15- common surgical problems in pregnancy Quiz
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Questions and Answers

What is the most common time for occurrence of adnexal torsion during pregnancy?

  • 15 to 20 weeks
  • 3 to 5 weeks
  • After the puerperium
  • 6 to 14 weeks (correct)

    • Which of the following is NOT a main reason for advising surgery for an adnexal mass during pregnancy?

  • Risk of common cold (correct)
  • Risk of torsion
  • Risk of rupture
  • Risk of malignancy

    • What type of tumors are most commonly associated with malignancy in ovarian tumors during pregnancy?

  • Mucinous cystadenomas
  • Germ cell tumors (correct)
  • Cystic corpus luteum
  • Serous cystadenomas

    • What is the correct course of action when an adnexal mass requires surgery during the first trimester?

    <p>Perform surgery in the second trimester unless complications arise</p> Signup and view all the answers

    What symptom might indicate a potential torsion of the adnexa?

    <p>Sudden onset of severe pelvic pain</p> Signup and view all the answers

    What is the primary risk associated with radiation exposure to a fetus before 8 weeks of gestation?

    <p>Growth restriction</p> Signup and view all the answers

    At what gestational age does the risk of teratogenic effects from radiation become unlikely?

    <p>After 20 weeks</p> Signup and view all the answers

    What is the recommended action regarding iodine contrast use during pregnancy?

    <p>It should be avoided.</p> Signup and view all the answers

    Which of the following statements about anesthetic agents is correct?

    <p>Anesthetic agents have no known teratogenic effects.</p> Signup and view all the answers

    What is the recommended intervention for pregnant women undergoing surgery to mitigate the risk of venous thromboembolism?

    <p>Provide pneumatic compression devices</p> Signup and view all the answers

    Which laboratory finding is considered elevated for white blood cell count during any trimester?

    <p>Above 16,000/μL</p> Signup and view all the answers

    What factor primarily determines the type of anesthesia used in a surgical procedure during pregnancy?

    <p>Planned surgical procedure</p> Signup and view all the answers

    What is the most common surgical disorder during pregnancy?

    <p>Cholecystitis</p> Signup and view all the answers

    What is the ideal treatment for nonperforated acute appendicitis in pregnant women?

    <p>Laparoscopic appendectomy</p> Signup and view all the answers

    Which complication has the highest reported rate in third-trimester patients undergoing surgery for appendicitis?

    <p>Fetal loss</p> Signup and view all the answers

    What should NOT be used as treatment for appendicitis in pregnant women?

    <p>Nonoperative therapy with antibiotics alone</p> Signup and view all the answers

    What is the possible complication rate of perforation in pregnant women with appendicitis?

    <p>25%</p> Signup and view all the answers

    What factors increase a multipara's risk for gallbladder disease during pregnancy?

    <p>Higher estrogen and progesterone levels</p> Signup and view all the answers

    What imaging modality has distinct advantages as a first-line approach for abdominal issues in pregnant women?

    <p>Ultrasound</p> Signup and view all the answers

    Which of the following conditions is NOT a differential diagnosis associated with abdominal pain in pregnant women?

    <p>Urinary tract infection</p> Signup and view all the answers

    How frequently does acute cholecystitis occur during pregnancies?

    <p>1 in 1600 to 1 in 10,000</p> Signup and view all the answers

    What is the primary symptom of peptic ulcer disease during pregnancy?

    <p>Dyspepsia</p> Signup and view all the answers

    What diagnostic method is preferred for patients with peptic ulcer disease during pregnancy when symptoms do not improve?

    <p>Endoscopy</p> Signup and view all the answers

    Which of the following is NOT a common cause of mechanical obstruction in pregnant women?

    <p>Gallstones</p> Signup and view all the answers

    What lifestyle change is recommended as a first-line treatment for dyspepsia during pregnancy?

    <p>Dietary and lifestyle changes</p> Signup and view all the answers

    What percentage of women with known peptic ulcer disease report improvement during pregnancy?

    <p>90%</p> Signup and view all the answers

    What is a frequent complication associated with bowel obstruction late in the disease progression?

    <p>Shock</p> Signup and view all the answers

    Which medication is typically used for severe cases of dyspepsia during pregnancy?

    <p>Proton pump inhibitors</p> Signup and view all the answers

    What is the classic triad of symptoms presented in patients with acute intestinal obstruction?

