Educational Series | Ultrasound Determination for Pregnant Patients with Abdominal Pain
Management of Biliary Disease in the Pregnant Patient · CASE PRESENTATION 23yo obese g4p3 F 28wks...
Transcript of Management of Biliary Disease in the Pregnant Patient · CASE PRESENTATION 23yo obese g4p3 F 28wks...
L I D I E L A J O I E , M D
S U N Y D O W N S T A T E
S U R G E R Y G R A N D R O U N D S
J U L Y 1 2 , 2 0 1 2
Management of Biliary Disease in the Pregnant Patient
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CASE PRESENTATION
23yo obese g4p3 F 28wks pregnant with 3 days back pain and RUQ pain after meals since 10 wks gestation
PMH: mild gallstone pancreatitis at 20wks gestation
PSH: none
Labs: WBC 11 bili 1.3 alk phos 265 AST/ALT 100/79 lipase 2599
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RUQ US: gallstones. No gallbladder wall thickening, pericholecystic fluid, or sonographic Murphys sign, CBD 4mm
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MANAGEMENT
Amylase, lipase, bilirubin returned to normal after 2 days NPO
Underwent open cholecystectomy with fetal heart rate monitoring
Findings: chronic cholecystitis
Postoperative course: diet advanced, discharged home POD 5
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BACKGROUND
Non-obstetric surgery is necessary in up to 1% of pregnancies in the US each year
Cholecystectomy for symptomatic cholelithiasis is second to appendectomy as the most common nonobstetric surgical procedure performed during pregnancy
Complications from nonoperative management of gallstone disease result in an increase in maternal & fetal mortality
For expectantly managed gallstone pancreatitis, maternal mortality of 15% and fetal mortality of 60% have been reported
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PHYSIOLOGIC CHANGES IN PREGNANCY
Abdominal discomfort, nausea, vomiting, diarrhea, and constipation are often encountered in pregnancy in the absence of intra-abdominal pathology
MATERNAL PHYSIOLOGIC CHANGES
Increased cardiac output
Increased heart rate
Decreased blood pressure
Decreased FRC
Delayed gastric emptying
Increased alkaline phosphatase (200)
Increased WBC (14K)
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PHYSIOLOGIC CHANGES IN PREGNANCY
Gallbladder volume doubles in the 2nd & 3rd trimesters
Gallbladder emptying is markedly slower than in the nonpregnant state
Up to 4% of pregnant patients have gallstones on routine obstetric ultrasound
Only 1 in 1000 pregnant patients develops symptoms
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DIFFERENTIAL DIAGNOSIS OF RUQ PAIN IN THE PREGNANT PATIENT
Gastroesophageal reflux
Peptic ulcer disease
Acute cholecystitis
Biliary colic
Acute pancreatitis
Hepatitis
Acute fatty liver of pregnancy
HELLP syndrome
Preeclampsia
Pneumothorax
Pneumonia
Acute appendicitis
Hepatic adenoma
hemangioma
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DIAGNOSTIC IMAGING
Ultrasound remains the initial imaging study of choice in the evaluation of the pregnant woman presenting with acute abominal pain
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DIAGNOSTIC IMAGING
Radiation exposure > 15 rads may lead to chromosomal mutations, neurologic abnormalities, mental retardation, and risk for leukemia especially between 10 to 17 wks gestation
Examination type
Est fetal radiation dose (cGy)
Chest X ray 0.00007
Abdominal CT 2.6
HIDA scan 0.15
Cholangiography 0.5
ERCP 2-12
Fluoroscopy 20 rads/min
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U L T R A S O N O G R A P H I C I M A G I N G D U R I N G P R E G N A N C Y I S S A F E A N D U S E F U L I N I D E N T I F Y I N G T H E E T I O L O G Y O F A C U T E A B D O M I N A L P A I N I N T H E P R E G N A N T P A T I E N T
E X P E D I T I O U S A N D A C C U R A T E D I A G N O S I S S H O U L D T A K E
P R E C E D E N C E O V E R C O N C E R N S F O R I O N I Z I N G R A D I A T I O N . C U M U L A T I V E R A D I A T I O N D O S A G E S H O U L D B E L I M I T E D T O
5 - 1 0 R A D S D U R I N G P R E G N A N C Y
I N T R A O P E R A T I V E A N D E N D O S C O P I C C H O L A N G I O G R A P H Y E X P O S E S T H E M O T H E R A N D F E T U S T O M I N I M A L
R A D I A T I O N A N D M A Y B E U S E D S E L E C T I V E L Y D U R I N G P R E G N A N C Y . T H E L O W E R A B D O M E N S H O U L D B E
S H E I L D E D W H E N P E R F O R M I N G C H O L A N G I O G R A P H Y
SAGES GUIDELINES: IMAGING TECHNIQUES DURING
PREGNANCY
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OPERATIVE CONSIDERATIONS www.downstatesurgery.org
OPERATIVE MODIFICATIONS IN PREGNANCY
Aortocaval compression by the gravid uterus in the supine position in the latter half of pregnancy can be overcome by placing a wedge under the right hip during positioning
Initial abdominal access can be accomplished with open, veress needle or optical trocar techniques
Camera port must be placed in supraumbilical position later in pregnancy, and remaining ports placed under direct visualization
