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Surgical Complications of Pregnancy

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Surgical Complications of Pregnancy Dr.Z Allameh MD Symptoms May be asymptomatic 2.5-10% of pregnant patients (Maringhini et al 1987) RUQ Pain most reliable ... – PowerPoint PPT presentation

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Title: Surgical Complications of Pregnancy


1
Surgical Complications of Pregnancy
  • Dr.Z Allameh MD

2
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

3
Non-Obstetric Causes for Surgery
  • Appendicitis
  • Biliary disease
  • Ovarian disorders
  • Breast disease
  • Cervical disease
  • Bowel obstruction

4
Rate of non-obstetric surgery
Rate 1527 pregnancies, 77 surgeries total
5
Appendicitis
  • 12000 to 16000 pregnancies
  • Incidence 0.05
  • Difficult diagnosis??
  • Immediate intervention a must

6
Pathogenesis
  • Appendiceal lumen obstruction
  • Fecaliths
  • Parasites
  • Foreign bodies
  • Lymphoid hyperplasia
  • Metastatic cancer

7
Occurrence
  • Retrospective studies (1990 UCLA, 1995 Good Sam,
    Phoenix)
  • 151 patients
  • No significant change in occurrence between
    trimesters
  • (Tamir 1990, Mourad 2000)

8
Diagnosis
  • Sometimes difficult in Pregnancy!
  • Displaced appendix?
  • Distorted lab values
  • Vague Symptoms
  • Fever? Tachycardia?

9
Appendix Location
  • 1932 Baer described location of appendix during
    pregnancy.
  • Since, most agree there is a shift in location.

10
Appendix location
  • Iran Study 1999
  • 291 patients R.A.
  • 3 groups
  • 165 preg. Elective C/S
  • 26 preg. With Appendicitis
  • 100 N.P. R.A. with Appendicitis
  • No sig difference!!

(H. Hodjati, T. Kazerooi, 2002)
11
Similar Study
  • Year 2000
  • Mourad and associates reported 80 of 45 patients
    studied to have RLQ pain.
  • ..consistent with Study in Iran

12
Symptoms
  • Normal Pregnancy
  • Abdominal tenderness
  • Nausea
  • Vomiting
  • Anorexia
  • Acute Appendicitis
  • Abdominal tenderness
  • Nausea
  • Vomiting
  • Anorexia

13
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)

14
Psoas and Obturator signs. Sensitivity/specifici
ty??
15
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

16
Can we do better than 50?
  • CT Scan
  • Numerous reports in surgical literature
    suggesting accuracy of gt97 in non-pregnant
    patients.

17
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18
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19
CT scanning, cont.
20
CT scan cont.
  • 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).

21
Teratogenicity, cont.
  • 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)

22
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)

23
Risks if untreated
  • Preterm contractions/labor
  • Rupture leading to peritonitis
  • Sepsis
  • Fetal tachycardia
  • Maternal/fetal death

24
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)

25
The mortality of appendicitis complicating
pregnancy is the mortality of delay Babler
1908
26
Treatment
  • Suspicion
  • Immediate surgery
  • Delay
  • Generalized peritonits
  • Antibiotics
  • Perioperative 2nd cephalosporin. May be
    discontinued post-op, minus perforation, gangrene
    or phlegmon

27
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)

28
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)

29
Anesthesia
  • General anesthesia considered safe
  • However
  • Kallen and Mazze 1990
  • Sylvester et al 1994
  • ..both raised questions about potentially
    increased risk of neural tube defects and
    hydrocephaly when general anesthesia is used in
    first trimester

30
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

31
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.

32
ACOG
  • Prophylactic Appendectomy
  • Slight risk associated with procedure.
  • Slight benefit in prophylaxis removal.
  • Should perform in certain groups
  • 10-30 yr. Age group undergoing dx. Lap for pelvic
    pain
  • Mentally handicapped
  • Pts. With multiple adhesions

33
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)

34
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

35
Workup
  • Ultrasound
  • Effective rate 90
  • Liver enzymes
  • Amylase, Lipase
  • CBC

36
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.

