Surgical Complications of Pregnancy Dr.Z Allameh MD.

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Surgical Complications of Pregnancy Dr.Z Allameh MD

Transcript of Surgical Complications of Pregnancy Dr.Z Allameh MD.

Page 1: Surgical Complications of Pregnancy Dr.Z Allameh MD.

Surgical Complications of Pregnancy

Dr.Z Allameh MD

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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

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Non-Obstetric Causes for Surgery

• Appendicitis• Biliary disease• Ovarian disorders• Breast disease• Cervical disease• