www.downstatesurgery.org Irina Kovatch, MD SUNY Downstate Morbidity and Mortality
www.downstatesurgery.org Irina Kovatch, MD SUNY Downstate Morbidity and Mortality March 15, 2012 www.downstatesurgery.org Case Presentation 36yo F at 37 wks of gestation c/o 4d hx of right sided abd pain, N/V, anorexia Seen in ED 3 days prior with similar complains and sent home on zofran/pepcid for gastroenteritis PMH: G1P0, gestational DM PSH: none Meds: humulin qhs, zofran, pepcid NKDA www.downstatesurgery.org Case Presentation AFVSS PE: no distress abd gravid, right sided tenderness, no rebound, no guarding Labs: WBC - 18.9, T.B. - 1.9 US: 6mm tubular structure in RLQ - may represent appendix GB sludge, no evidence of acute cholecystitis, CBD 2mm MRI Air and fluid containing density noted inferior to the cecum www.downstatesurgery.org www.downstatesurgery.org Hospital Course Admitted to L&D OB evaluation NPO/IVF/IV Abx OR 2/8/12 epidural anesthesia ex-lap, washout of contained perforated appendicitis, placement of 2 JP drains preop and postop fetal monitoring – wnl www.downstatesurgery.org Hospital Course 2/9/12 WBC 21 fetal distress (category III fetal heart tracing) Emergency c-section under GETA placental abruption hemorrhagic amniotic fluid EBL - 2L Intraop surgical re-evaluation abd washout and repositioning of the drains www.downstatesurgery.org Hospital Course POD 1-4 Ileus WBC decreased to 15 JP – purulent output www.downstatesurgery.org CT Abd/Pelvis Abscess in RLQ 7.1x5.4 cm www.downstatesurgery.org Hospital Course POD 6 IR drainage of abscess (60cc, 12 Fr pigtail) Diet POD 7-12 JPs – minimal output IR drain – 50cc/day of purulent fluid www.downstatesurgery.org Repeat CT Abd/Pelvis collection resolved www.downstatesurgery.org POD 22 - Drain Study no abscess, output: 8-25 cc/day www.downstatesurgery.org Neonate Admitted to NICU in critical condition APGAR: 5 (1min), 8 (5min) Weight - 3505 gm Labs: WBC - 25.7, Creat - 1.7, pH - 7.0, BE: -11.9 Treatment CPAP x 2 days IV Abx NPO x 3 days IV D10 (FS 30-60) www.downstatesurgery.org Neonate Sepsis Hypoglycemia Poor Moro reflex Brain ischemia and petechial hemorrhage on MRI Cortical thumbs bilaterally Left shoulder distocia and left Erb’s Palsy Large PDA with L -> R shunt and right atrial enlargement Posterior thorax hemangioma www.downstatesurgery.org Questions www.downstatesurgery.org Pregnant women and non-obstetric surgery Elective nonobstetric surgery is avoided because of additional risks to the mother and the fetus Surgical procedures are necessary in ~0.75% Advances in diagnostic modalities have improved the clinician's ability to diagnose surgical conditions Reduced need for exploratory surgery Reduced risks associated with delayed diagnosis of disorders requiring surgical intervention Diagnostic modalities: CT, MRI, US and Doppler www.downstatesurgery.org Indications for Nonobstetric Conditions Requiring Surgery During Pregnancy www.downstatesurgery.org Physiological Changes Related to Pregnancy Cardiovascular and hemodynamic Hematologic Endocrine and metabolic Respiratory tract Gastrointestinal tract www.downstatesurgery.org Cardiovascular and Hemodynamic Expansion of the plasma volume and an increase in RBC mass begin at week 4 of pregnancy and peak at 28-34 weeks Plasma volume expansion exceeds the increase in red cell volume, leading to "physiologic anemia“ Major hemodynamic changes include increase in cardiac output reductions in SVR and systemic BP Changes in coagulation factors produce a hypercoagulable state www.downstatesurgery.org Hematologic Major hematologic changes include Physiologic anemia Neutrophilia Mild thrombocytopenia Increased procoagulant factors, and diminished fibrinolysis WBC begins to increase in the 2nd month of pregnancy and plateaus in the 2nd or 3rd trimester (9000 - 15,000 cells/microL) www.downstatesurgery.org Endocrine and Metabolic Endocrine adaptations begin just after conception evolve through delivery revert back to the nonpregnant state over several weeks virtually all endocrine glands are affected Placental hormones have major affect on glucose and lipid metabolism to ensure that the fetus has an ample supply of fuel and nutrients at all times www.downstatesurgery.org Respiratory Tract Hormonal changes associated with pregnancy and the mechanical effect of the gravid uterus elevate the diaphragm and increase the thoracic diameter Pregnancy is a state of relative hyperventilation centrally mediated through progesterone respiratory rate does not change, but tidal volume increases resulting in a 50% increase in MV PaO2 increases and PaCO2 decreases during pregnancy www.downstatesurgery.org Gastrointestinal Tract Higher incidence of GERD and gastric aspiration increased intra-abdominal pressure relaxation of the lower esophageal sphincter Gallbladder volume and the lithogenicity of bile are increased Serum alk phos levels are significantly increased, amylase levels may be normal or slightly elevated Abdominal bloating and constipation are probably caused by hormonal changes that reduce small bowel and colonic motility www.downstatesurgery.org Surgical Issues Potential concerns of