Surgical Complications of Pregnancy Matthew Voth M.D. WCGME PGY-2

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