Common Surgical Disorders in Pregnancy PDF

Common Surgical Disorders in Pregnancy ZIYA KALEM,MD ISTINYE UNIVERSITY FACULTY OF MEDICINE The incidence of surgical disease is the same in pregnant and nonpregnant patients. A total of 1.5-2% of all pregnancies undergo nonobstetric surgical intervention Symptoms of surgical d...

Common Surgical Disorders in Pregnancy ZIYA KALEM,MD ISTINYE UNIVERSITY FACULTY OF MEDICINE The incidence of surgical disease is the same in pregnant and nonpregnant patients. A total of 1.5-2% of all pregnancies undergo nonobstetric surgical intervention Symptoms of surgical diseases are often similar in pregnant and nonpregnant patients. The most common surgical disorders in pregnancy Appendicitis Cholecystitis Intestinal obstruction Adnexal torsion Trauma Cervical and Breast disease. Altered anatomy and physiology and potential risks to the mother and fetus make diagnosis and management of surgical disorders more difficult during pregnancy anesthesiologist, neonatologist, general surgeon and obstetrician should collaborate. Good judgment regarding the timing, methods and extent of treatment is important In the absence of peritonitis, visceral perforation, or hemorrhage, surgical disorders during gestation generally have little effect on placental function and fetal development MATERNAL CONSIDERATIONS Physiologic and anatomic changes alter the evaluation and management of the surgical patient The 30-50% increase in plasma volume during pregnancy affects cardiac output and may alter drug distribution and laboratory test results Red cell mass increases but not as much as the plasma volume, resulting in a slight physiologic anemia. Colloid osmotic pressure is decreased during pregnancy Systolic and diastolic blood pressures characteristically drop during the early second trimester, with a gradual return to baseline by term. Functional pulmonary residual capacity decreases. Tidal volume and respiratory rate increases. A compensated mild respiratory alkalosis exists. increased glomerular filtration rate and decreased serum creatinine and blood urea nitrogen values Gastrointestinal motility is diminished, resulting in delayed gastric emptying and constipation. Enlarging uterus may alter the anatomic relation among the different organs. The enlarged uterus may compress the inferior vena cava and result in the hypotensive vena cava compression syndrome. FETAL CONSIDERATIONS Radiation Exposure Limited diagnostic CT or x-ray procedures can be undertaken with care in the pregnant patient. The fetus should be shielded whenever possible. The risk of adverse fetal effects associated with radiation exposure changes with gestational age and is related to the radiation dose to the fetus These risks fall principally into 2 categories: teratogenicity and carcinogenicity Before 8 weeks, the fetus is at risk for radiation induced growth restriction. At 8-15 weeks, the embryo is the most susceptible to mental retardation, with an approximately 4% risk on exposure at 10 cGy and 60% at 150 cGy. Teratogenic effects are unlikely in embryos older than 20 weeks. Current evidence suggests no increased structural or developmental fetal risk with radiation doses< Exposure to Contrast it has been recommended that use of iodine contrast be avoided during pregnancy Intravenous use of nonionic contrast media has been reported to have no effect on neonatal thyroid function Gadolinium as a class C drug; based on available evidence, the use of gadolinium in pregnancy appears to be safe. Surgical and Anesthesia Risks Anesthetic agents have no known teratogenic effects, and this has been confirmed in multiple large studies. All surgeries except truly emergent surgery should be postponed until the second trimester because common first-trimester events such as miscarriage and vaginal bleeding may be misattributed to the surgery. DIAGNOSTIC CONSIDERATIONS History Pain Nausea and vomiting Syncope Fever Vaginal bleeding Urinary frequency and urgency Physical Examination vital signs general condition bowel sounds abdominal rigidity rebound tenderness presence or absence of a mass. Laboratory Studies The white blood cell count is considered elevated if the value is above 16,000/μL in any trimester. An interval of several hours usually passes between onse of hemorrhage and detection of lowered hematocrit valu ANESTHESIA The type of anesthesia is determined primarily by the planned surgical procedure THROMBOPROPHYLAXIS Both pregnancy and surgery increase the risk of venous thromboembolism (VTE). Beginning in early pregnancy, vitamin K coagulation