Surgical Conditions in Pregnancy

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 symptoms.

Considerations for Pregnant Patients

Surgical 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.

In the 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.

Appendicitis in Pregnancy

Appendicitis 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. 

Cholelithiasis in Pregnancy

Reproductive-aged women 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.

Adnexal Masses 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 trimester