Surgical Complications of Pregnancy Matthew Voth M.D. WCGME PGY-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 Non-Obstetric Causes for Surgery • • • • • • Appendicitis Biliary disease Ovarian disorders Breast disease Cervical disease Bowel obstruction Rate of non-obstetric surgery 45 40 35 30 25 20 % Cases 15 10 5 0 Adnexal Mass Appendicitis Gallstones Other Rate – 1:527 pregnancies, 77 surgeries total Appendicitis – 1:2000 to 1:6000 pregnancies – Incidence 0.05% – Difficult diagnosis?? – Immediate intervention a must Pathogenesis: • Appendiceal lumen obstruction: – – – – – Fecaliths Parasites Foreign bodies Lymphoid hyperplasia Metastatic cancer Occurrence • Retrospective studies (1990 UCLA, 1995 Good Sam, Phoenix) • 151 patients • No significant change in occurrence between trimesters 40 35 30 25 UCLA G.Sam 20 15 10 5 • (Tamir 1990, Mourad 2000) 0 1st 2nd 3rd Diagnosis • Sometimes difficult in Pregnancy! – – – – Displaced appendix? Distorted lab values Vague Symptoms Fever? Tachycardia? Appendix Location • 1932 Baer described location of appendix during pregnancy. • Since, most agree there is a shift in location. 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) Similar Study • Year 2000 • Mourad and associates reported 80% of 45 patients studied to have RLQ pain. • …..consistent with Study in Iran Symptoms • Normal Pregnancy – – – – Abdominal tenderness Nausea Vomiting Anorexia • Acute Appendicitis – – – – Abdominal tenderness Nausea Vomiting Anorexia Symptoms cont…. • 1975 Study Parkland: 34 pts over 15 years. – Direct abdominal tenderness is rarely absent. – Rebound tenderness 5575% – Rectal tenderness, especially 1st trimester – Anorexia in only 1/3-2/3 pts, vs. almost 100% non pregnant. – (Cunningham 1975) Psoas sign Obturator sign Psoas and Obturator signs. Sensitivity/specificity?? 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 Can we do better than 50%? • CT Scan • Numerous reports in surgical literature suggesting accuracy of >97% in non-pregnant patients. CT scanning, cont…. 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). 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) 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) Risks if untreated • • • • • Preterm contractions/labor Rupture leading to peritonitis Sepsis Fetal tachycardia Maternal/fetal death Risks cont…. • 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) “The mortality of appendicitis complicating pregnancy is the mortality of delay” Babler 1908 Treatment • Suspicion: – Immediate surgery • Delay – Generalized peritonits • Antibiotics – Perioperative 2nd cephalosporin. May be discontinued post-op, minus perforation, gangrene or phlegmon 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) 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) 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 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 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. 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 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) 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 Workup • Ultrasound – Effective rate 90% • Liver enzymes • Amylase, Lipase • CBC 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. 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 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 Surgical Management • Laparascopic approach • Slight increase of low birth weights safe, generally to 3rd trimester • Slight increase of infant death within 7 • Remember M/F Risks days • Increase in contractions, especially >24 weeks 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) 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 Adnexal Masses Cont… 30 • 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 25 20 15 % Mass 10 5 0 C.Ter. S/M Cys C. Luteal Benign Adnexal Masses cont…. • 2 additional studies support percentages: • Sunoo 1990 • Hopkins 1986 – 1/3 Teratomas – 1/3 Cystadenomas Complications • Whitecar study cont.. • Ovarian Torsion – most common and serious sequelae – 5% occurrence – rupture most common in 1st trimester Management • Multiple Studies – – – – – – – 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 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? MRI? • 1990 Kier et al – Correctly identified 17 of 17 adnexal masses with MRI vs. 12 out of 17 with ultrasound Axial SSFSET2Wimage “No single diagnostic procedure results in a radiation dose that threatens the wellbeing 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) 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 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 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.” Bowel Obstruction • Est. 1:17000 deliveries » (Meyerson 1995) • Increasing secondarily to increased PID prevalence and increased surgeries resulting in more adhesions 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 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.” SUMMARY • See Handout References • Mourad J; Elliott JP; Erickson L; Lisboa L Am J Obstet Gynecol 2000 May;182(5):1027-9. • Tamir IL; Bongard FS; Klein SR Am J Surg 1990 Dec;160(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 *Otake M; Schull WJ; Yoshimaru J Radiat Res (Tokyo) 1991 Mar;32 Suppl:249-64. *Brent RL SO - Semin Oncol 1989 Oct;16(5):347-68. *Lim HK; Bae SH AJR Am J Roentgenol 1992 Sep;159(3):53942. *Mazze and Kallen Am J Obstet Gynecol. 1989 Nov;161(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 173:187, 1995 *Cunningham, Gant, Leveno, Silstrap, Hauth, Wenstrom: Williams Obstetrics 21st Edition 2001