International guidelines on management of general surgical emergencies in the pregnant or breastfeeding woman

Résumé fourni par la source

Although it is generally accepted that elective surgery should be avoided during pregnancy and in the immediate postpartum phase, a small proportion of women have acute surgical pathology requiring emergency surgical intervention. Up to 2 per cent of pregnancies are complicated by non-obstetric surgical problems1, and between 1 in 500 and 1 in 700 pregnant women develop an acute abdomen2. Appendicectomy is consistently reported as the commonest non-obstetric operation performed during pregnancy3. In addition, the condition of pregnancy can increase the likelihood of some surgical disease. The changing levels of progesterone and oestrogen can change the bile flow, and have been shown to lead to biliary sludge and gallstone formation4. The changing anatomy itself can lead to complications, such as umbilical hernias. Many conditions that present to the general surgeon commonly occur during childbearing years. The tragic consequences from using medications such as thalidomide and diethylstilbesterol in pregnancy have led to raised vigilance regarding the safety of all prescription drugs, including anaesthetics during pregnancy5. Radiation associated with imaging has the greatest impact on rapidly dividing cells so will have more of an impact on a fetus, and a lactating mother is also more at risk; therefore, it can be more difficult to diagnose surgical disease during pregnancy. For this reason, pregnancy is often an exclusion criterion for many research studies, so it is often not clear how to manage these patients when they present while pregnant. To date, no formal guidelines have been written for the optimum investigations and management of patients presenting with general surgical disease during pregnancy or while breastfeeding. The purpose of these guidelines is to develop a document that will cover all conditions that could present to the general surgeon covering the emergency take. They will not cover pre-existing conditions or specialist management of conditions such as cancer or inflammatory bowel disease after diagnosis. They also will not cover anaesthetic considerations in pregnancy or major trauma as there are already guidelines covering these areas. The guideline development will follow the AGREE II methodology6. The subject will be divided into eight topic areas, with a lead surgeon for each topic. Specific questions will be formulated using the PICO (Patients, Intervention, Comparison, Outcome) model structure for each area of interest. Each research question will be reviewed following the PRISMA guidance7. A systematic literature search will use the PubMed database and the Cochrane Database of Systematic Reviews, and manual searches of relevant articles. If up-to-date high-quality meta-analyses or systematic reviews are available, conclusions from these will be used. Ideally RCTs or large cohort studies will be used to address questions. Where these do not exist, case series, case reports, and expert opinions will be included. For each question, recommendations will be made, and the level of evidence graded according to the Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence8. Virtual consensus meetings will be held with specialists in the surgical subspecialties, radiologists, anaesthetists, and obstetricians, to develop clear recommendations to answer each question. All attendees at the consensus meeting will be given advanced access to the publications used to answer the questions. During the meeting online, voting will be used to agree the recommendations, using a Likert scale of 1 (strongly disagree) to 5 (strongly agree). Only recommendations scoring over 80 per cent 4s and 5s will be included. Those that score less than this will be rephrased and a second round of voting will take place. Patient representatives will be involved during the development of the PICO questions, and then will be involved in the writing of a patient summary. The guidelines are being developed by surgeons from the Association of Surgeons of Great Britain and Ireland (ASGBI) Emergency General Surgery Guidelines Steering Group, with collaboration from The Upper Gastrointestinal Surgeons Society (TUGSS), British Hernia Society, Obstetric Anaesthetists’ Association, Managing Medical Obstetric Emergencies Trauma, and Faculty of Pain Medicine. They will be developed within the UK for an international audience but most relevant for high-income health systems. The authors and their roles are listed in Table 1. Authors and roles ASGBI, Association of Surgeons of Great Britain and Ireland; EGS, Emergency General Surgery. Authors and roles ASGBI, Association of Surgeons of Great Britain and Ireland; EGS, Emergency General Surgery. Authors will develop the PICO questions, conduct the systematic review, present the results at the consensus meetings, and write up the results for publication. The corresponding author will coordinate and chair all the meetings, write an introduction and conclusion for the guidelines, and complete the submission. 12 October 2022: Virtual steering group meeting; agree protocol to submit to BJS. 9 November 2022: Virtual steering group meeting; agree PICO questions. December and January 2023: Teams for each topic area to perform systematic reviews to identify evidence base for PICO questions. 8 February and 1 March 2023: Virtual consensus meetings. March 2023: Write up guidelines and submit to patient group. The virtual meeting platform is funded by the ASGBI. The authors declare no conflict of interest. There is no new data collected for this guideline. All data is referenced and Pubmed cited.

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