SURGICAL CONDITIONS IN PREGNANCY
Patients who are pregnant can
experience the same sur-gical conditions as those who are not pregnant, such as
appendicitis, cholelithiasis, and bowel injury. In early gestation, ectopic
pregnancy and torsion of the adnexa should be considered. Later in pregnancy,
placental abrup-tion and uterine rupture can cause acute abdominal signs and
treatment of a pregnant woman should take into con-sideration both maternal and
fetal health needs. Radiographicor other studies
should not be avoided just because the patient is pregnant, though precautions
should be used. For procedures such as radiographs of the chest, an ab-dominal
shield may be used to avoid unnecessary expo-sure to the fetus. Exposure to low
doses of radiation is safe for the fetus when considered against failure to
treat or to diagnose a condition requiring surgery.
perioperative period, fetal heart tones should be mon-itored to the extent
possible, consistent with the stage of ges-tation and need for intervention,
usually by electronic fetal monitoring.
The completely supine position
should be avoided, if pos-sible. Instead the patient should be placed in a
decubitus lateral tilt to prevent the supine hypotensive syndrome, in which
pressure on the vena cava reduces venous return to the heart, causing a drop in
blood pressure and uterine blood flow. Oxygen administration may be helpful. In
general, clinicians caring for these patients should be con-stantly aware of
both maternal and fetal considerations. For example, the residual lung volume
is diminished in pregnancy, which provides less reserve for respiratory
function. Delayed gastric emptying makes aspiration of stomach contents during
a surgical procedure more likely.
is a common surgical problem in reproductive-aged
women, and therefore a common surgical problem in pregnancy. Similar symptoms
of the disease occur in preg-nancy; of note, leukocytosis associated with
appendicitis may be masked with the normal leukocytosis of pregnancy.
The appendix may be displaced upward as pregnancy ad-vances, and can cause a shift in the location of abdominal pain associated with appendicitis, though pain is still most commonly located in the right lower quadrant. When appen-dicitis is diagnosed and treated early (before appendiceal rupture and generalized peritonitis), fetal and maternal outcomes are good. Surgical management has traditionally been with openappendectomy; however, laparoscopy is increasingly being utilized for management of appendicitis in pregnancy.
frequently have gallstones.Cholelithiasis can be exacerbated during pregnancy due to hor-monal effects that slow
gallbladder emptying and cause an increase in residual gallbladder volume. Asymptomatic
cholelithiasisshould be managed expectantly. If the patient develops biliary
colic, attempts should be made to conservatively treat the patient with
hydration, pain control, dietary restric-tion, and possible nasogastric tube. However, ifcholecystitisoccurs with common bile duct obstruction, ascending
cholangitis, pancreatitis, or acute abdomen, immediate surgical management is
required. Maternal and fetal outcomes tend to be excel-lent if surgical
removal is undertaken before these serious consequences are allowed to worsen.
As with appendicitis, traditional surgical management has been open
cholecys-tectomy; however, in recent years, more evidence supports the safe use
of laparoscopic cholecystectomy in pregnancy.
Abnormal ovarian or adnexal masses
can occur in preg-nancy. Often, they are discovered during routine ultra-sound
examination of the fetus. Most of these masses are benign and spontaneously
resolve during pregnancy. Forthese
reasons, expectant management is often advocated for ad-nexal masses in
pregnancy. Approximately 4% to 7% of per-sistent complex masses are
malignant. With large masses, there is an increased risk of ovarian torsion or
cyst rupture. In general, surgical management is best performed in the second