by 
Pearl JP, Price RR, Tonkin AE, Richardson WS, Stefanidis D. SAGES guidelines for the use of laparoscopy during pregnancy. Surg Endosc. Springer US; 2017;31:3767–82.
Diagnosis and Workup
Guideline 1: Ultrasound imaging during pregnancy is safe and effective in identifying the etiology of acute abdominal pain in many patients and should be the initial imaging test of choice (+++; Strong).
Guideline 2: Ionizing radiation exposure to the fetus increases the risk of teratogenesis and childhood leukemia. Cumulative radiation dosage should be limited to 50-100 milligray (mGy) during pregnancy (+++; Strong).
Guideline 3: Abdominal CT scan may be used in emergency situations during pregnancy. CT scan should not be the initial imaging test of choice. (++; Weak).
Guideline 4: MR Imaging without the use of intravenous Gadolinium can be performed at any stage of pregnancy. MRI is preferred over CT scan for diagnosis of non-obstetric abdominal pain in the gravid patient (++; Weak).
Guideline 6: Intraoperative and endoscopic cholangiography exposes the mother and fetus to minimal radiation and may be used selectively during pregnancy. The lower abdomen should be shielded when performing cholangiography during pregnancy to decrease the radiation exposure to the fetus (++; Weak).
Guideline 7: In the absence of access to imaging modalities, laparoscopy may be used selectively in the workup and treatment of acute abdominal processes
Patient Selection
Guideline 8: Laparoscopic treatment of acute abdominal disease offers similar benefits to pregnant and non-pregnant patients compared to laparotomy (+++; Strong).
Guideline 9: Laparoscopy can be safely performed during any trimester of pregnancy when operation is indicated (+++; Strong).
Treatment Patient
Guideline 10: Gravid patients beyond the first trimester should be placed in the left lateral decubitus position or partial left lateral decubitus position to minimize compression of the vena cava (++; Strong).
Guideline 11: Initial abdominal access can be safely accomplished with an open (Hasson), Veress needle, or optical trocar technique, by surgeons experienced with these techniques, if the location is adjusted according to fundal height (++; weak).
Guideline 12: CO2 insufflation of 10-15 mmHg can be safely used for laparoscopy in the pregnant patient. The level of insufflation pressure should be adjusted to the patient’s physiology (++; weak).
Guideline 13: Intraoperative CO2 monitoring by capnography should be used during laparoscopy in the pregnant patient (+++; Strong).
Guideline 14: Intraoperative and postoperative pneumatic compression devices and early postoperative ambulation are recommended prophylaxis for deep venous thrombosis in the gravid patient (++; weak).
Guideline 15: Laparoscopic cholecystectomy is the treatment of choice in the pregnant patient with symptomatic gallbladder disease, regardless of trimester (++; weak).
Guideline 16: Choledocholithiasis during pregnancy can be managed safely with preoperative endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy followed by laparoscopic cholecystectomy, laparoscopic common bile duct exploration at the time of cholecystectomy, or postoperative ERCP. Comparative studies are lacking. (++; weak).
Guideline 17: Laparoscopic appendectomy is the treatment of choice for pregnant patients with acute appendicitis (++; Weak).
Guideline 18: Laparoscopic adrenalectomy, nephrectomy and splenectomy are safe procedures in appropriately selected pregnant patients (+; Weak).
Guideline 19: Laparoscopy is a safe and effective treatment in gravid patients with symptomatic ovarian cystic masses. Observation is acceptable for all other cystic lesions provided ultrasound is not concerning for malignancy and tumor markers are normal. Initial observation is warranted for most cystic lesions < 6 cm in size (++; Weak).
Guideline 20: Laparoscopy is recommended for both diagnosis and treatment of adnexal torsion (++; Strong).
Guideline 21: Fetal heart monitoring of a fetus considered viable should occur preoperatively and postoperatively in the setting of urgent abdominal surgery during pregnancy (++; Weak).
