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Surgery in Pregnancy

Dilip Gill, PGY I General Surgery
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Dilip Gill

on 13 May 2011

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Transcript of Surgery in Pregnancy

Surgery in Pregnancy Dilip Gill
PGY I General Surgery
May 13, 2011 Objectives 1 2 3 5 6 7 8 9 10 11 PHYSIOLOGIC CHANGES OF PREGNANCY RADIOLOGY SAFETY CONCERNS IN PREGNANCY PREVENTION OF PRETERM LABOR 4 ABDOMINAL PAIN AND THE ACUTE ABDOMEN IN PREGNANCY MINIMALLY INVASIVE SURGERY IN PREGNANCY BREAST MASSES IN PREGNANCY HEPATOBILIARY DISEASE IN PREGNANCY SMALL BOWEL DISEASE IN PREGNANCY APPENDICITIS IN PREGNANCY TRAUMA IN PREGNANCY Summary PHYSIOLOGIC CHANGES OF PREGNANCY

RADIOLOGY SAFETY CONCERNS IN PREGNANCY

PREVENTION OF PRETERM LABOR

ABDOMINAL PAIN AND THE ACUTE ABDOMEN IN PREGNANCY

MINIMALLY INVASIVE SURGERY IN PREGNANCY

BREAST MASSES IN PREGNANCY

HEPATOBILIARY DISEASE IN PREGNANCY

SMALL BOWEL DISEASE IN PREGNANCY

APPENDICITIS IN PREGNANCY

TRAUMA IN PREGNANCY

SUMMARY Progesterone and estrogen
Principle hormones which mediate maternal physiologic changes in pregnancy Surgery in the Pregnant Patient

1% of pregnancies require nonobstetric surgery

Indications for surgical intervention are common for the patient's age group and unrelated to pregnancy

Acute appendicitis, symptomatic cholelithiasis, breast masses, or trauma

Changes in maternal anatomy and physiology and safety of the fetus important Surgery in the Pregnant Patient

Presentation of surgical diseases may be atypical or mimic signs and symptoms associated with a normal pregnancy

Standard evaluation may be unreliable

Physicians may be more conservative in evaluation and treatment

Delay in diagnosis and treatment Elevated progesterone levels & decreased serum motilin
Result in smooth muscle relaxation
Multiple effects
Esophagus- lower esophageal sphincter tone decreased plus increased intra-abd pressure results in increase incidence of GERD
Stomach- diminished gastric tone and motility
Small bowel- motility reduced, increasing small bowel transit time
Colon- constipation due to increased colonic sodium and water absorption, decreased motility, and mechanical obstruction by the gravid uterus
Increase portal venous pressure causes increase pressure in collateral venous circulation, results in dilation of the veins at GE junction and the hemorrhoidal veins leading to hemorrhoids. Gallbladder

Gallbladder function and bile composition altered

During the second and third trimesters, volume of gallbladder may be twice that found in the nonpregnant state

Gallbladder emptying markedly slower

Increased biliary stasis and changes in bile composition result in an increased risk for gallstones

However, symptomatic cholelithiasis similar to incidence in age-related nonpregnant patients Liver

Resemble liver disease

Spider angiomas and palmar erythema (elevated serum estrogen)

Hypoalbuminemia, elevated serum cholesterol, alkaline phosphatase, and fibrinogen levels

Serum bilirubin and hepatic transaminase levels remain unchanged Cardiovascular system

Peripheral vascular resistance is decreased due to diminished vascular smooth muscle tone

Cardiac output increases by up to 50% during first trimester (increased stroke volume resulting increased plasma volume and RBC mass)
Increase in maternal heart rate also contributes

Cardiac output falls back to normal late in pregnancy

During third trimester, cardiac output dramatically decreased when supine (IVC compression)

Sympathetic tone usually maintains peripheral vascular resistance and blood pressure

10% of patients may experience supine hypotensive syndrome, in which the sympathetic response is not adequate to maintain blood pressure

Anesthetic agents may inhibit the compensatory sympathetic response, causing a more precipitous fall in blood pressure Other