factors and type-1 plasminogen activator inhibitor increase. Pneumatic compression devices have few contraindications and should be considered for all pregnant women undergoing surgery LAPAROSCOPY IN PREGNANCY Adnexal masses Appendectomy Cholecystectomy nephrectomy splenectomy Retroperitoneal lymphadenectomy. Possible drawbacks are the risk of injury to the pregnant uterus, technical difficulty with exposure because of the enlarged uterus, increased carbondioxide absorption, and decreased uterine blood flow secondary to excessive intra-abdominal pressure. Attempts should be made to keep intraabdominal pressure between 8 and 12 mm Hg and not to exceed 15 mm Hg Intraoperative C02 monitoring should be used to maintain end-tidal C02 between 32 and 34 mm Hg.  APPENDICITIS  Symptoms include abdominal pain, usually localized to right lower or mid quadrant, with nausea, vomiting, and/or anorexia.  Patients may have an elevated white blood cell count with a left shift.  US or CT scan demonstrates enlargement or inflammation of the appendix. Cinical Findings Acute appendidtis is the most common extrauterine complicatlon of pregnancy Suspected appendicitis accounts for nearly two-thirds of all nonobstetric exploratory celiotomies performed during pregnancy; most cases occur in the second and third trimester. Appendidtis occurs in 0.1-1.4 per 1000 pregnancies. Although the incidence of disease is not increased during Symptoms & Signs Right lower quadrant or middle quadrant pain almost always is present when acute appendicitis occurs in pregnancy but may be ascribed to so-called round ligament pain or urinary tract infection. Traditionally it was taught that pregnancy displaces the appendix upwardly. However, some retrospective studies suggest that there is only minimal appendiceal migration throughout pregnancy. Rectal and vaginal tenderness are present in 80% of patients, particularly in early pregnancy Nausea, vomiting, and anorexia usually are present as in the nonpregnant patient. Laboratory Findings The relative leukocytosis of pregnancy (normal 6000 - 16.000/μL) clouds interpretation of infection. Althought not all patient with appendicitis have white blood cell counts above 16,000/µL. at least 75% show a left shift in the differential Urinalysis may reveal significant pyuria (20%) as well as microscopic hematuria. This is particularly true In the latter half of pregnancy, when the appendix migrates closer to the retroperitoneal ureter. lmaging To avoid the risk of radiation to the fetus, US has a distinct role as the first-line imaging modality in pregnancy An appendix measuring > 6 mm should be considered abnormal Differential Diagnosis Pyelonephritis placental abruption gastroenteritis early labor small bowel round ligament syndrome obstruction chorioamnionitis, diverticulitis degenerating myoma pancreatitis salpingitis mesenteric adenitis adnexal torsion diverticulitis ectopic pregnancy corpus luteum cyst Complications Postoperative preterm labor has been reported to occur in 25% of second-trimester and as high as 50% of thirdtrimester patients. Perinatal loss may occur in association with preterm labor and delivery or with generalized peritonitis and sepsis, occurring in 0-1.5% of uncomplicated appendicitis cases. Twenty-five percent of pregnant women with appendicitis will progress to perforation With appendiceal rupture, fetal loss rates are reportedly as high as 30%, and maternal mortality rates as high as 4% are reported Appendiceal rupture occurs most frequently in the third trimester. Treatment Immediate surgical intervention is indicated once the diagnosis of appendicitis is made While nonoperative therapy with antibiotics alone can be used in a subset of nonpregnant adults with appendicitis, it is not recommended in pregnant women. laparoscopic appendectomy may be as safe as open appendectomy Treatment of nonperforated acute appendicitis complicating pregnancy is appendectomy. In the setting of perforation, peritonitis, or abscess formation, broad-spectrum intravenous antibiotics should be given  CHOLECYSTITIS & CHOLELITHIASIS  Patients usually present with abdominal pain in the right upper quadrant or epigastric region.  Serum laboratories may demonstrate an elevation in the white blood cell count and/or elevated liver enzymes.  