Non-obstetrical Surgical Emergencies in Pregnancy

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Non-obstetrical Surgical Emergencies in Pregnancy

• Steven Stanten MD
• Rupert Horoupian MD

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

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Non-Obstetric Causes for Surgery

• Appendicitis
• Biliary disease
• Ovarian disorders
• Breast disease
• Cervical disease
• Bowel obstruction

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Introduction

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

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Rate of non-obstetric surgery
Rate 1527 pregnancies, 77 surgeries total
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Challenges

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

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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

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Teratogenicity of Irradiation (cont)

• ACR No single diagnostic procedure results in a
  radiation dose that threatens the well being of
  the developing embryo and fetus

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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

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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

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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

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Other Risks

• Pneumoperitoneum
• Animal studies indicate decreased unteroplacental
  blood flow with CO2 pressures gt15mmHg
• Also, some infants developed acidemia
• Barnard et al 1995
• Hunter et al 1995

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Adenexa

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

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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?

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The Adnexa

• Estimated 1200 deliveries (adnexal masses)
• Based on two studies
• Katz 1993
• Koonings 1988
• Est. 11300 adnexal masses require surgery
• Whitecar 1999

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MRI?

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

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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

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Adnexal Masses cont.

• 2 additional studies support percentages
• Sunoo 1990
• Hopkins 1986
• 1/3 Teratomas
• 1/3 Cystadenomas

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Complications

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

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Management

• Multiple Studies
• Thornton 1987
• Whitecar 1999
• Fleischer 1990
• Caspi 2000
• Hess 1988
• Platek 1995
• Parker 1996

• Best Approach
• (lt5cm) Exp. Mgmt
• (5-10cm) Watch unless complex on sonography
• If gt6cm after 16 WGA, operate

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Biliary Tract Disease

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

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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

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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)

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Biliary Tract Disease (cont)

• Treatment
• Symptomatic
• Pain meds
• Nausea meds
• IV fluids
• Surgical consultation

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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

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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.

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Management (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

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Biliary Tract Disease (cont)

• 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

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Biliary Tract Disease (cont)

• Treatment
• Laparoscopic cholecystectomy is feasible during
  pregnancy
• Even in 3rd trimester
• Upper gestational age not defined
• Intra-op fetal minitoring
• Post-op fetal monitoring

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Biliary Tract Disease (cont)

• 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

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Biliary Tract Disease (cont)

• Laparoscopic cholecystectomy
• Less invasive
• Earlier recovery
• Less scarring
• Less hospital costs

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Surgical Management

• 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 gt24 weeks

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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 gt16 weeks gestation
• Open trocar insertion
• Avoid high intra-abdominal pressures

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Open trocar insertion

• The obvious
• Minimize
• Aspiration
• Sedatives GERD and decreased gastric emptying
• Hypoxia
• Hypercarbia
• Hypocapnia
• Hypoxia
• Hypotension
• Aortocaval compression
• Nitrous oxide

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Pancreatitis

• 13000 14000 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)

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Appendicitis

• 12000 to 16000 pregnancies
• Incidence 0.05
• Difficult diagnosis??
• Immediate intervention a must

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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

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Occurrence

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

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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 lt1500 gms 1.7 3.2 1.5 (2.2)
• Birthweight lt2500 gms 1.4 1.8 2.2 (2.0)
• (No increased risk of stillborn or congenital
  malformation)

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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

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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

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Pathogenesis

• Appendiceal lumen obstruction
• Fecaliths
• Parasites
• Foreign bodies
• Lymphoid hyperplasia
• Metastatic cancer
• Carcinoid tumor

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Symptoms

• Normal Pregnancy
• Abdominal tenderness
• Nausea
• Vomiting
• Anorexia

• Acute Appendicitis
• Abdominal tenderness
• Nausea
• Vomiting
• Anorexia

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Symptoms

• Pain
• Anorexia
• Nausea / vomiting
• Pain migration RLQ / RUQ / Flank
• Fever

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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)

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Appendix Location

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

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Physical Examination

• Tenderness RLQ
• Rebound Guarding (peritoneal signs)
• Rovsing sign
• Dunphys sign
• Psoas sign (retroperitoneal retrocecal appendix)
• Obturator sign (pelvic appendix)
• Rectal examination tenderness (cul-de-sac)
• Low grade fever

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Psoas and Obturator signs. Sensitivity/specifici
ty??
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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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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)

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Graded Compression Ultrasound

• Normal appendix lt 6 mm diameter
• Non-pregnant Sensitivity 85
• Specificity 92
• Pregnant cecal displacement uterine
• imposition makes precise examination
• difficult

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Can we do better than 50?