anesthesia and surgery include teratogenesis miscarriage hemorrhage resulting in hypotension and/or transfusion infection aspiration untoward reactions to anesthetic agents preterm labor/delivery risks and complications associated with specific surgical procedures www.downstatesurgery.org Surgical Issues Physician and patient need to weigh the risks of surgery and anesthesia on the developing fetus against the maternal and fetal risks of delaying surgical intervention There are no randomized trials evaluating management of nonobstetrical surgery in pregnant patients - all recommendations are made based on data from observational studies, expert opinion, and extrapolation from trials in nonpregnant individuals www.downstatesurgery.org Surgical Issues Whenever a pregnant woman undergoes nonobstetrical surgery, consultations among her obstetrical provider, surgeon, anesthesiologist, and neonatologist are important Personnel and the capacity to perform an emergent cesarean delivery should be readily available if fetus has attained a viable gestational age www.downstatesurgery.org Thromboprophylaxis Pregnancy is a hypercoagulable state It protects against excessive blood loss at delivery, but also increases the risk of a thromboembolic event in the postsurgical period SCDs should be used in all pregnant women undergoing surgery The need for pharmacologic thromboprophylaxis should be determined on a case-by-case basis scope and length of the procedure additional risk factors for venous thrombosis www.downstatesurgery.org Antibiotic Prophylaxis The need for antibiotic prophylaxis depends on the specific procedure Antibiotics with a good safety profile in pregnant women include Cephalosporins Penicillins Erythromycin, azithromycin and clindamycin Aminoglycosides are relatively safe, but carry a risk of fetal (and maternal) ototoxicity and nephrotoxicity www.downstatesurgery.org Antibiotic Prophylaxis Doxycycline is avoided during pregnancy because other tetracyclines have been associated with transient suppression of bone growth and with staining of developing teeth Trimethoprim and nitrofurantoin are avoided in the 1st trimester because of a potential for increased incidence of congenital malformations Fluoroquinolones are avoided during pregnancy and lactation because they are toxic to developing cartilage in experimental animal studies www.downstatesurgery.org Timing of Nonobstetric Surgical Intervention A literature review of studies reported 10.5% of patients in the 1st trimester miscarried (compared to 8-16% baseline), but there were few details about these patients and no control group Some studies have reported higher rates of miscarriage in 1st trimester abdominal surgery, but it is not clear whether these higher rates were due to the surgery itself, the underlying maternal condition prompting the surgery, or other factors www.downstatesurgery.org Timing Non-urgent surgery should be delayed, if possible, until the early to mid 2nd trimester to avoid use of potentially harmful drugs during organogenesis In the early 2nd trimester the uterus is still small enough to not obliterate the operative field, and the rate of spontaneous preterm labor is much lower when compared to the 3rd trimester (1 and 9%, respectively) www.downstatesurgery.org Prophylactic Glucocorticoids If gestational age is 24-34 weeks, giving a course glucocorticoids prior to surgery may reduce perinatal morbidity/mortality if preterm birth occurs Decision depends on the estimate of whether the patient is at increased risk of preterm birth Despite the potential benefits to the fetus, antenatal corticosteroids are best avoided in the setting of systemic infection because they impair the ability of the maternal immune system to contain the infection www.downstatesurgery.org Prophylactic Tocolytics There is no proven benefit to routine administration of prophylactic perioperative tocolytic therapy Tocolytics are indicated for treatment of preterm labor until resolution of the underlying, selflimited condition that may have caused the contractions Minimizing uterine manipulation may reduce the risk of development of uterine contractions and preterm labor www.downstatesurgery.org Surgical Approach Laparoscopic surgery offers the same advantages as to the nonpregnant woman and can be performed safely during pregnancy The surgical approach should be based on the skills of the surgeon and the availability of the appropriate staff and equipment During laparotomy, the type of incision depends on the surgical procedure and gestational age a vertical midline incision is recommended as gestation advances to facilitate exposure and to allow for extension of the incision www.downstatesurgery.org Fetal Heart Rate Monitoring Maternal hemodynamic stability does not guarantee that placental perfusion and fetal oxygenation are optimal The fetal heart rate should be documented pre- and post-operatively at all gestational ages Continuous monitoring is recommended for all viable fetuses (>23-24 weeks) throughout surgery by using an electronic fetal heart rate monitor by Doppler ultrasound for abdominal operations, transvaginal