Inguinal swelling secondary to varicosities of the round ligament

Often mistaken for an inguinal or femoral hernia

Careful physical examination and ultrasound if needed

The varicosities generally resolve postpartum Respiration

Oxygen consumption increases during pregnancy

Minute ventilation increases by 50% due to increase in tidal volume (elevated progesterone)

Progesterone increases sensitivity of respiratory centers to CO2 and direct stimulant to the respiratory centers

Maternal PaO2 levels during late pregnancy increased (100 mmHg) and PaCO2 decreased (27 mmHg)

Renal compensation maintains normal maternal pH

Decreased PaCO2 increases CO2 gradient from the fetus to the mother, facilitating CO2 transfer

The oxygen-hemoglobin dissociation curve shifted to the right

Results in increased oxygen transfer to the fetus

Elevation of the diaphragm by as much as 4 cm results in a decrease in total lung volume by 5% Kidney

Increased GFR by 50% and 75% increase in renal plasma flow

BUN decreases by 25%

Serum creatinine decreases

Increased angiotensin and aldosterone increase Na reabsorption but serum Na decreased (increased plasma volume)

Serum osmolality decreased Plasma

Increase in plasma volume and RBC mass

Increased leukocyte count

Platelet count declines throughout pregnancy

Clotting factors increased Physiologic Changes of Pregnancy RADIOLOGY SAFETY CONCERNS IN PREGNANCY Fetal Radiation Exposure With Radiographic Imaging

EXAMINATION TYPE ESTIMATED FETAL RADIATION EXPOSURE (cGy)

Two-view chest radiograph 0.00007
Cervical spine radiograph 0.002
Pelvis radiograph 0.04
Head CT <0.050
Abdomen CT 2.60
Upper GI series 0.056
Barium enema 3.986
Hepatobiliary (HIDA) scan 0.150 Radiographic studies useful

Concern with radiation exposure to fetus

Max dose of ionizing radiation during the entire pregnancy is 5 cGy

Highest risk from radiation from preimplantation to 15 weeks gestation (organogenesis, teratogenic effects)

Perinatal radiation associated with childhood leukemia

Radiation dose associated with congenital malformation is higher than 10 cGy MRI

MRI avoids exposure to ionizing radiation but unknown risk

Animal studies have shown no teratogenic effect from the electromagnetic radiation, static magnetic field, radiofrequency magnetic fields, or IV contrast used during MRI

National Radiological Protection Board advises against MRI during first trimester Ultrasound

Routinely used

Avoids exposure to ionizing radiation

Limitations

Deeper structures difficult to visualize

Limited field of view

Operator dependent Right Upper Quadrant

Gastroesophageal reflux
Peptic ulcer disease
Acute cholecystitis
Biliary colic
Acute pancreatitis
Hepatitis
Acute fatty liver of pregnancy
HELLP syndrome
Preeclampsia
Pneumothorax
Pneumonia
Acute appendicitis
Hepatic adenoma
Hemangioma Lower Abdomen

Threatened, incomplete, or complete abortion
Abruptio placentae
Preterm labor
Pelvic inflammatory disease
Tubo-ovarian abscess
Inflammatory bowel disease
Irritable bowel syndrome
Pyelonephritis
Flank
Pyelonephritis
Hydronephrosis of pregnancy
Acute appendicitis (retrocecal appendix)
Diffuse Abdominal Pain
Early acute appendicitis
Small bowel obstruction
Acute intermittent porphyria
Sickle cell crisis Right Lower Quadrant

Acute appendicitis
Ectopic pregnancy
Renal or ureteral colic
Pelvic inflammatory disease
Tubo-ovarian abscess
Endometriosis
Adnexal torsion
Ruptured ovarian cyst
Ruptured corpus luteum Common Causes of Abdominal Pain in the Pregnant Patient ABDOMINAL PAIN AND THE ACUTE ABDOMEN IN PREGNANCY Abdominal Pain

Difficult to distinguish pathophysiologic cause from normal pregnancy-associated symptoms
Changes in position and orientation of abdominal viscera from the enlarging uterus and alterations in physiology may modify perception or manifestation of an intra-abdominal process
Both patient and physician may attribute symptoms to normal pregnancy, resulting in delay in evaluation and treatment
Serious adverse effects The Society of American Gastrointestinal Endoscopic Surgeons recommends the following guidelines for
laparoscopic surgery during pregnancy:

1. Obstetric consultation preop
2. Intervention deferred until 2nd trimester
3. Pneumatic compression devices (hypercoagulable state and venous stasis from pneumoperitoneum)
4. Fetal status and maternal end-tidal CO2 and ABG monitored
5. Lead shield to uterus if intraop cholangiography and fluoroscopy used selectively
6. Abdominal access attained using an open technique
7. Dependent positioning is used to shift the uterus off IVC
8. Pneumoperitoneum pressures are minimized to 8 to 12 mm Hg and not allowed to exceed 15 mm Hg Advantages and Disadvantages of Use of Laparoscopy Instead of Laparotomy in Pregnancy

Advantages

Decreased fetal depression secondary to decreased narcotic requirement
Lower rates of wound infections and incisional hernias
Diminished postop maternal hypoventilation
Decreased manipulation of the uterus
Faster recovery with early return-to-normal function
Decreased risk for ileus

Disadvantages

Possible uterine injury during trocar placement
Decreased uterine blood flow
Preterm labor risk secondary to the increased intra-abdominal pressure
Increased risk of fetal acidosis and unknown effects of CO2 pneumo
Decreased visualization with gravid uterus MINIMALLY INVASIVE SURGERY IN PREGNANCY PREVENTION OF PRETERM LABOR Incidence of preterm labor related to gestational age and indication for surgery

Rate of premature labor by surgical intervention is 3.5%

Gestational age and severity of underlying disease most predictive of risk

Later gestation, the higher the risk

Intraperitoneal surgeries most likely to have postop course complicated

Delay in treatment appears to increase the chance of preterm labor

Laparoscopic and open techniques have equal incidence of preterm labor Tocolytics after surgery (no consensus)

Most suggest tocolytics only be used if contractions are noted during postop monitoring or are appreciated by patient

Tocolytics generally successful

Terbutaline, magnesium, and indomethacin are equivalent

Prophylactic use depends on the patient's gestational age and the underlying disease process Pregnancy-associated breast cancer defined as breast cancer diagnosed during pregnancy or within 1 year after pregnancy

Increasingly as more women delay childbearing

Pregnancy-associated breast cancer reported to occur in 1 in 10,000 to 1 in 3000 pregnant women BREAST MASSES IN PREGNANCY Most common nongynecologic malignancy associated with pregnancy

May be more common in women with a genetic predisposition to breast cancer (BRCA) Delays in diagnosis and treatment common

Delay in diagnosis of nearly 6 months (improving)

Given tumor doubling size of 130 days, a delay in diagnosis and treatment of 1 month increases the risk for nodal metastasis by 0.9%, whereas a delay of 6 months increases the risk by 5.1%

Present with larger primary tumor and higher risk for positive axillary lymph nodes

Worse prognosis because more avanced disease at presentation (hyperestrogenic state)

Lower estrogen receptor positive cancer (down regulation)

Physiologic changes of breast engorgement, rapid cellular proliferation, and increased vascularity make a reliable physical examination difficult Imaging difficult to interpret

Mammography limited risk to fetus with shield

Mammography high false-negative rate due to increased density

Ultrasonography safe

MRI usefulness in the pregnant patient is yet to be determined

MRI not recommended (gadolinium contrast is category C drug, to be used only if the potential benefit outweighs the potential risk

Gadolinium crosses placenta and has been associated with fetal abnormalities in rats Tissue diagnosis essential

Core-needle biopsy safe and reliable

Pressure dressing (hypervascularity)

Milk fistula (stop lactation for several days before and empty breast of milk just before

FNA reliable alternative

Accuracy dependent on pathologist's experience in distinguishing the proliferative changes of pregnancy from cancer Tx is surgical resection

Modified radical mastectomy long considered appropriate choice (no adjuvant radiation)

In stages I and II cancer, mastectomy with axillary dissection is preferred

Axillary dissection necessary because aggressive nature of pregnancy-associated breast cancer

Sentinel node biopsy poses unknown risk to fetus and is avoided Late second trimester or later, immediate breast-conserving lumpectomy and axillary dissection followed with radiation postpartum is a treatment option

First or early second trimester of pregnancy, lumpectomy and axillary dissection can be followed by chemotherapy after the first trimester and radiation after delivery

