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Surgical Complications of Pregnancy

Surgical Complications of Pregnancy. Dr.Z Allameh MD. OBJECTIVES. Understand etiologies of common, non-obstetric surgical occurrences in the pregnant patient Review diagnosis modalities and techniques

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Surgical Complications of Pregnancy

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  1. Surgical Complications of Pregnancy Dr.Z Allameh MD

  2. OBJECTIVES • Understand etiologies of common, non-obstetric surgical occurrences in the pregnant patient • Review diagnosis modalities and techniques • Address risks/benefits of intervention with regard to gestational age and maternal/fetal physiology • Discuss operative/anesthesia techniques most well suited • Review literature based outcomes/data

  3. Non-Obstetric Causes for Surgery • Appendicitis • Biliary disease • Ovarian disorders • Breast disease • Cervical disease • Bowel obstruction

  4. Rate of non-obstetric surgery Rate – 1:527 pregnancies, 77 surgeries total

  5. Appendicitis • 1:2000 to 1:6000 pregnancies • Incidence 0.05% • Difficult diagnosis?? • Immediate intervention a must

  6. Pathogenesis: • Appendiceal lumen obstruction: • Fecaliths • Parasites • Foreign bodies • Lymphoid hyperplasia • Metastatic cancer

  7. Occurrence • Retrospective studies (1990 UCLA, 1995 Good Sam, Phoenix) • 151 patients • No significant change in occurrence between trimesters • (Tamir 1990, Mourad 2000)

  8. Sometimes difficult in Pregnancy! Displaced appendix? Distorted lab values Vague Symptoms Fever? Tachycardia? Diagnosis

  9. Appendix Location • 1932 Baer described location of appendix during pregnancy. • Since, most agree there is a shift in location.

  10. Appendix location • Iran Study 1999 • 291 patients R.A. • 3 groups • 165 preg. Elective C/S • 26 preg. With Appendicitis • 100 N.P. R.A. with Appendicitis • No sig difference!! (H. Hodjati,* T. Kazerooi, 2002)

  11. Similar Study • Year 2000 • Mourad and associates reported 80% of 45 patients studied to have RLQ pain. • …..consistent with Study in Iran

  12. Normal Pregnancy Abdominal tenderness Nausea Vomiting Anorexia Acute Appendicitis Abdominal tenderness Nausea Vomiting Anorexia Symptoms

  13. Symptoms cont…. • 1975 Study Parkland: 34 pts over 15 years. • Direct abdominal tenderness is rarely absent. • Rebound tenderness 55-75% • Rectal tenderness, especially 1st trimester • Anorexia in only 1/3-2/3 pts, vs. almost 100% non pregnant. • (Cunningham 1975)

  14. Psoas and Obturator signs. Sensitivity/specificity??

  15. Lab Values • WBC often as high as 15,000/mm3 in normal pregnancy. Bailey et. Al 1973-83 41 cases of acute appendicitis in pregnancy 57% accurate initial diagnosis based on P.E., labs, & Sx. Mazze and Kallen 1991 778 cases with 65% accurate diagnosis Sharp 1994 -50% accuracy reported

  16. Can we do better than 50%? • CT Scan • Numerous reports in surgical literature suggesting accuracy of >97% in non-pregnant patients.

  17. CT scanning, cont….

  18. CT scan cont…. • Teratogenicity • Hiroshima • Studied 45 years later • Perinatal exposure • No evidence of mental retardation or microcephaly if exposed before 8 or after 25 WGA • Highest risk (12 Rads at 8-15 weeks, 21 rads at 16-25 weeks).

  19. Teratogenicity, cont…. • *No evidence of any increased risk with exposure of up to 5 Rads. • Maximal risk at 1 rad is 0.003% • 15% embryos naturally abort • 2.7-3.0% have genetic malformations • 4% IUGR • 8-10% late onset genetic abnormalities ( • (Brent RL 1989)

  20. Ultrasound • 1992 Study • 45 pts, suspected Appendicitis • Diagnosis missed in 7% of cases due to gravid uterus (all in 3rd trimester) • 42 cases +, 100% sensitivity • 96% specificity • 98% accuracy (2 similar studies support findings) (Lim HK; Bae SH 1992)

  21. Risks if untreated • Preterm contractions/labor • Rupture leading to peritonitis • Sepsis • Fetal tachycardia • Maternal/fetal death

  22. Risks cont…. • Increased Gest age = increased complication rate • Uterine contractions – as high as 80% of pts >24 WGA • Appendiceal perforation • 4-19% non-pregnant patients • 57% pregnant patients • (Innability to isolate infection by omentum) (Am Sur 2000 Jun: 66)

  23. “The mortality of appendicitis complicating pregnancy is the mortality of delay”Babler 1908

  24. Treatment • Suspicion: • Immediate surgery • Delay • Generalized peritonits • Antibiotics • Perioperative 2nd cephalosporin. May be discontinued post-op, minus perforation, gangrene or phlegmon

  25. Laparoscopy • Safe – especially in the first 20 weeks • (Reedy et al. 1997) • Risks: • Low birth weight infants • Preterm labor • Fetal growth restriction (no diff. Vs. laparotomy) (Mazze and Kallen 1989)