    <p>Abdominal pain, vomiting, and obstipation</p> Signup and view all the answers

    What condition might be mistaken for normal changes in pregnancy due to similar symptoms?

    <p>Peptic ulcer disease</p> Signup and view all the answers

    What is the most common cause of mechanical intestinal obstruction during pregnancy?

    <p>Adhesions</p> Signup and view all the answers

    Which symptom is most commonly associated with acute cholecystitis?

    <p>Right upper quadrant pain with tenderness</p> Signup and view all the answers

    What is the significance of a thickened gallbladder wall in ultrasound findings?

    <p>It suggests the presence of gallstones or cholecystitis.</p> Signup and view all the answers

    In the context of pregnancy, which condition is particularly difficult to differentiate from cholecystitis?

    <p>Appendicitis</p> Signup and view all the answers

    Which laboratory finding is indicative of associated pancreatitis?

    <p>Elevated lipase</p> Signup and view all the answers

    What is the recommended initial management for symptomatic cholecystitis in pregnancy?

    <p>Intravenous hydration and bowel rest</p> Signup and view all the answers

    What percentage of fetal loss is associated with concurrent pancreatitis during gallbladder surgery in pregnant patients?

    <p>3-20%</p> Signup and view all the answers

    Which sign might suggest severe cases of cholecystitis?

    <p>Mild jaundice</p> Signup and view all the answers

    Which condition could be indicated by the presence of hemolysis, elevated liver enzymes, and low platelet count in a pregnant patient?

    <p>HELLP syndrome</p> Signup and view all the answers

    When should antibiotics be administered in the management of cholecystitis?

    <p>If no improvement is seen within 12-24 hours or systemic symptoms are noted</p> Signup and view all the answers

    Which imaging method has the highest diagnostic accuracy for detecting gallstones in pregnancy?

    <p>Ultrasound</p> Signup and view all the answers

    Study Notes

    Common Surgical Disorders in Pregnancy

    • Surgical disease incidence is similar in pregnant and non-pregnant patients.
    • 1.5-2% of pregnancies experience non-obstetric surgical intervention.
    • Symptoms of surgical diseases are often similar in both pregnant and non-pregnant patients.
    • Common surgical disorders in pregnancy include: appendicitis, cholecystitis, intestinal obstruction, adnexal torsion, trauma, cervical and breast disease.

    Maternal Considerations

    • Physiological and anatomical changes in pregnancy alter surgical patient evaluation and management.
    • Plasma volume increases by 30-50% during pregnancy, affecting cardiac output and potentially altering drug distribution and lab results.
    • Red blood cell mass increases, but not as much as plasma volume, leading to a slight physiological anemia.
    • Colloid osmotic pressure decreases during pregnancy.
    • Systolic and diastolic blood pressures typically drop during the first part of the second trimester before gradually returning to baseline by term.
    • Functional pulmonary residual capacity decreases, while tidal volume and respiratory rate increase.
    • A compensated mild respiratory alkalosis exists.
    • Glomerular filtration rate increases, while serum creatinine and blood urea nitrogen values decrease.
    • Gastrointestinal motility is decreased, causing delayed gastric emptying and constipation.
    • The enlarging uterus alters the anatomical relationships of different organs.
    • The uterus can compress the inferior vena cava, potentially resulting in a hypotensive vena cava compression syndrome.

    Fetal Considerations

    • Diagnostic CT scans or X-rays should be limited and carefully considered for use in pregnant patients.
    • Fetus should be shielded during procedures whenever possible.
    • Risk of adverse fetal effects from radiation exposure varies with gestational age and is related to radiation dose to the fetus.
    • Before 8 weeks, the fetus has a higher risk for radiation-induced growth restriction.
    • In the 8-15 week period, the fetus has the highest risk for mental retardation with radiation exposure. The risk is approximately 4% at 10 cGy and 60% at 150 cGy.
    • Teratogenic effects from radiation are unlikely on embryos older than 20 weeks.
    • Use of iodine-based contrast is generally avoided during pregnancy.
    • Non-ionic contrast media has no effect on neonatal thyroid function.
    • Gadolinium use is considered safe based on current evidence.

    Surgical and Anesthesia Risks

    • Anesthetic agents have no known teratogenic effects.
    • Surgery should be postponed until the second trimester, except for true emergencies, due to common first-trimester events such as miscarriage and vaginal bleeding that may be misattributed to the surgery.