Chemotherapy is indicated for node-positive cancers or node-negative tumors greater than 1 cm

Current chemotherapeutic regimens are relatively safe after the first trimester

Methotrexate avoided (spontaneous abortion)

Cyclophosphamide and doxorubicin can enter breast milk; breast-feeding is contraindicated during chemotherapy Radiation typically not offered during pregnancy

Exposure greater than 1 Gy during 1st trimester has high likelihood of causing fetal death (standard therapeutic course of 50 Gy) HEPATOBILIARY DISEASE IN PREGNANCY Classified as exclusive to pregnancy, simulataneous but not exclusive, and before pregnancy

(Ex. acute fatty liver of pregnancy, HELLP syndrome)

Acute fatty liver of pregnancy- etiology unkown, more common in first pregnancies and twins, and male fetus

Usually third trimester

20% maternal and fetal mortality rate

Sx malaise, nausea, vomiting, and RUQ pain and significant liver dysfunction within 2 weeks of onset

Progression to fulminant hepatic failure quickly

No specific treatment (prompt delivery) 10% of women with preeclampsia or eclampsia have associated liver involvement (severe elevation of hepatic enzymes to HELLP to rupture)

Hepatic hemorrhage or rupture occurs during third trimester

Right upper quadrant pain and tenderness, peritonitis, unstable within hours

Suspected with preeclampsia and RUQ pain

CT for diagnosis (U/S nonspecific)

Management depends on suspicion of ongoing intraperitoneal hemorrhage (stable vs unstable) (serial imaging vs packing/hep artery ligation) Cholecystectomy 2nd most common surg procedure in pregnancy

Most pregnant women w/ cholelithiasis are asymptomatic

2% to 4% of pregnant women may be found to have gallstones

0.05% to 0.1% of those women will be symptomatic

Surgical intervention considered primary management of gallstones in pregnancy

Timing for cholecystectomy for biliary colic depends on gestational age and the severity of symptoms

Risk for preterm labor is nearly 0% during the second trimester and 40% during the third trimester

Open technique using the Hasson trocar is recommended for obtaining access to the abdomen. SMALL BOWEL DISEASE IN PREGNANCY Intestinal obstruction third most common nonobstetric surgical issue in pregnancy

SBO usually occur during second and third trimesters

Adhesions #1

Other causes include volvulus, intussusception, malignancy, or hernia

Symptoms identical

Diagnosis by serial examination and plain abdominal xray

Treatment identical

However, lower threshold for operative management necessary

Laparotomy after 8 hours (if not improving) is performed before perforation or bowel necrosis occurs APPENDICITIS IN PREGNANCY Acute appendicitis most common nonobstetric surgical problem (1 in 1500 pregnancies)

Typical clinical findings of nausea, vomiting, abdominal pain, and mild leukocytosis may be findings in normal pregnancy

Delay in diagnosis results in an increased perforation rate of 10%

This has significant consequences for the patient and fetus

Fetal mortality increases from 1.5% in acute appendicitis to 35% in perforated appendicitis

Pain located higher in the abdomen later in gestation

Treatment is emergent appendectomy

Debate is then for open or laparoscopic technique SUMMARY

Pregnant patients susceptible to same surgical diseases as nonpregnant patients of similar age

Maternal physiologic changes and enlarging uterus may result in atypical presentation

Delay in diagnosis and treatment greater risk

Early consultation with an obstetrician TRAUMA IN PREGNANCY

Trauma leading nonobstetric cause of maternal mortality

Critical point is resuscitation of fetus accomplished by resuscitation of the mother

Initial evaluation and treatment identical

Increased blood volume associated with pregnancy

Signs of blood loss such as tachycardia and hypotension may be delayed until the patient loses nearly 30% of her blood volume (fetus hypoperfusion

Most common cause of fetal death after blunt injury is abruptio placentae References


Sabiston Textbook of Surgery, 18th Edition, Townsend.

Schwartz’s Principles of Surgery, 8th Ed. New York, McGraw-Hill.

Cohen-Kerem R, Railton C, Oren D, et al: Pregnancy outcome following non-obstetric surgical intervention. Am J Surg 2005; 190:3.
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