  26. Mazze and Kallen • 5405 pregnant women undergoing surgery 1973-1981 • 41% 1st • 35% 2nd • 24% 3rd • 16% Laparascopic 54% General anesthesia • Increased risk of: • Death by 7 days 1.4 – 3.2 – 1.9 (2.1) • Birthweight <1500 gms 1.7 – 3.2 – 1.5 (2.2) • Birthweight <2500 gms 1.4 – 1.8 – 2.2 – (2.0) • (No increased risk of stillborn or congenital malformation)

  27. Anesthesia • General anesthesia considered safe • However…… • Kallen and Mazze 1990 • Sylvester et al 1994 • ..both raised questions about potentially increased risk of neural tube defects and hydrocephaly when general anesthesia is used in first trimester

  28. Other Risks • Pneumoperitoneum • Animal studies indicate decreased unteroplacental blood flow with CO2 pressures >15mmHg • Also, some infants developed acidemia • Barnard et al 1995 • Hunter et al 1995

  29. 0.05% of pregnancies Detailed P.E. – may be ambiguous Ultrasound may be helpful if prompt Do not delay diagnosis Consult Surgery immediately Perioperative ABX General Anesthesia acceptable No sig. Diff in morbidity/mortality with Laparascopy vs laparotomy Extended monitoring for labor pattern necessary post operatively. Appendectomy Review

  30. ACOG • Prophylactic Appendectomy • Slight risk associated with procedure. • Slight benefit in prophylaxis removal. • Should perform in certain groups: • 10-30 yr. Age group undergoing dx. Lap for pelvic pain • Mentally handicapped • Pts. With multiple adhesions

  31. Gall Bladder • Biliary Disease • Increased biliary sludge in pregnancy • Increased bile viscosity • Increased micelles • Gall bladder relaxation • Increased risk of gallstone formation • Cholelithiasis cause of 90% cases of cystitis • 0.2-0.5/1000 pregnancies require surgery (Landers eta ak 1987)

  32. Symptoms • May be asymptomatic • 2.5-10% of pregnant patients • (Maringhini et al 1987) • RUQ Pain – most reliable symptom • (pain may radiate to back) • Vomiting approx 50% • Can mimic appendicitis in 3rd trimester

  33. Workup • Ultrasound • Effective rate 90% • Liver enzymes • Amylase, Lipase • CBC

  34. Management • Several studies – Conservative vs. Surgical • Landers et al 1987 • Glasgow et al 1998 • Dixon et al 1987 • 15-50% of pts treated medically reported continued symptoms throughout pregnancy.

  35. Mgmt. cont… • Davis et al 2000 • 77 cases • Primary surgical management • Reported better outcomes with surgical management • Less risk to fetus if performed in 2nd trimester

  36. Individual Based • No solid consensus on management • If Medically treated • Demerol over morphine for pain • IVF • NG suction • Low fat diet • Asymptomatic Stones- surgery not recommended

  37. Laparascopic approach safe, generally to 3rd trimester Remember M/F Risks Slight increase of low birth weights Slight increase of infant death within 7 days Increase in contractions, especially >24 weeks Surgical Management

  38. Pancreatitis • 1:3000 – 1:4000 pregnancies • High incidence of Gallstones • Elevated Amylase, Lipase • Medical management • NG tube • NPO • IVF, Pain control • Parkland Study 1995 • 43 patients, all tx. medically • All did well – Avg stay 8 days (Ramin eta al 1995)

  39. The Adnexa • Estimated 1:200 deliveries (adnexal masses) • Based on two studies • Katz 1993 • Koonings 1988 • Est. 1:1300 adnexal masses require surgery • Whitecar 1999

  40. Adnexal Masses Cont… • 1990 Study • Whitecar 1990 • 130 pregnancies • 5% malignant rate • ½ Serous Carcinomas of low malignant potential • 30% cystic teratomas • 28% serous/mucinous cystadenomas • 13% corpus luteal • 7% benign

  41. Adnexal Masses cont…. • 2 additional studies support percentages: • Sunoo 1990 • Hopkins 1986 • 1/3 Teratomas • 1/3 Cystadenomas

  42. Complications • Whitecar study cont.. • Ovarian Torsion • most common and serious sequelae • 5% occurrence • rupture most common in 1st trimester

  43. Multiple Studies Thornton 1987 Whitecar 1999 Fleischer 1990 Caspi 2000 Hess 1988 Platek 1995 Parker 1996 Best Approach: (<5cm) Exp. Mgmt (5-10cm) Watch unless complex on sonography If >6cm after 16 WGA, operate Management

  44. Williams Obstetrics Concludes: • 1. What is the mass and is it malignant? • 2. Is there a good likelihood that the mass will regress? • 3. Will the mass result in dystocia and/or torsion and possible rupture?

  45. MRI? • 1990 Kier et al • Correctly identified 17 of 17 adnexal masses with MRI vs. 12 out of 17 with ultrasound

  46. “No single diagnostic procedure results in a radiation dose that threatens the well-being of the developing embryo and fetus.” American College of RadiologyHowever, the National Radiological Protection Board arbitrarily advises against the use of MRI in the first trimester. (Garden, 1991)

  47. Trauma • Affects approx. 7% of pregnant women • Indications for Surgical Exploration: • Penetrating abdominal injury • Clinical evidence of intraperitoneal hemorrhage • Suspected Bowel Perforation • Suspected injury to uterus or fetus

  48. Breast Disease • “Any suspicious breast mass found during pregnancy should prompt an aggressive plan to determine its cause, whether by FNA or open biopsy.” • Williams 21st Edition

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