    Diagnostic Considerations

    • Patient history includes pain, nausea/vomiting, syncope, fever, vaginal bleeding, and urinary frequency/urgency.
    • Physical examination involves vital signs, general condition, bowel sounds, abdominal rigidity, rebound tenderness, and presence/absence of a mass.
    • Laboratory studies should observe white blood cell count, which is considered elevated above 16,000/µL in any trimester. An interval of several hours often passes between onset of hemorrhage and the detection of a reduced hematocrit value. Anesthesia type is determined by the planned surgical procedure.

    Thromboprophylaxis

    • Both pregnancy and surgery increase the risk of venous thromboembolism (VTE).
    • Factors like vitamin K coagulation and type-1 plasminogen activator inhibitor increase during early pregnancy.
    • Pneumatic compression devices are generally safe to use for pregnant women undergoing surgery.

    Laparoscopy in Pregnancy

    • Laparoscopy is used for procedures such as adnexal masses, appendectomy, cholecystectomy, nephrectomy, splenectomy, and retroperitoneal lymphadenectomy.

    Possible Drawbacks of Laparoscopy

    • Risk of injury to the pregnant uterus.
    • Technical difficulty with exposure due to the enlarged uterus.
    • Increased carbon dioxide absorption, and decreased uterine blood flow secondary to excessive intra-abdominal pressure.
    • Intra-abdominal pressure should be kept between 8 and 12 mm Hg and not exceed 15 mm Hg.
    • Intraoperative CO2 monitoring should maintain end-tidal CO2 between 32 and 34 mm Hg.

    Appendicitis

    • Symptoms include abdominal pain, usually localized to the right lower or mid quadrant, nausea/vomiting, and/or anorexia.
    • Patients may exhibit an elevated white blood cell count with a left shift.
    • US or CT scan reveals enlarged or inflamed appendix.
    • Acute appendicitis is the most common extra-uterine complication during pregnancy.
    • Suspected appendicitis accounts for about two-thirds of non-obstetric exploratory celiotomies during pregnancy, with most cases occurring in the second to third trimesters.
    • Appendicitis occurs in 0.1 to 1.4 per 1000 pregnancies.
    • Pain, nausea, vomiting, and anorexia are typical symptoms, similar to those in non-pregnant patients.
    • Rectal/vaginal tenderness is present in about 80% of patients, especially in early pregnancy.
    • Urinalysis may reveal pyuria, and sometimes microscopic hematuria, particularly in the latter half of pregnancy when the appendix migrates close to the retroperitoneal ureter.
    • An appendix greater than 6 mm is considered abnormal.

    Differential Diagnosis

    • Differential diagnoses for appendicitis include pyelonephritis, gastroenteritis, small bowel obstruction, diverticulitis, pancreatitis, mesenteric adenitis/diverticulitis, corpus luteum cysts, placental abruption, early labor, round ligament syndrome, chorioamnionitis, degenerating myoma, salpingitis, adnexal torsion, and ectopic pregnancy.

    Complications

    • Postoperative preterm labor occurs in 25% of second-trimester and up to 50% of third-trimester patients.
    • Perinatal loss may be associated with preterm labor/delivery, generalized peritonitis, or sepsis.
    • Risk of perinatal loss is 0-1.5% in uncomplicated appendicitis cases.
    • Appendiceal rupture leads to a greater fetal loss rate (reportedly as high as 30%) and maternal mortality (as high as 4%).
    • Appendiceal rupture is most common in the third trimester.

    Treatment

    • Immediate surgical intervention is indicated once appendicitis is diagnosed.
    • Nonoperative therapy with antibiotics is an option for a subset of non-pregnant adults with appendicitis but not recommended for pregnant women.
    • Laparoscopic appendectomy is considered as safe as open appendectomy.
    • Treatment of non-perforated appendicitis during pregnancy involves appendectomy.
    • For perforated appendicitis, peritonitis, or abscess, broad-spectrum intravenous antibiotics are given.