US of the right upper quadrant of the abdomen is usually diagnostic in these cases. Clinical Findings Gallbladder disease is the second most common surgical disorder during pregnancy. Gallstones are responsible for 90% of cholecystitis Acute cholecystitis occurs in 1 in 1600 to 1 in 10,000 pregnancies It has been estimated that at least 3.5% of pregnant women have gallstones Multiparas are at increased risk of gallbladder disease. Both progesterone and estrogen increase bile lithogenicity; progesterone decreases gallbladder contractility. Symptoms & Signs anorexia, nausea, vomiting, dyspepsia, and intolerance of fatty foods. Biliary tract disease may cause right upper quadrant, epigastric, right scapular, shoulder, and even left upper quadrant or left lower quadrant pain that tends to be episodic. Biliary colic attacks are of acute onset and are triggered by meals, and may last from a few minutes to several hours. Fever, right upper quadrant pain, and tenderness under the liver with deep inspiration (Murphy's sign) are often present in patients with acute cholecystitis. In severe cases, the patient may have mild jaundice or appear septic. Laboratory Findings Elevated white blood cell count , aspartate transaminase (AST) and alanine transaminase (ALT) alkaline phosphatase and bilirubin Elevated lipase and amylase support the diagnosis of an associated pancreatitis Imaging US findings of gallbladder stones; a thickened gallbladder wall, fluid collection around the gallbladder, a dilated common bile duct, or even swelling in the pancreas are suggestive of cholelithiasis and cholecystitis. The diagnostic accuracy of US for detecting gallstones in pregnancy is 95%, making it the diagnostic test of choice. Differential Diagnosis The major diagnostic difficulty imposed by pregnancy is differentiating between cholecystitis and appendicitis Associated pancreatitis maybe present Severe preeclampsia with associated right upper quadrant abdominal pain and abnormal liver function tests; hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome Treatment Removal of the gallbladder and gallstones may be preferred over conservative medical therapy when pancreatitis is concurrent, as it is associated with fetal loss in 3-20% of pregnant patients The initial management of symptomatic cholelithiasis and cholecystitis in pregnancy is nonoperative with bowel rest, intravenous hydration, correction of electrolyte imbalances, and analgesics. Antibiotics are not routinely given, they should be administered if no improvement is seen in 12-24 hours or if systemic symptoms are noted. Surgical intervention is indicated if symptoms fail to improve with medical management, for recurrent episodes of biliary colic, and for complications such as recurrent cholecystitis, choledocholithiasis, and gallstone pancreatitis Because recurrence rates for symptomatic biliary disease during pregnancy may be as high as 60 -92%, active surgical management, especially in the second trimester, has been advocated in recent years.  ACUTE PANCREATITIS  Patients usually present with epigastric pain that may radiate to the back.  Serum amylase and lipase levels are elevated, finding diagnostic of pancreatitis.  US may demonstrate an enlarged pancreas and fluid within the peritoneal cavity Clinical Findings The incidence of acute pancreatitis in pregnancy reportedly ranges from 1 in 1000 to 1 in 5000 deliveries Pancreatitis occurs most frequently in the third trimester and puerperium. The mortality rate associated with acute pancreatitis may be higher during pregnancy because of delayed diagnosis. Many cases of pancreatitis are idiopathic as in the nonpregnant state Cholelithiasis is the most commonly identified cause Symptoms & Signs Gravidas with pancreatitis usually present with severe, steady epigastric pain that often radiates to the back Pain is often exacerbated by food intake. Nausea and vomiting Laboratory Findings The cornerstone of diagnosis is the determination of serum amylase and lipase levels. A laboratory serum amylase level that is more than 2 times above the upper limit of normal suggests pancreatitis. In severe pancreatitis, hypocalcemia develops as calcium is complexed by fatty acids liberated by lipase. lmaging Sonographic examination may demonstrate an enlarged pancreas with a blunted contour, peritoneal or peripancreatic fluid and abscess or pseudocyst formation. Treatment Treatment of acute pancreatitis is aimed at correcting any underlying predisposing factors and treating the pancreatic inflammation. Treatment is primarily medical and supportive, including bowel rest with or without nasogastric suction, intravenous fluid and electrolyte replacement, and parenteral analgesics. Antibiotics are reserved for cases with evidence of an acute infection. In patients with gallstone pancreatiti.s, consideration is given to early cholecystectomy or ERCP after the acute inflammation subsides. Pregnancy does not influence the course of pancreatitis.  