ultrasound may be used www.downstatesurgery.org Fetal Heart Rate Monitoring If adequate maternal oxygenation and uterine perfusion are maintained, the fetus usually tolerates surgery and anesthesia well Qualified personnel should be available to monitor and interpret the fetal heart rate An obstetrician should be readily available in case an emergency cesarean delivery is indicated The fetal heart rate should be monitored in the recovery room, intermittently for pre-viable fetuses, and continuously for the viable fetus www.downstatesurgery.org Delivery Cesarean delivery is performed for standard obstetrical indications; the presence of a recent abdominal incision does not preclude pushing in the second stage of labor www.downstatesurgery.org Anesthesia Risks - GETA Difficult and failed intubation – 8x Desaturation – 3x Aspiration Hemodynamic instability Increased risk of anesthesia-related maternal mortality Newborn effects - all anesthetic induction and maintenance agents cross the placenta neonate may require intubation www.downstatesurgery.org Anesthesia Risks - Regional Has a better safety profile for the mother than GETA and is preferred for surgery during pregnancy The major concern is maternal hypotension which may reduce placental perfusion However, most pregnant women undergoing surgery for nonobstetric conditions will need either laparoscopy or urgent explorative laparotomy requiring GETA GETA has a 17-fold higher complication rate than regional anesthesia www.downstatesurgery.org Acute Appendicitis Most common general surgical problem encountered during pregnancy Incidence: 0.06 - 0.1% or 1 in 1500 deliveries Pregnant women appear to be less likely to have appendicitis than age-matched nonpregnant women www.downstatesurgery.org Clinical Manifestations Similar to those in nonpregnant individuals Slightly higher rate of appendicitis in the 2nd trimester More likely to rupture during pregnancy, possibly due to delay in diagnosis and intervention RLQ pain is the most common symptom Although the location of the appendix migrates a few centimeters cephalad with the enlarging uterus, most commonly pain occurs close to McBurney's point regardless of the stage of pregnancy www.downstatesurgery.org Differential Diagnosis Includes the causes of abdominal pain in nonpregnant individuals and pregnancy-related causes of abdominal pain Leukocytosis can be a normal finding In appendicitis, nausea and vomiting, if they occur, follow the onset of pain Peritoneal findings may be less prominent because gravid uterus keeps the anterior abdominal wall (and omentum) away from the inflamed appendix www.downstatesurgery.org Imaging - US Initial imaging modality of choice Sensitivity – 86%, specificity 81% Allows for visualization of the pelvic organs and can be used to exclude other causes of RLQ pain Noncompressible blind ended tubular structure in the RLQ with a maximal diameter >6 mm The gravid uterus can interfere with performance of this technique, esp. in the 3rd trimester, leading to a high negative laparotomy rate when ultrasound results are inconclusive www.downstatesurgery.org Imaging - MRI Can be useful in cases where ultrasound examination is inconclusive Sensitivity – 91%, specificity – 98% Offers an alternative to CT and avoids exposure to ionizing radiation If there is going to be a prolonged wait before an MRI can be performed, the increasing risk of rupture over time should be considered www.downstatesurgery.org Imaging - CT Modifications to the CT protocol can limit estimated fetal radiation exposure to less than 3 mGy (vs. standard abdominal CT of 20 - 40 mGy) and do not limit diagnostic performance Doses known to potentially cause adverse fetal effects 30 mGy for risk of carcinogenesis 50 mGy for deterministic effects CT should be used when clinical findings and ultrasound are inconclusive and MRI is not available www.downstatesurgery.org Management Approach Decision to proceed to surgery is based on diagnostic imaging and clinical judgment Delaying intervention >24 hours increases the risk of perforation (14–43%) Risk of fetal loss is higher if appendix had perforated (36 vs. 1.5%) if peritonitis/peritoneal abscess (fetal loss: 6 vs. 2%, early delivery: 11 vs. 4%) Higher negative laparotomy rate (20 – 35%) is considered acceptable www.downstatesurgery.org Outcome Maternal morbidity following appendectomy is comparable to nonpregnant women unless the appendix has perforated Pregnancy related complications are frequent surgery in the 1st trimester - spontaneous abortion 33% surgery in the 2nd trimester - premature delivery 14% Cesarean delivery is rarely indicated at the time of appendectomy Scant information on long-term outcome in offspring www.downstatesurgery.org Perforated Appendix Urgent laparotomy is necessary with appendectomy and irrigation and drainage of the peritoneal cavity Nonpregnant patients presenting with contained perforation may benefit from non-operative approach immediate surgery associated with increased morbidity - e.g. postoperative abscess, enterocutaneous fistula Very limited evidence to support this approach in pregnant