37
Mgmt. 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

38
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

39
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

40
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)

41
The Adnexa
  • Estimated 1200 deliveries (adnexal masses)
  • Based on two studies
  • Katz 1993
  • Koonings 1988
  • Est. 11300 adnexal masses require surgery
  • Whitecar 1999

42
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

43
Adnexal Masses cont.
  • 2 additional studies support percentages
  • Sunoo 1990
  • Hopkins 1986
  • 1/3 Teratomas
  • 1/3 Cystadenomas

44
Complications
  • Whitecar study cont..
  • Ovarian Torsion
  • most common and serious sequelae
  • 5 occurrence
  • rupture most common in 1st trimester

45
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

46
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?

47
MRI?
  • 1990 Kier et al
  • Correctly identified 17 of 17 adnexal masses with
    MRI vs. 12 out of 17 with ultrasound

48
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)
49
Trauma
  • Affects approx. 7 of pregnant women
  • Indications for Surgical Exploration
  • Penetrating abdominal injury
  • Clinical evidence of intraperitoneal hemorrhage
  • Suspected Bowel Perforation
  • Suspected injury to uterus or fetus

50
Breast Disease
  • Any suspicious breast mass found during
    pregnancy should prompt an aggressive plan to
    determine its cause, whether by FNA or open
    biopsy.
  • Williams 21st Edition

51
Breast surgery cont
  • Williams 21st edition cont
  • Surgical Treatment should not be delayed.
  • In the absence of metastatic disease, wide
    excision, modified radical mastectomy or total
    mastectomy with axillary node staging can be
    performed.
  • (Issacs 1995, Berry 1999) Risks from these
    procedures are minimal and the incidence of
    abortion is negligible.

52
Bowel Obstruction
  • Est. 117000 deliveries
  • (Meyerson 1995)
  • Increasing secondarily to increased PID
    prevalence and increased surgeries resulting in
    more adhesions

53
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

54
Surgery for Cervical Cancer
  • 2-3 of invasive cervical cancers occur in
    pregnant women
  • Invasive Cancer requiring surgery
  • Many ethical concerns
  • Religious/cultural beliefs
  • Gestational age important
  • ACOG Bulletin
  • Treatment for pregnant patients with invasive
    carcinoma of the cervix should be individualized
    on the basis of evaluation of maternal and fetal
    risks.

55
SUMMARY
  • See Handout

56
References
  • Mourad J Elliott JP Erickson L Lisboa L Am J
    Obstet Gynecol 2000 May182(5)1027-9.
  • Tamir IL Bongard FS Klein SR Am J Surg 1990
    Dec160(6)571-5 discussion 575-6.
  • Cunningham, F.G., McCubbin, Appendicitis
    complicating pregnancy. Obstet Gynecol 1975 Apr
    45(4) 415-20
  • H. Hodjati, T. Kazerooni Departments of
    General Surgery and Obstetrics/Gynecology,
    Shiraz University of Medical Sciences. Shiraz,
    Iran. IJMS Vol 27, No. 2, June 2002
  • United Nations Scientific Committee on the
    Effects of Atomic Radiation, Sources and Effects
    of Ionizing Radiation, UN Publication E.94.IX.2,
    UN Publications, United Nations, New York, 1993

57
Otake M Schull WJ Yoshimaru J Radiat Res
(Tokyo) 1991 Mar32 Suppl249-64. Brent RL SO -
Semin Oncol 1989 Oct16(5)347-68. Lim HK Bae
SH AJR Am J Roentgenol 1992 Sep159(3)539-42.
Mazze and Kallen Am J Obstet Gynecol. 1989
Nov161(5)1178-85 Landers, Carmenn 1987 OB/GYN
1987 Jan 69 (1) 131-3 Ramin KD, Ramin SM,
Richey SD, Cunningham FG Acute pancreatitis in
pregnancy. Am J Obstet Gynecol 173187,
1995 Cunningham, Gant, Leveno, Silstrap, Hauth,
Wenstrom Williams Obstetrics 21st Edition 2001
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