PEPTIC ULCER DISEASE  Patients typically present with epigastric discomfort.  Endoscopy is diagnostic of peptic ulcer disease Pathogenesis Pregnancy appears to be protective against the development of gastrointestinal ulcers, as gastric secretion and motility are reduced and 90% of women with known peptic ulcer disease experience significant improvement during pregnancy Infection with Helicobacter pylori is associated with the development of peptic ulcer disease. Signs and symptoms of peptic ulcer disease in pregnancy can be mistakenly dismissed as being a normal part of the gravid state. Dyspepsia is the major symptom of ulcers during gestation Endoscopy is the diagnostic method of choice for these patients if empiric clinical therapy, including lifestyle and diet modifications, antacids, antisecretory agents, and treatment for H pylori when positive, fail to improve symptoms. Perforation, bleeding, and obstruction, have been reported very rarely Other causes of upper gastrointestinal bleeding in pregnancy are reflux esophagitis and Mallory-Weiss tears Treatment Dyspepsia during pregnancy first should be treated with dietary and lifestyle changes, supplemented with antacids or sucralfate. When symptoms persist, Hi- receptor antagonists or, in severe cases, proton pump inhibitors can be used.  ACUTE INTESTINAL OBSTRUCTION  Patients typically present with the classic triad of abdominal pain, vomiting, and obstipation.  The diagnosis is confirmed with abdominal x-ray series. estimated to occur in approximately 1-3 of every 10,000 pregnancies. However, it is the third most common nonobstetric reason for laparotomy during pregnancy (following appendicitis and biliary tract disease). The same classic triad of abdominal pain, vomiting, and obstipation is observed in pregnant and nonpregnant women with intestinal obstruction It occurs most commonly in the third trimester. The most common causes of mechanical obstruction are adhesions (60%) and volvulus (25%), followed by intussusception, hernia, and neoplasm. Late in the course of disease, fever, oliguria, and shock occur as manifestations of massive fluid loss into the bowel, acidosis, and infection. Treatment The management of bowel obstruction in pregnancy is essentially no different from treatment of nonpregnant patients. The cornerstones of therapy are bowel decompression, intravenous hydration, correction of electrolyte imbalances, and timely surgery when indicated. INFLAMMATORY BOWEL DISEASE  Crohn's disease is one subcategory, characterized by insidious onset; episodes of low-grade fever, diarrhea, and right lower quadrant pain  Ulcerative colitis is the other subcategory of inflammatory bowel disease, manifesting with bloody diarrhea, lower abdominal cramps, fecal urgency, anemia, and low serum albumin. It is diagnosed with sigmoidoscopy and only involves the colon. Treatment Initial management includes dietary modifications or bulking agents. Other medications that have been safely used in pregnancy are sulfasalazine, prednisone, 5-aminosalicylates, anti-tumor necrosis factor-a, and occasionally antibiotics. Patients receiving sulfasalazine should be given folate supplementation because sulfasalazine inhibits its absorption.  HEMORRHOIDS  Patients with hemorrhoids typically present with complaints of painless bleeding, prolapse, pain, pruritus, and/or fecal soilage.  Hemorrhoids are visible on physical examination or anoscopy. Pregnancy is the most common cause of symptomatic hemorrhoids. Approximately 9-35% of pregnant and postpartum women suffer from hemorrhoids. Higher incidences of constipation, increased blood volume, and venous congestion secondary to the enlarging uterus contribute to hemorrhoid formation. Patients with hemorrhoids typically present with complaints of painless bleeding, prolapse, pain, pruritus, and/or fecal soilage. Treatment The current management approach to hemorrhoid disease is conservative, with simple outpatient treatment preferred, particularly during pregnancy and the puerperium. Medical therapy with dietary changes, avoidance of excessive straining, fiber supplementation, stool softeners, and hemorrhoidal analgesics often is the only requirement for nonthrombosed hemorrhoids. 6 weeks or longer are needed to perceive improvement.  OVARIAN MASSES  Most ovarian masses during pregnancy present as an incidental finding on routine obstetrical US to evaluate the fetus.  