women www.downstatesurgery.org Surgical Approach If diagnosis is certain - transverse incision over the point of maximal tenderness If diagnosis is less certain - lower midline vertical incision permits adequate exposure of the abdomen for diagnosis and treatment of other surgical conditions can also be used for a cesarean delivery, if necessary Several case reports and small case series on the use of laparoscopic appendectomy in pregnancy suggested that it can be performed successfully during all trimesters and with few complications www.downstatesurgery.org Laparoscopic Approach Long-term data on the safety and efficacy are limited One systematic review noted a higher rate of fetal loss Decision should take into consideration skill and experience of the surgeon clinical factors such as the size of the gravid uterus Modification of the technique during pregnancy slight left lateral positioning during the second half of pregnancy open entry techniques limiting intra-abdominal pressure to <12 mmHg www.downstatesurgery.org Gallstone Disease Acute cholecystitis is the 2nd most common nonobstetrical surgical emergency Pregnancy increases the risk for gallstones by decreasing gallbladder motility and increasing cholesterol saturation of bile Presentation of gallstone disease is similar to that in the nongestational state www.downstatesurgery.org Diagnosis WBC and alk phos level are normally elevated in pregnancy - reduces the diagnostic usefulness of these tests Significant elevations of the transaminases, alk phos or D. bili raises suspicion for CBD , cholangitis, or the Mirizzi syndrome US offers the most reliable method for making the diagnosis of gallstones and acute or chronic cholecystitis www.downstatesurgery.org Management Supportive care for 1st episode of biliary colic Cholecystectomy for patients with recurrent biliary attacks Surgery is safest and easier to perform in the 2nd or early 3rd trimester, and is technically difficult near term Nonsurgical interventions (e.g. ursodeoxycholic acid) are contraindicated in pregnant women www.downstatesurgery.org Surgery Acute cholecystitis should be treated with cholecystectomy during the initial hospitalization decreases relapse rates and hospital readmissions Definitive surgical therapy is required for any patient with signs of sepsis when gangrene or perforation is suspected if patient develops progressive fever or intractable pain www.downstatesurgery.org Laparoscopic Approach Should be used to perform cholecystectomy when feasible and available better surgical exposure earlier recovery and reduced postoperative pain fewer wound complications Convert to open technique to avoid injury to surrounding structures if laparoscopic procedure cannot be safely and/or effectively completed www.downstatesurgery.org Complicated Biliary Disease Patients with choledocholithiasis, cholangitis, or biliary pancreatitis require intravenous fluids antibiotics analgesia bowel rest followed by prompt intervention with ERCP and/or surgery www.downstatesurgery.org Bowel Obstruction Third most common non-obstetrical complication most common cause - intraabdominal adhesions (previous surgery or pelvic infection) intussusception and volvulus (5 and 25% respectively) More likely to happen with advancing gestation Diagnosis and treatment are similar to that in nonpregnant individuals Delay in treatment increases maternal and fetal morbidity and mortality www.downstatesurgery.org Breast Cancer Pregnancy-associated breast cancer is relatively uncommon Incidence is increasing as more women delay childbearing Predominantly poorly differentiated and diagnosed at an advanced stage Breast US and mammography should be used to evaluate any suspicious breast masses www.downstatesurgery.org Treatment Clinically suspicious breast mass requires biopsy for definitive diagnosis regardless of whether or not a woman is pregnant despite negative mammographic or ultrasound findings Locally advanced stage disease [stage III or IV] and/or suspicious symptoms should prompt a complete radiographic staging evaluation Modifications of the standard staging work-up may be required to protect the fetus www.downstatesurgery.org Trauma Consider anatomic and physiologic changes related to pregnancy during evaluation/management Initial evaluation should focus on establishing maternal cardiopulmonary stability Any treatment required to save the mother's life or treat her critical status should be undertaken, regardless of her pregnancy Sometimes, emptying the uterus by performing a cesarean delivery is required to save the mother's life www.downstatesurgery.org Trauma Once catastrophic trauma has been excluded, patient should be evaluated for obstetric complications Abruption leading to nonreassuring fetal heart rate patterns and death can occur despite relatively mild maternal trauma or discomfort If fetal viability stage is reached, continuous fetal and uterine monitoring is recommended for at least 4 hrs Anti-D immune globulin is administered to unsensitized Rh(D)-negative women who experience abdominal trauma
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