1007/s10140-014-1260-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Accepted: 07/28/2014] [Indexed: 01/28/2023]
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Abstract
Acute appendicitis is the most common non-obstetric indication for surgical intervention in pregnancy, complicating 1/500 to 1/2000 deliveries. Due to the anatomical and physiological changes associated with pregnancy, appendicitis may present a diagnostic dilemma, leading to management delays and thus increasing the risk of appendiceal perforation. Many of the common presenting symptoms of appendicitis are common features of normal pregnancy including lower abdominal pain, nausea, vomiting and leukocytosis. Furthermore, the enlarging gravid uterus may displace the appendix to varying degrees thus altering the classic symptom pattern of appendicitis. The often nonspecific presentation in pregnancy may necessitate the utilization of diagnostic imaging to aid in accurate diagnosis. However, the perforated appendix is the most common surgical cause of fetal loss and the time required for any diagnostic aid must be weighed against the increasing risk of perforation caused by delay in surgical intervention.
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Imaging of pregnant and lactating patients: part 2, evidence-based review and recommendations. AJR Am J Roentgenol 2012; 198:785-92. [PMID: 22451542 DOI: 10.2214/ajr.11.8223] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE The objectives of this article are to discuss the current evidence-based recommendations regarding the use of diagnostic imaging in the evaluation of pulmonary embolism, appendicitis, urolithiasis, and cholelithiasis during pregnancy. CONCLUSION Diagnostic imaging should be performed during pregnancy only with an understanding of the maternal and fetal risks and benefits, the comparative advantages of different modalities, and the unique anatomic and physiologic issues associated with pregnancy.
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