Some women may experience pelvic pain or discomfort due to the mass. The incidental finding of an adnexal mass in pregnancy has become more common with the routine use of ultrasonography The majority of the masses are functional or corpus luteum cysts and spontaneously resolve by 16 weeks' gestation. More than 90% of unilateral, noncomplex masses < 5 cm in diameter. Pathologic ovarian neoplasms tend not to resolve. The most common pathologic ovarian neoplasms during pregnancy are benign cystic teratoma, serous or mucinous cystadenoma, and cystic corpus luteum. Treatment The 3 main reasons for advising surgery for an adnexal mass in pregnancy are the risks of rupture, torsion, and malignancy. If adnexal masses diagnosed in the first trimester require surgery in pregnancy, it is generally advisable to perform the operation via laparotomy or laparoscopy in the second trimester unless signs or symptoms suggestive of torsion or highly aggressive malignancy  TORSION OF THE ADNEXA  Adnexal torsion may be suspected in the woman with an adnexal mass who experiences the sudden onset of pelvic pain, usually severe in nature.  US is useful in confirming the presence of an adnexal mass.  Laparoscopy or laparotomy is diagnostic for confirming the presence of torsion Pathogenesis Torsion of the adnexa can involve the ovary, tube, and ancillary structures, either separately or together. The most common time for occurrence of adnexal torsion is between 6 and 14 weeks and in the immediate puerperium. Symptoms include abdominal pain and tenderness that usually are sudden in onset and result from occlusion of the vascular supply to the twisted organ Shock and peritonitis may occur. Ultrasonography frequently demonstrates an adnexal mass and altered blood flow on Doppler studies. The diagnosis of torsion is ultimately made at surgery. Treatment Prompt operation is necessary to prevent tissue necrosis, preterm labor, and potential perinatal death.  CARCINOMA OF THE OVARY  Symptoms of ovarian cancer are often vague and mimic some of the common symptoms associated w pregnancy.  Certain US findings, although not diagnostic of malign can be suggestive of malignancy.  The diagnosis is confirmed on pathologic examination of surgically excised tissue. Pathogenesis Carcinoma of the ovary occurs in< 0.1% of all gestations and has been encountered in all trimesters Between 1 %and 10% of all ovarian tumors complicating pregnancy are malignant Most malignant neoplasms are germ cell tumors (dysgerminoma, endodermal sinus tumor, malignant teratoma, embryonal carcinoma, and choriocarcinoma) Treatment Solid and complex ovarian tumors with significant solid components discovered during pregnancy generally sho be treated surgically because of the low but significant incidence of cancer (1-10%).  CANCER IN PREGNANCY The incidence of cancer in pregnancy is approximately I in 1000. The most common malignancies diagnosed during pregnancy are cervical cancer (26%), breast cancer (26%), leukemias (15%), lymphomas10% and malignant melanomas (8% ).  CARDIAC DISEASE  Cardiac disease complicates 1-4% of all pregnancies i the United States.  Rheumatic and congenital heart disease constitute the majority of cases. Most available reports on cardiac surgery during pregnan involve closed and open mitral valvuloplasties and mitral aortic valve replacement.  NEUROLOGIC DISEASE  The most common neurosurgical emergency to complicate pregnancy is intracranial hemorrhage.  Symptoms and signs of subarachnoid hemorrhage include headache, nausea and vomiting, stiff neck, photophobia, seizures, and a decreasing level of consciousness. Cerebral aneurysm rupture is responsible for approximately 70% of intracranial hemorrhage; arteriovenous malformations (AVM) cause 25%, and the remaining cases are due to eclampsia, coagulopathy, trauma, and intracranial tumors. Early surgical or endovascular intervention after aneurysmal hemorrhage during pregnancy is associated with reduced maternal and fetal mortality.  TRAUMA  Automobile accidents are the most common nonobstetric cause of death during pregnancy.  The most common cause of fetal death is death of the mother.  Initial treatment focuses on immediate stabilization of the mother followed by evaluation of the fetus. Approximately 7% of pregnancies are complicated by trauma, such as motor vehicle accidents (40%), falls (30%), direct assaults to the maternal abdomen (20%), and other causes (10%). Automobile accidents are the most common nonobstetric cause of death during pregnancy The most common cause of fetal death is death of the mother. The second most common cause of fetal death is placental abruption.