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L A P A R O S C O P I C T R E A T M E N T O F A C U T E A B D O M I N A L D I S E A S E S H A S T H E S A M E I N D I C A T I O N S I N P R E G N A N T
A N D N O N - P R E G N A N T P A T I E N T S
L A P A R O S C O P Y C A N B E S A F E L Y P E R F O R M E D D U R I N G A N Y T R I M E S T E R O F P R E G N A N C Y
I N S U F F L A T I O N P R E S S U R E O F 1 0 - 1 5 M M H G C A N B E S A F E L Y U S E D F O R L A P A R O S C O P Y I N T H E P R E G N A N T
P A T I E N T
SAGES GUIDELINES: SURGICAL TECHNIQUES
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MANAGEMENT OF BILIARY DISEASE
Diagnosis made based on same symptoms, laboratory & radiographic criteria
Biliary Colic
Acute cholecystitis
Choledocholithiasis
Gallstone pancreatitis
Cholangitis
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SURGICAL OUTCOMES
In a review of 12K patients, maternal mortality was 0.006% and miscarriage rate 5.8% after nonobstetric surgery
0%
10%
20%
30%
40%
50%
1st trimester 2nd trimester 3rd trimester
Open Cholecystectomy
spontaneous abortion
preterm labor
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ADVANTAGES TO LAPAROSCOPY
DISADVANTAGES TO LAPAROSCOPY
Decreased fetal narcosis Lower rates of wound
infections & hernias Diminished maternal
hypoventilation Decreased uterine
manipulation Faster recovery Decreased risk of ileus
Risk of uterine injury during trocar placement
Decreased uterine blood flow
Increased risk of fetal acidosis from CO2 pneumoperitoneum
Decreased visualization with gravid uterus
LAPAROSCOPY VS. LAPAROTOMY www.downstatesurgery.org
L A P A R O S C O P I C C H O L E C Y S T E C T O M Y I S T H E T R E A T M E N T O F C H O I C E I N T H E P R E G N A N T P A T I E N T , R E G A R D L E S S O F
T R I M E S T E R
C H O L E D O C H O L I T H I A S I S D U R I N G P R E G N A N C Y M A Y B E M A N A G E D W I T H P R E O P E R A T I V E E R C P W I T H
S P H I N C T E R O T O M Y F O L L O W E D B Y L A P A R O S C O P I C C H O L E C Y S T E C T O M Y , L A P A R O S C O P I C C B D E X P L O R A T I O N ,
O R P O S T O P E R A T I V E E R C P
SAGES GUIDELINES: MANAGEMENT OF BILIARY
DISEASE IN PREGNANCY
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ANESTHETIC CONCERNS
Based on direct effects of anesthetic agents and effects of maternal hypotension on fetus
No definitive evidence to link anesthesia with fetal outcome, but given that differentiation of the major organ systems occurs in the 1st trimester, delaying semielective surgical procedures until the 2nd trimester may theoretically reduce risk for teratogenicity
Risk for preterm delivery is highest in the 3rd trimester
Delays in treatment have also been shown to increase the chance of preterm labor
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PERIOPERATIVE MEDICATIONS
SAFE AVOIDED
ACETAMINOPHEN
NSAIDS
MORPHINE or FENTANYL PCA
Decrease respiratory depression & drug transfer to fetus
1ST & 2ND GEN CEPHALOSPORINS
CIPROFLOXACIN
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FETAL MONITORING
Before and after surgery if 1st or 2nd trimester
Continuous intraoperative monitoring in late 2nd and in 3rd trimester whenever possible
Transvaginal ultrasound can be used during abdominal operations
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F E T A L H E A R T M O N I T O R I N G S H O U L D O C C U R P R E O P E R A T I V E L Y A N D P O S T O P E R A T I V E L Y I N T H E
S E T T I N G O F U R G E N T A B D O M I N A L S U R G E R Y D U R I N G P R E G N A N C Y
T O C O L Y T I C S S H O U L D N O T B E U S E D P R O P H Y L A C T I C A L L Y I N P R E G N A N T W O M E N U N D E R G O I N G S U R G E R Y B Y T
S H O U L D B E C O N S I D E R E D P E R I O P E R A T I V E L Y W H E N S I G N S O F P R E T E R M L A B O R A R E P R E S E N T
SAGES GUIDELINES: PERIOPERATIVE CARE
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Question 1
Which of the following physiologic changes does NOT occur during pregnancy? A: dilutional anemia
B: mild, compensated respiratory acidosis
C: increased cardiac output
D: decreased gastric and intestinal motility
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Question 2
During pregnancy, when is the optimal time to perform abdominal operations? A: 5 to 9 weeks
B: 10 to 13 weeks
C: 15 to 18 weeks
D: 26 to 28 weeks
E: after 32 weeks
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Question 3
Regarding laparoscopy during pregnancy, which of the following is recommended? A: Antibiotic prophylaxis with a fluoroquinolone
B: Right lateral decubitus position
C: Limiting carbon dioxide pneumoperitoneum to 12 mmHg
D: Using an umbilical entry site for laparoscopy for gestational ages beyond 24 weeks
E: Performing open rather than laparoscopic procedures after 24 weeks gestation
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