    Cholecystitis & Cholelithiasis

    • Patients typically present with right upper quadrant or epigastric pain.
    • Serum lab results may show elevated white blood cell count and/or liver enzymes.
    • Ultrasound of the right upper quadrant is usually diagnostic.
    • Gallbladder disease is the second most common surgical disorder during pregnancy.
    • Gallstones are responsible for 90% of cholecystitis cases.
    • Acute cholecystitis occurs in 1 in 1600 to 1 in 10,000 pregnancies.
    • About 3.5% of pregnant women have gallstones.
    • Multiparas are at an increased risk of gallbladder diseases.
    • Progesterone increases bile lithogenicity, while it decreases gallbladder contractility.
    • Symptoms include anorexia, nausea, vomiting, dyspepsia, and intolerance of fatty foods.
    • Biliary tract disease can cause pain in the right upper quadrant, epigastric, right scapular, shoulder, or even left upper or lower quadrant. Biliary colicky attacks may last from a few minutes to hours and are often triggered by meals.
    • Right upper quadrant pain and tenderness under the liver (Murphy’s sign) are typical in patients with acute cholecystitis.
    • Serum tests for white blood cells, AST, ALT, alkaline phosphatase, and bilirubin are useful.
    • Elevated lipase and amylase suggest an associated pancreatitis.

    Imaging

    • Ultrasound is the diagnostic choice for gallstones, showing thickened gallbladder wall, fluid around the gallbladder, dilated common bile duct, or pancreas swelling.
    • Diagnostic accuracy of ultrasound is 95% for detecting gallstones in pregnant women.

    Differential Diagnosis

    • The most difficult diagnosis is distinguishing cholecystitis from appendicitis.
    • Associated pancreatitis might be present.
    • Severe preeclampsia (HELLP) syndrome may include associated right upper quadrant abdominal pain and abnormal liver function tests (hemolysis, elevated liver enzymes, and low platelet count).

    Treatment

    • Removal of gallbladder and gallstones may be the preferred approach to cholecystitis, if pancreatitis is present, as it's associated with fetal loss (3-20% of patients).
    • Initial management for symptomatic cholelithiasis/cholecystitis in pregnancy is non-operative treatment, which includes bowel rest, intravenous hydration, correction of electrolyte imbalances, and analgesics.
    • Routine antibiotics are not necessary unless there’s no improvement after 12 – 24 hours or if systemic symptom is evident.
    • Recurrent cases or problems require surgical intervention, e.g. recurrent cholecystitis, choledocholithiasis, and gallstone pancreatitis, with surgical management, especially in second trimester.

    Acute Pancreatitis

    • Typically presents with epigastric pain radiating to the back.
    • Diagnosis is confirmed with elevated amylase and lipase levels.
    • Ultrasound may show an enlarged pancreas and fluid within the peritoneal cavity.
    • Pancreatitis frequently occurs in the third trimester and the puerperium.
    • Pancreatitis incidence is around 1 in 1000 to 1 in 5,000 deliveries.
    • Mortality rates may be higher during pregnancy due to delayed diagnosis.
    • Causes like cholelithiasis are common during pregnancy.

    Peptic Ulcer Disease

    • Typically presents with epigastric discomfort.
    • Endoscopy confirms diagnosis.
    • Pregnancy appears to protect against gastrointestinal ulcers.
    • Gastric secretion and motility are reduced during pregnancy.
    • About 90% of women with known peptic ulcers show improvement during pregnancy.
    • Helicobacter pylori is linked to peptic ulcer development.
    • Symptoms may be mistaken for normal pregnancy symptoms.
    • Major symptom of ulcers during pregnancy is dyspepsia.
    • Endoscopy is the diagnostic method of choice if symptoms persist after lifestyle changes, antacids, antisecretory agents, and H pylori treatment.
    • Perforation, bleeding, and obstruction are rare.
    • Reflux esophagitis and Mallory-Weiss tears are other potential causes of upper gastrointestinal bleeding in pregnancy.
    • Dyspepsia management during pregnancy involves lifestyle changes, antacids, or sucralfate.
    • In persistent cases, H receptor antagonists or proton pump inhibitors may be necessary.

    Acute Intestinal Obstruction

    • Classic triad: abdominal pain, vomiting, and obstipation.
    • Diagnosis is confirmed through abdominal X-ray series.
    • This occurs in approximately 1-3 per 10,000 pregnancies.
    • The most frequent nonobstetrical reason for laparotomy during pregnancy.

    Inflammatory Bowel Disease

    • Crohn's disease is characterized by insidious onset, low-grade fever, diarrhea, and right lower quadrant pain.
    • Ulcerative colitis involves the colon, characterized by bloody diarrhea, lower abdominal cramps, urgency, anemia, and low serum albumin.
    • Initial management includes dietary modifications or bulking agents.
    • Medications like sulfasalazine, prednisone, 5-aminosalicylates, anti-tumor necrosis factor-alpha, and antibiotics might be used.
    • Patients on sulfasalazine need folate supplementation because sulfasalazine inhibits folate absorption.

