General surgery emergencies in the pregnant patient • Approximately 1 in 500-635 pregnant women will require non-obstectric General surgery emergencies in the abdominal surgery during their pregnant patient pregnancies • Appendicitis and trauma are among the more common indications Postgraduate Course in General Surgery Jessica E. Gosnell MD Colemen et al, Am J Obstet Gynecol, 1997 March 25, 2013 Kammemer et al, Med Clin North Am, 1979 SAGES guidelines, 2008 General surgery emergencies in the The physiologic changes of pregnancy pregnant patient can make diagnosis more difficult CV: “ physiologic anemia of pregnancy ” • • What is appropriate imaging? • RESP: Increase in minute • When is fetal monitoring needed? ventilation, airway edema • When do I call OB? • GU: dilated urinary collecting system • When do I call Peds? • ID: relative leukocytosis • How safe is a general anesthetic? (10-20K) • Is laparoscopic surgery or open better? • GI: decreased transit time, anorexia, nausea, vomiting 1
The Anatomic changes of Pregnancy Physical exam during pregnancy • Findings may be less prominent • Peritoneal signs can be decreased/absent due to More horizontal stomach lifting, stretching of the anterior abdominal wall Transverse colon pushed up • Fetus – Independent fetal viability? (About 20-24 wks) Small intestines • No: documentation of presence or absence of fetal Displaced in upper heart tones quadrants • Yes: more thorough evaluation by OB is required. Monitor fetal heart rate and uterine tone continuously Ascending and descending Colon pushed towards flanks General Surgery emergencies during Laboratory studies Pregnancy • • Recall that many commonly used lab tests have altered Appendicitis reference ranges during pregnancy • Trauma • Cholecystitis • Bowel obstruction • Pancreatitis Taylor and Perry, Acute abdomen and Pregnancy, emedicine 2009 2
Acute appendicitis during Acute appendicitis during Pregnancy Pregnancy • Most common non-obstetric cause of acute - Appy Author Year N Incid Perf Fetal mort abdomen Mazze et al 1991 778 1:936 36% 6% 1.8% • 1:500 to 1:2000 pregnancies • Same incidence as that in non-pregnant Uebernueck et 2004 94 1:499 23% 15% 7% al women Tamir et al 1990 84 - 18% 27% 5.9% • Occurs in all trimesters • Lower fetal mortality rates when diagnosed and Anderson et al 1999 56 1:766 25% - 7.1% treated within 24hrs Ohta, JCEM 2001 Mazze, Obstet Gynecol 1991 Acute appendicitis during Pregnancy • Displacement of the appendix by gravid uterus • Altered location of the somatic component • Variable cecal fixation 3 rd month 6 th month 8 th month (Baer, JAMA 1932) (Baer, JAMA 1932) 3
Ultrasound - Appendix Computed Tomography Normal - thin wall Increased blood flow Appendicitis Radiation exposure during MRI pregnancy Tetratogenic vs. Carcinogenic Gray(Gy): A SI unit of absorbed dose One Gy=100rads. One mGy=1/1000Gy (Birchard, Am J Roet 2005) 4
Recognized teratogenetic effects Threshold for teratogenesis • Microcephaly, microphthalmia • Estimated threshold dose: 5 -15 rad • Mental retardation, behavioral defects • Dose from standard pelvic CT: 5 -10 rad • Growth retardation • No detected increase in human studies • Cataracts AJR 1996; 167: 1377-1379 Radiology 1986; 159: 787-792 Exposure of the pregnant patient to diagnostic radiations: a Br J Radiol 1987; 60: 17-31 guide to medical management. Lippincott 1985; 19-223 Radiation exposure during Pregnancy Carcinogenesis Endpoint Risk Baseline risk of childhood cancer (0-15 yrs) 19/10,000 Excess risk per rad of fetal whole body dose 4.6-6.4/10,000 Relative risk of childhood cancer after 5 rad 2 UNSCEAR 1972 Report to the UN General Assembly National Radiological Protection Board, 1993: 15-157 Thrombosis and Haemostasis 1989; 61: 189-196 Centers for Disease Control, March 23, 2005 5
