1. Non-obstetrical Surgical Emergencies in Pregnancy
Steven Stanten MD
Rupert Horoupian MD

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

3. 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

4. Non-Obstetric Causes for Surgery
Appendicitis
Biliary disease
Ovarian disorders
Breast disease
Cervical disease
Bowel obstruction

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

6. Rate of non-obstetric surgery
Rate – 1:527 pregnancies, 77 surgeries total

7. Challenges Physiologic changes Diagnostic imaging limitations
Anesthesia issues
Delay in diagnosis
Communication
Fetal issues
Maternal issues

8. 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

9. Teratogenicity of Irradiation (con’t)
ACR – No single diagnostic procedure results in a radiation dose that threatens the well being of the developing embryo and fetus

10. 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

11. 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

12. 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

13. Other Risks Pneumoperitoneum
Animal studies indicate decreased unteroplacental blood flow with CO2 pressures >15mmHg
Also, some infants developed acidemia
Barnard et al 1995
Hunter et al 1995

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

15. 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?

16. The Adnexa Estimated 1:200 deliveries (adnexal masses)
Based on two studies
Katz 1993
Koonings 1988
Est. 1:1300 adnexal masses require surgery
Whitecar 1999

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

18. Adnexal Masses Cont… 1990 Study Whitecar 1990 30% cystic teratomas
130 pregnancies
5% malignant rate
½ Serous Carcinomas of low malignant potential
30% cystic teratomas
28% serous/mucinous cystadenomas
13% corpus luteal
7% benign

19. Adnexal Masses cont…. 2 additional studies support percentages:
Sunoo 1990
Hopkins 1986
1/3 Teratomas
1/3 Cystadenomas

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

21. Management Multiple Studies Best Approach: Thornton 1987 Whitecar 1999
Fleischer 1990
Caspi 2000
Hess 1988
Platek 1995
Parker 1996
Best Approach:
(<5cm) Exp. Mgmt
(5-10cm) Watch unless complex on sonography
If >6cm after 16 WGA, operate

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

23. Symptoms May be asymptomatic RUQ Pain – most reliable symptom
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

24. 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
/1000 pregnancies require surgery
(Landers eta ak 1987)

25. Biliary Tract Disease (con’t)
Treatment
Symptomatic
Pain meds
Nausea meds
IV fluids
Surgical consultation

26. 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

27. 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.

28. Management (con’t) Davis et al 2000 77 cases
Primary surgical management
Reported better outcomes with surgical management
Less risk to fetus if performed in 2nd trimester

29. Biliary Tract Disease (con’t)
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

30. Biliary Tract Disease (con’t)
Treatment
Laparoscopic cholecystectomy is feasible during pregnancy
Even in 3rd trimester
Upper gestational age not defined
Intra-op fetal minitoring
Post-op fetal monitoring

31. Biliary Tract Disease (con’t)
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

32. Biliary Tract Disease (con’t)
Laparoscopic cholecystectomy
Less invasive
Earlier recovery
Less scarring
Less hospital costs

33. 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 >24 weeks

34. 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 >16 weeks gestation
Open trocar insertion
Avoid high intra-abdominal pressures

35. Open trocar insertion The obvious Minimize Aspiration
Sedatives – GERD and decreased gastric emptying
Hypoxia
Hypercarbia
Hypocapnia
Hypotension
Aortocaval compression
Nitrous oxide

36. Pancreatitis 1:3000 – 1:4000 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)

37. Appendicitis 1:2000 to 1:6000 pregnancies Incidence 0.05%
Difficult diagnosis??
Immediate intervention a must

38. 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

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

40. 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 <1500 gms 1.7 – 3.2 – 1.5 (2.2)
Birthweight <2500 gms 1.4 – 1.8 – 2.2 – (2.0)
(No increased risk of stillborn or congenital malformation)

41. 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

42. 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

43. Pathogenesis: Appendiceal lumen obstruction: Fecaliths Parasites
Foreign bodies
Lymphoid hyperplasia
Metastatic cancer
Carcinoid tumor

44. Symptoms Normal Pregnancy Acute Appendicitis Abdominal tenderness
Nausea
Vomiting
Anorexia
Acute Appendicitis
Abdominal tenderness
Nausea
Vomiting
Anorexia

45. Symptoms Pain Anorexia Nausea / vomiting
Pain migration – RLQ / RUQ / Flank
Fever

46. 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)

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

48. Physical Examination Tenderness – RLQ
Rebound & Guarding (peritoneal signs)
Rovsing sign
Dunphy’s sign
Psoas sign (retroperitoneal retrocecal appendix)
Obturator sign (pelvic appendix)
Rectal examination tenderness (cul-de-sac)
Low grade fever

49. Psoas and Obturator signs. Sensitivity/specificity??

50. Lab Values WBC often as high as 15,000/mm3 in normal pregnancy.
Bailey et. Al
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

51. 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)

52. Graded Compression Ultrasound
Normal appendix: < 6 mm diameter
Non-pregnant: Sensitivity 85%
Specificity 92%
Pregnant: cecal displacement & uterine
imposition makes precise examination
difficult

53. Can we do better than 50%? CT Scan
Numerous reports in surgical literature suggesting accuracy of >97% in non-pregnant patients.

54. CT Scan

55. 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 weeks).

56. 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
% have genetic malformations
4% IUGR
8-10% late onset genetic abnormalities (
(Brent RL 1989)

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

58. Risks (con’t) Increased Gest age = increased complication rate
Uterine contractions – as high as 80% of pts >24 WGA
Appendiceal perforation
4-19% non-pregnant patients
57% pregnant patients
(Innability to isolate infection by omentum)
(Am Sur 2000 Jun: 66)

59. 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

60. Diagnosis “Pain in RLQ is the most common presenting
syndrome of appendicitis in pregnancy regardless
of gestational age “
(Am J Obstet Gynecol 2001 Jul;185(1):259-60)
“Physical examination is the most reliable tool for
diagnosis” (Am Surg 2000 Jun;66(6):555-9)
“Fever and WBC are not clear indicators”
(Am J Obstet Gynecol 2001 Jul;185(1):259-60

61. “The mortality of appendicitis complicating pregnancy is the mortality of delay” Babler 1908

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

63. 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

64. 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)

65. Laparoscopy Safe – especially in the first 20 weeks Risks:
(Reedy et al. 1997)
Risks:
Low birth weight infants
Preterm labor
Fetal growth restriction
(no diff. Vs. laparotomy)
(Mazze and Kallen 1989)

66. Incidence During Pregnancy
1:1000 pregnant women - appendectomy
1:1500 proved appendicitis (Mazze & Kallen,1991)
1st trimester – 30% / 22%
2nd trimester – 45% / 27%
3rd trimester – 25% / 50%
(Mourad,2000)

67. 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

68. 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.

69. Acute Appendicitis Delay in diagnosis Fetal mortality
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%

70. “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)

71. Bowel Obstruction Est. 1:17000 deliveries
(Meyerson 1995)
Increasing secondarily to increased PID prevalence and increased surgeries resulting in more adhesions

72. 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

73. 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

74. 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