    Hemorrhoids

    • Common complaints include painless bleeding, prolapse, pain, pruritus, and/or fecal soilage.
    • Hemorrhoids are typically visible on examination or anoscopy.
    • Pregnancy is frequently the cause of symptomatic hemorrhoids, occurring in 9 – 35% of pregnant women.
    • Constipation, increased blood volume, and venous congestion due to the enlarging uterus contribute to hemorrhoid formation.

    Ovarian Masses

    • Most ovarian masses during pregnancy are incidental findings during routine obstetric ultrasounds.
    • Common symptoms are pelvic pain or discomfort.
    • Most masses are functional (e.g., corpus luteum cysts) and resolve spontaneously within sixteen weeks.
    • Unilateral, non-complex masses less than 5 cm in diameter tend to resolve.
    • Pathologic masses, like benign cystic teratomas, or cystadenomas/corpus luteum cysts do not resolve.

    Torsion of the Adnexa

    • Adnexal torsion is suspected in pregnant women presenting with a sudden onset of severe pelvic pain with a detectable adnexal mass.
    • Ultrasound is helpful in confirming the adnexal mass.
    • Laparoscopy or laparotomy confirms the torsion.
    • Torsion may affect the ovary, tube, and adjacent structures, often between 6 and 14 weeks of pregnancy or in the immediate puerperium.
    • Symptoms usually include abdominal pain and tenderness, suddenly appearing. The torsion results from blockage of the vessels that supply the affected organ.
    • Potential complications include shock and peritonitis.
    • Doppler ultrasound is useful in detecting altered blood flow in suspected cases.
    • Diagnosis often requires prompt surgical intervention to prevent tissue damage, preterm labor, or perinatal loss.

    Carcinoma of the Ovary

    • Ovarian cancer symptoms are often vague and resemble common pregnancy symptoms.
    • Ultrasound findings may suggest malignancy although a diagnosis requires confirming with pathology reports on surgically excised tissue.
    • Ovarian cancer, usually less than 0.1% of all pregnancies, occurs in all trimesters.
    • Between 1% and 10% of ovarian tumors that affect pregnancies prove to be malignant.
    • Malignant tumors frequently include germ cell tumors like dysgerminoma, endodermal sinus tumor, malignant teratoma and choriocarcinoma.

    Treatment of Ovarian Tumors

    • Surgical treatment is usually preferred for solid, complex ovarian tumors with prominent solid components identified during pregnancy, due to a relatively low, but significant, incidence (1-10%) of cancer.

    Cancer in Pregnancy

    • Cancer incidence during pregnancy is approximately 1 in 1000.
    • Most common cancers include cervical cancer (26%), breast cancer (26%), leukemias (15%), lymphomas (10%), and malignant melanomas (8%).

    Cardiac Disease

    • Cardiac disease complicates 1-4% of all pregnancies in the United States.
    • Rheumatic and congenital heart diseases are the most frequent causes.
    • Cardiac surgery in the case of pregnancy often involves mitral valve procedures, such as valvuloplasty or replacement.

    Neurological Disease

    • Intracranial hemorrhage is the most common neurosurgical emergency during pregnancy.
    • Subarachnoid hemorrhage is a common type and usually presents with headache, nausea, vomiting, stiff neck, photophobia, seizures, and decreasing level of consciousness.
    • Cerebral aneurysm rupture accounts for about 70% of intracranial hemorrhage.
    • Arteriovenous malformation (AVM) accounts for about 25% of cases. Other causes include eclampsia, coagulopathy, trauma, and intracranial tumors.
    • Early surgical intervention for aneurysmal hemorrhage during pregnancy is associated with reduced maternal and fetal mortality.

    Trauma

    • Motor vehicle accidents, falls, and assaults are the most common causes of non-obstetrical trauma and death during pregnancy.
    • The death of the mother is the most frequent cause of fetal loss.
    • Immediate stabilization of the mother and subsequent evaluation of the fetus are initial treatment priorities.

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    Common Surgical Disorders in Pregnancy PDF

    Description

    This quiz covers key concepts and considerations regarding adnexal masses and torsion during pregnancy. Questions touch on surgery, radiation risks, and appropriate interventions for management. It is essential for medical professionals working with pregnant patients.

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