• CT Scan
• Numerous reports in surgical literature
  suggesting accuracy of gt97 in non-pregnant
  patients.

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CT Scan
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CT Scan

• 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).

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Teratogenicity

• 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)

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Risks if untreated

• Preterm contractions/labor
• Rupture leading to peritonitis
• Sepsis
• Fetal tachycardia
• Maternal/fetal death

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Risks (cont)

• Increased Gest age increased complication rate
• Uterine contractions as high as 80 of pts gt24
  WGA
• Appendiceal perforation
• 4-19 non-pregnant patients
• 57 pregnant patients
• (Innability to isolate infection by omentum)
• (Am Sur 2000 Jun 66)

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Diagnostic Problem

• Position of appendix - Normally
• 70 intraperitoneal
• 30 pelvic, retroileal, retrocolic
• Pregnancy anatomical changes
• Gravid uterus - displacement upward outward
• Flank pain (3rd trimester) (Baer,1932)
• Increased separation of peritoneum causes
  decreased perception of somatic pain and
  localization

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Diagnosis

• Pain in RLQ is the most common presenting
• syndrome of appendicitis in pregnancy
  regardless
• of gestational age
• (Am J Obstet Gynecol 2001 Jul185(1)259-60)
• Physical examination is the most reliable tool
  for
• diagnosis (Am Surg 2000 Jun66(6)555-9)
• Fever and WBC are not clear indicators
• (Am J Obstet Gynecol 2001 Jul185(1)259-60

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The mortality of appendicitis complicating
pregnancy is the mortality of delay Babler
1908
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Treatment

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

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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

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Laparoscopy

• Advantage
• Less post-op complication
• Better visualization
• Disadvantage
• Co2 pneumoperitoneum
• Dec. uterine blood flow
• Fetal acidosis
• Premature labor
• Safe especially in 1st half of pregnancy (size
• of gravid uterus)
• Similar perinatal outcomes compared to
• laparotomies (Reedy and colleagues,1997)

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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)

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Incidence During Pregnancy

• Incidence 0.05
• 11000 pregnant women - appendectomy
• 11500 proved appendicitis (Mazze
  Kallen,1991)
• 1st trimester 30 / 22
• 2nd trimester 45 / 27
• 3rd trimester 25 / 50
• (Mourad,2000)

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Complications

• Abortion , Fetal loss 15 (1st trimester)
• Decreased birth weight
• Other surgical complication wound
• infection, atelectasis etc.
• No increased infertility (Viktrup and Hee,1998)
• No congenital malformation
• No stillborn infants

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Appendectomy Review

• 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.

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Acute Appendicitis

• Delay in diagnosis
• Increase in morbidity
• Increase in mortality
• Fetal mortality
• Non-perf 3-5
• Perf as high as 30
• Maternal mortality
• Non-perf 0
• Perf as high as 4

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

• Est. 117000 deliveries
• (Meyerson 1995)
• Increasing secondarily to increased PID
  prevalence and increased surgeries resulting in
  more adhesions

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Bowel Obstruction cont

• 60-70 adhesions
• 15-20 volvulus
• Diagnosis
• Abdominal pain, nausea vomiting
• Abdominal X-ray 38/42 (Perdue 1992)
• Treatment
• Open laparotomy- Prompt
• Maternal mortality 6
• Fetal Mortality 26
• Williams 20th edition

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Diverticular disease

• Very unusual
• Case reports only
• Difficult dx
• -Young patients
• -other causes more likely
• Medical treatment the same
• Surgical treatment the same
• -antibiotics
• -resect and anastamose
• -resect with colostomy

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Conclusions

• Surgical emergencies happen
• Call consultants early
• Delay in diagnosis can cause serious problems
• Better diagnostic modalities available
• Surgical care has improved
• All resulting in improvement in maternal and
  fetal outcome