Radiation exposure during MRI safety pregnancy • Good indication: Benefit >> risk • CT and pregnancy: • MRI >> ionizing radiation – Teratogenesis unlikely at diagnostic doses • Avoid first trimester studies if possible, avoid – Carcinogenesis is a real risk gadolinium – “ Safety of MRI not established for the fetus ” • MRI and pregnancy: • FDA guidelines: – No proven risk, but avoid first trimester studies – MRI < 0.4 W / kg – MRI has several useful obstetric applications • Contrast and pregnancy: • Availability after hours?? – Iodinated contrast is (probably) safe – Gadolinium is (relatively) contraindicated Trauma during Trauma during Pregnancy Pregnancy • Leading non-obstetric cause of maternal death • Thorough assessment and resuscitation of the mother • Most common cause are motor vehicle accidents, followed by violence/assaults, and falls • Maintenance of uretoplacental perfusion and fetal oxygenation (avoidance of hypoxima, acidosis, • Blunt trauma (84%) associated with placental hypothermia, hypotension) abruption • Clear understanding/documentation of gestational • Penetrating trauma (16%) may cause direct fetal age and fetal viability, with fetal monitoring after injury viable • Even mild trauma may result in an increase in long- • Imaging as necessary term adverse events (preterm labor, small for gestational age • Awareness of fetomateral hemorrhage and need for Rh immune globulin (Mediana 2006;42(7):586) (Mediana 2006;42(7):586) 6
Acute cholecystitis during Pregnancy • 2nd most common non-obstetric cause of acute • Retrospective study, 1992-2002 abdomen • 1:1600 to 1:10,000 pregnancies • UCSF, Stanford initially tx ’ ’ ’ d with IVF, bowel rest, narcotics, Abx ’ • Same incidence as that in non-pregnant women • 76 patients with symptomatic cholelithiasis: all • Occurs in all trimesters • High recurrence rate for complications of cholelithiasis where appropriate with medical management – 53 treated medically – 10 underwent surgery (refractory pain, worsening clinical status, or those in 2nd trimester) (Kammerer, Med Clin North Am 1979) (Am J Surg, 2004) Bowel obstruction during Acute cholecystitis in Pregnancy Pregnancy • 3rd most common non-obstetric cause of acute abdomen • 1:1600 to 1:16,000 pregnancies • Same incidence as that in non-pregnant women • Occurs in all trimesters (Ballantyne, Am Surg 1985) (Am J Surg, 2004) 7
Bowel obstruction during Acute pancreatitis during Pregnancy Pregnancy • Adhesions-60-70% • 1 in 1000-3000 pregnancies • Volvulus – • Caused most commonly by gallstones (67-100%), EtOH, approaches 25% hyperlipidemia – Sigmoid • Associated with a high rate of fetal mortality (up to 37%) – Cecal • Can occur in all trimesters, but most common in 3rd • Intussusception, hernia, cancer rare Beware of diagnosis of hyperemesis gravidarum in pts in their 2 nd and 3 rd trimester, (Ramin et al, Am J Obstet Gynecol 1995) who have had prior abdominal surgery Is general anesthesia safe during Other causes of abdominal pain during pregnancy? pregnancy Non-obstetric obstetric • Maternal death rate low, comparable to that of the non-pregnant patient • Pyelonephritis • Preterm labor • Studies of babies of over 10 thousand pregnant • Urinary calculi • Abruptio placenta women suggest birth defect rate of 2-3.9% after GA, • Gastroenteritis • Chorioamnionitis also comparable to that of non-pregnant women • Acute mesenteric adenitis • Adnexal torsion • Chance of miscarriage or fetal death 5.8% over all • Acute mesenteric ischemia • Ectopic/heterotopic pregnancy trimesters, 10.5% in the first trimester (much higher) necrosis • Pelvic inflammatory disease • Rate of premature labor 8.3% • Rectus hematoma • Meckel ’ ’ ’ s diverticulum ’ • Round ligament pain • Perforated duodenal ulcer • Uteroovarian vein rupture • Myomatous red degeneration • Tuberculosis peritonitis • Uterine rupture • Pneumonia • Rupture of uterine AVM • Acute intermittent porphyria Cohen-Keren 2005, Duncan 1986)) 8
Is laparoscopic surgery safe during Laparoscopic surgery during pregnancy: pregnancy? theoretical concerns • Trocar injury • CO2 pneumoperitoneum – fetal acidosis – decreased uterine blood flow (Rizzo, JLAST 2003) Guidelines for laparoscopic surgery during pregnancy Laparoscopic port placement • Obtain abdominal access with an “ “ “ “ open technique ” ” ” ” • Protect uterus with lead shield if IOC is a possibility • Shift the uterus off the inferior vena cava • Minimize pneumoperitoneum pressures to 8-12mm Hg www.sages.org Society of American Gastrointestinal and Endoscopic Surgeons, rev 2008 (Gurbuz et al. Surg Endosc 1997) 9
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