The Pregnant Surgical Patient

Approach to Abdominal Pain Initial Management: - H&P: expected date of delivery, presence of pregnancy related complications - Consult obstitrician; use fetal monitor if >24 weeks - Minimize radiation, U/S useful - Spontaneous abortion highest in 1st trimester, optimal: 2nd trimester Urgent Surgical Problems: Trauma: Homicide most common cause of traumatic maternal death When mother survives, abruptio placentae is most common cause of fetal death o Blunt: Pelvic fx: extensive vascular supply, risk of hidden blood loss Increased risk of bladder injury due to displacement by uterus GI injuries uncommon, protected by gravid uterus Direct injury to fetus unusual, protected by abd wall and uterus o Penetrating: more damaging to fetus than mother Mortality lower, shielding effect of uterus and fetus Risk increased in 2nd/3rd trimester uterus moves out of pelvis Ex lap for high-velocity penetrating injuries, low velocity injuries above the pelvis likely visceral injury Severity/frequency of domestic violence in pregnancy o Management: 1st stabilize mother Hypovolemia: masked by increased blood volume and enhanced CO; Need 1.5x normal amount of fluid to counteract expanded intravascular volume; place in left lat decub to displace uterus off IVC Workup: plain films, CT or U/S; open peritoneal lavage; Kleihauer-Betke test for fetal RBCs if Rh-neg mother, give RhoGAM Possible C-section if maternal decompensation doesnt respond to resuscitation Appendicitis: 0.05-0.1% of pregnancies, most common surgical problem Uterus pushes appendix cephalad and posteriorly; RLQ pain most consistent symptom Adler sign: if point of max tenderness shifts medially w/ left lateral positioning=adnexal/uterine Leukocytosis present in pregnancy without infection *ULTRASOUND: no risk to fetus, identifies inflamed appendix; MRI is also safe o Differential Diagnosis: pyelonephritis, ectopic implantation, ovarian torsion/cyst o Management: appendectomy regardless of trimester; risk with rupture is high -- RLQ muscle sparing approach @ max tenderness; lap appy controversial Intestinal Obstruction: most commonly cause by adhesions; suspect in N/V and h/o abd surgery Large bowel obstruction: volvulus, Ogilvie syndrome (colonic pseudo-obstruction) o Management: same as non-pregnant patient; surgery if ischemia/perf/failure to resolve; Large bowel: reduce volvulus with sigmoidoscopy; if fails, operative intervention Pseudo obstruction: bowel rest, lyte replacement, rectal tube; c-scope and gas aspiration Perforated duodenal ulcer: prompt operative intervention, plicate perforation Spontaneous visceral rupture: - Liver: associated with preeclampsia/eclampsia; Older multiparous pt in 3rd trimester - Renal: hydronephrotic kidney - Splenic: splenic artery aneurysm, spont capsular rupture; due to increased blood volume - Esophagus: emesis, xray reveals air in mediastinum; UGI demonstrates site of rupture o Management: volume support, emergency surgery, correct coagulopathy Attempt Medical Management in the Follow Conditions: Biliary tract disease: Gallstones: cholesterol supersaturation and biliary stasis promoted in pregnancy o Elective chole: after delivery; treat now with IV fluids, bowel rest, abx, fetal monitoring o During pregnancy: recurrent colic, choleystitis, choledocholithiasis, pancreatitis; 2nd trimester, laparoscopy safe Pancreatitis: gallstones, hypertrigylceridemia o Tx: IV fluids, NPO, NG tube, analgesia; may need TPN; ERCP and sphincterotomy safe Peptic ulcer disease: symptomatic improvement with pregnancy, estrogen reduces gastric acidity o Tx: symptomatic relief (direct-acting agents), H2 blockers, PPI, H. pylori treatment IBD: flares common in 1st trimester and early postpartum o Tx: steroids + sulfadiazine (cause congenital malformations, benefits outweigh risks)

o Operative indication: toxic megacolon (UC), abscess/fistula/obstruction (Crohns) Physiologic Changes of Pregnancy Respiratory: pulm blood flow, tidal volume, minute ventilation, FRC, O2 consuption, CO2 production - Hyperpnea of pregnancy: caused by progesterone (respiratory stimulant), improved gas exchange w/fetus CV: cardiac output, heart rate; blood volume; in gravid uterus, compression of IVC may CO GI: increased intake; +n/v, GERD (esophagogastric junction tone); gastric empything, slowed transit time GU: GFR l CrCl and BUN; kidneys enlarge. Ureters become dilated Heme: plt production; hypercoagulable state; leukocytosis Periop Considerations in Pregnant Patients - Fetal Monitoring: tocometer for contractions, Doppler for fetal HR, u/s for fetal movement/tone - Radiology: minimize xrays/CT scans; use alternatives when possible: ultrasound and MRI - Anesthesia: risk of aspiration increased, position in left lat decub to minimize hypotension o Anesthesia drugs pose risks to fetus; if pressors needed: ephedrine - Semielective procedures: perform in 2nd trimester - Routine use of tocolytics: not recommended Laparoscopy: risks and benefits SAGES guidelines = safe and effective - ?? Risks of CO2 pneumoperitoneum: uterine blood flow, IVC return, FRC, CO, may cause acidosis - Limit risks: Trendelenburg, left uterine displacement, intra-abd pressures <15mmHg, limit duration - Newest recommendations: safe during any trimester CV Conditions - Types: rheumatic heart disease, congenital heart disease added stress of pregnancy o M&M from dysrhythmia and CHF w/pulmonary edema - Management: counseling before conception, correct prior to pregnancy if possible o Lowest risk to mom in 1st trimester, highest risk to fetus in 1st trimester; delay til deliverable Malignancies - Types: Breast (19%), thyroid (17%), cervical (11%), Hodgkin disease (7%) and ovarian (6%) - Normal treatment surgery, radiation, chemo all risks to feturs - Breast CA: during or up to 1 yr after delivery, poorer prognosis; aspirate mass to r/o cyst, mammo safe o Once diagnosed, modified radical mastectomy; do not delay because of pregnancy Burns -- fetal mortality 89% if mom has >50% TBSA burns; est airway, less able to compensate for hypoxia Minor Surgical Problems of Pregnancy Heartburn decreased LEW pressure; Tx: antacids, positional changes Constipation Tx: increased fiber and roughage, laxative foods, fluid intake; Rx: Metamucil/colace Hemorrhoid 10% of pregnant patients from motility and constiptation; maintain bowel function o Tx: sitz baths, local astringent, supine position, replace hemorrhoids, astringent suppositories Varicose veins worse with successive pregnancies, increased stasis and venous pressure o Tx: increased exercise, elevation of legs, support stockings DVT: increased risk in late stages/early postpartum, clotting factors/fibrinolytic activity, venous stasis o Work up: phlebography, serial impedance plethysmography o Tx; LMWH for duration of pregnancy, postpartum anticoagulation continued for 6 weeks o Prophylaxis: recommended for subsequent pregnancies Round ligament pain: usual cause of groin pain, due to traction, usually on left o Groin hernia extremely uncommon, expanded uterus acts as shield against abd wall o Tx: local heat and abd support