Anesthesiological management of laparoscopic surgery during the second trimester of pregnancy. Case Report 

Background
Up to 2% of pregnant women may present a pathology that would require a non-obstetric surgery [1]. Although the advantages that laparoscopy approach offers during the pregnancy are well documented, it becomes an anesthesiological challenge concerning anatomic and physiologic changes related to pregnancy and anesthetic and surgical effects on the fetus.
Case report
A 34 year-old woman on her 19th week of gestation, without relevant medical history, was admitted at the ER of our hospital due to abdominal pain of acute onset.
With the provisional diagnosis of acute abdominal pain in a second trimester pregnant woman, an ultrasound scan was requested. It revealed the presence of free abdominal fluid in the abdominal cavity compatible with hemoperitoneum. Initial blood tests showed hemoglobin levels of 9,4g/dL and 19,72x10E9/L leucocytes, with normal platelet count and coagulation parameters.
In successive blood counts a progressive drop of the hemoglobin was evidenced, deciding to perform an explorative laparoscopy in order to identify the cause and control the bleeding.
Total intravenous anesthesia was performed. Hemodynamic stability was constant during the pneumoperitoneum. Inspection of the abdominal cavity found fresh venous blood from a crumbly vascular network located on the anterior uterus wall, where hemostasis was correctly performed. The patient was extubated without incidences and was admitted to the reanimation care unit. 
Discussion
Current literature provides  recommendations for safe laparoscopy during pregnancy. CO2 insufflation pressure should be kept between 10 to 15 mm Hg and intraoperative CO2 monitoring by capnography should be used during laparoscopy [2]. Fetal heart rate must be monitored both pre- and post-operatively. According to SAGES guidelines, the use of prophylactic tocolytics are not advised , although they should be considered perioperatively in coordination with obstetric consultation when signs of preterm labor are present [3].

References
1. Crowhurst JA. Anaesthesia for non-obstetric surgery during pregnancy. Acta Anaesthesiol Belg. 2002;53:295–7.
2. E. Reitman. Anaesthetic considerations for non-obstetric surgery during pregnancy. British Journal of Anaesthesia 107 (S1): i72–i78 (2011)
3. SAGES. Guidelines for diagnosis, treatment, and use of laparoscopy for surgical problems during pregnancy. Surg Endosc. 2008;22:849–861.

Learning points
1.	This case exemplifies that the laparoscopic approach is the technique of choice in both complicated and uncomplicated non-obstetric surgery during the second trimester.
2.	The main  target of pregnancy anesthesia is the mother-fetal binomial safety. 
3.	Anesthetic techniques should adapt to the anatomical and physiological changes of pregnancy to improve the mother safety.

Anesthetic management of laparoscopic surgery during the second trimester of pregnancy. Case report