Guideline 22: Tocolytics should not be used prophylactically in pregnant women undergoing surgery but should be considered perioperatively when signs of preterm labor are present (++++; Strong).
Explications:
Ultrasound is up to 80% sensitive and 94% specific for the diagnosis of obstetric and gynecologic causes of abdominal pain including placental abruption, ectopic pregnancy, and ovarian torsion.
Ultrasound is the diagnostic study of choice for biliary pathology in the gravid patient with diagnostic accuracy above 90% . In pregnant patients with right lower abdominal pain, the appendix can be visualized in up to 60% of cases , but exams inconclusive for appendicitis may reach up to 90% .
As an example, the radiation dose to the conceptus for a plain abdominal radiograph averages 1-3 mGy, while a CT of the pelvis averages less than 30 mGy of exposure.
Exposure of the conceptus to 5 mGy increases the risk of spontaneous abortion, major malformations, and childhood malignancy to one additional case per 6,000 live births above baseline risk. More than 99% of fetuses are unaffected by radiation doses less than 20 mGy . The risk of aberrant teratogenesis is low at 50 mGy or less and that the risk of malformation is significantly increased at doses above 150 mGy.
Radiation exposure during cholangiography is estimated to be 20-50 mGy.
The radiation exposure during endoscopic retrograde cholangiopancreatography (ERCP) averages 20-120 mGy, but can be substantially higher for long procedures.
Pregnant patients in their first trimester do not require altered positioning, as the small size of the uterus does not compromise venous return.
Initial access to the abdomen via a subcostal approach using either the open or closed technique has been recommended to avoid the uterus.
Pregnancy is a hypercoagulable state with a 0.1-0.2% incidence of deep venous thrombosis. CO2 pneumoperitoneum may increase the risk of deep venous thrombosis by predisposing to venous stasis. Insufflation of 12 mmHg causes a significant decrease in blood flow that cannot be completely reversed with intermittent pneumatic compression devices.
There are no data regarding use of unfractionated or low molecular weight heparin for prophylaxis in pregnant patients undergoing laparoscopy, though its use has been suggested in patients undergoing extended major operations . In patients who require anticoagulation during pregnancy, unfractionated heparin has proven safe and is the agent of choice.
Recurrent gallbladder symptoms develop in 92% of patients managed non-operatively who present in the first trimester, 64% who present in the second trimester, and 44% who present in the third trimester. If the biliary disease remains uncomplicated, the rates of preterm labor and spontaneous abortion are similar for operative and non- operative management . However, approximately 50% of patients with recurrent symptoms require hospitalization and up to 23% of such patients develop acute cholecystitis, cholangitis, or gallstone pancreatitis. Complicated gallstone disease results in preterm labor in up to 20% of cases and fetal loss in 10% to 60% of cases, depending on severity.
When choledocholithiasis progresses to cholangitis, preterm labor or spontaneous abortion may occur in up to 10% of cases.
Depending on local expertise, the least invasive procedure that extracts common duct stones should be performed. Both ERCP and laparoscopic common duct exploration are safe in pregnant women.
There is no role for non-operative management of uncomplicated acute appendicitis in pregnant women because of a higher rate of peritonitis, fetal demise shock, and venous thromboembolism as compared to operative management. Recent evidence for the use of antibiotics alone for treating acute appendicitis has not been extended to the gravid patient. Weak evidence-level data suggest an increase in maternal morbidity, preterm labor, and fetal loss in cases of negative laparoscopy for presumed appendicitis, compared to laparoscopic appendectomy for acute uncomplicated appendicitis. The possible cause of increased morbidity in negative laparoscopy is unclear and has not been further investigated in prospective studies.
While intraoperative fetal heart rate monitoring was once thought to be the most accurate method to detect fetal distress during laparoscopy, no intraoperative fetal heart rate abnormalities have been reported in the literature. Preoperative and postoperative monitoring of the fetal heart rate for a fetus considered viable is the current standard, with no increased fetal morbidity having been reported. The current lower limit of viability is between 22 weeks and 24 weeks.