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Non-obstetrical Surgical Emergencies in Pregnancy

Non-obstetrical Surgical Emergencies in Pregnancy. Steven Stanten MD Rupert Horoupian MD. Non-Obstetrical Surgical Emergencies in Pregnancy. Steven Stanten M.D. Rupert T. Horoupian M.D. OBJECTIVES. Understand etiologies of common, non-obstetric surgical occurrences in the pregnant patient

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Non-obstetrical Surgical Emergencies in Pregnancy

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  1. Non-obstetrical Surgical Emergencies in Pregnancy Steven Stanten MD Rupert Horoupian MD

  2. Non-Obstetrical Surgical Emergencies in Pregnancy Steven Stanten M.D. Rupert T. Horoupian M.D.

  3. 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

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

  5. Introduction • 1-2% of pregnancies complicated by non-obstetrical surgical problem • Adenexal masses • Appendicitis • Biliary tract disease • Small bowel obstruction • Diverticular disease

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

  7. Challenges • Physiologic changes • Diagnostic imaging limitations • Anesthesia issues • Delay in diagnosis • Communication • Fetal issues • Maternal issues

  8. Teratogenicity of Irradiation • Etiology of most birth defect unknown • Drugs and chemicals 3% of risk • Embryogenesis at 8-9 weeks • Nervous system develops beyond • ACOG – exposure , 5 rads is not associated with increase in fetal anomalies or prgnancy loss

  9. Teratogenicity of Irradiation (con’t) • ACR – No single diagnostic procedure results in a radiation dose that threatens the well being of the developing embryo and fetus

  10. Physiologic Changes During Pregnancy That Effect Surgery • Respiratory System • Increase in minute ventilation • Decrease in functional residual capacity • Oxygen consumption increase greater than cardiac output increase • Decrease in Sv O2 • Aortocaval compression

  11. Physiologic Changes During Pregnancy That Effect Surgery • Cardiovascular changes • Cardiac output increases 30% • Aortocaval compression with increase in abdominal pressure • Decrease in BP with reverse trendelenberg • Increase in blood volume

  12. Surgical Considerations • Pneumoperitoneum • Increase in peak airway pressures • Decrease in total lung compliance • Hypoxic episodes possible • Supine position causes decrease in PaO2 • Hyperventilation to keep PaCO2 down can cause decrease uteroplacental perfusion • Decrease PaO2 +/or increase in PaCO2 can cause fetal harm

  13. 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

  14. Adenexa • 1 in 200 pregnancies complicated by adenexal mass greater than 6cm • Treatment depends on trimester

  15. 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?

  16. 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

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

  18. 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

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

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

  21. 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

  22. Biliary Tract Disease • Complicates 25 out of 1000 pregnancies. • Biliary colic • Acute cholecystitis • Causes • Increased bile viscosity • Decreased bile flow

  23. 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

  24. 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)

  25. Biliary Tract Disease (con’t) • Treatment • Symptomatic • Pain meds • Nausea meds • IV fluids • Surgical consultation

  26. 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

  27. 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.

  28. Management (con’t) • Davis et al 2000 • 77 cases • Primary surgical management • Reported better outcomes with surgical management • Less risk to fetus if performed in 2nd trimester

  29. Biliary Tract Disease (con’t) • Laparoscopic cholecystectomy • Antibiotics • NG or OG Tube • Compression stockings • Open trocar vs. Verees needle • Pressure to 12 mm Hg or lower • Coagulation is OK • Cholangiogram is OK • Do not move patient position rapidly

  30. Biliary Tract Disease (con’t) • Treatment • Laparoscopic cholecystectomy is feasible during pregnancy • Even in 3rd trimester • Upper gestational age not defined • Intra-op fetal minitoring • Post-op fetal monitoring

  31. Biliary Tract Disease (con’t) • Treatment • SAGES Guidelines “Laparoscopic surgery in pregnancy when possible should be deferred to the 2nd trimester or after delivery” Decreased rate of spontaneous Abortion Decrease likelihood of pre-term labor

  32. Biliary Tract Disease (con’t) • Laparoscopic cholecystectomy • Less invasive • Earlier recovery • Less scarring • Less hospital costs

  33. 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

  34. Surgical Recommendations • Late 1st or 2nd trimester is best • Reports out that 3rd trimester is OK • Evaluate fetal HR and uterine contractility pre and post if >16 weeks gestation • Open trocar insertion • Avoid high intra-abdominal pressures

  35. Open trocar insertion • The obvious • Minimize • Aspiration • Sedatives – GERD and decreased gastric emptying • Hypoxia • Hypercarbia • Hypocapnia • Hypoxia • Hypotension • Aortocaval compression • Nitrous oxide

  36. 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)

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

  38. Appendicitis • The most common surgical condition of the abdomen • Lifetime occurrence of 7% • Peak incidence 10-30y • The most common non-obstetric surgical intervention during pregnancy

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

  40. 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)

  41. Acute Appendicitis • Extensive differential diagnosis • Displacement of the appendix • Fever and tachycardia may not be present • No rectal tenderness • +/- anorexia • Leads to delay in diagnosis

  42. Differential Diagnosis • Renal stone / APN • Gastroenteritis • Pancreatitis • Cholecystitis • Mesenteric adenitis • Hernia • Bowel obstruction • Preterm labor • Placenta abruptio • Chorioamnionitis • Adnexal torsion • Ectopic pregnancy • Pelvic inflammatory • Round lig. pain

  43. Pathogenesis: • Appendiceal lumen obstruction: • Fecaliths • Parasites • Foreign bodies • Lymphoid hyperplasia • Metastatic cancer • Carcinoid tumor

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

  45. Symptoms • Pain • Anorexia • Nausea / vomiting • Pain migration – RLQ / RUQ / Flank • Fever

  46. 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)

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

  48. Physical Examination • Tenderness – RLQ • Rebound & Guarding (peritoneal signs) • Rovsing sign • Dunphy’s sign • Psoas sign (retroperitoneal retrocecal appendix) • Obturator sign (pelvic appendix) • Rectal examination tenderness (cul-de-sac) • Low grade fever

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

  50. 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

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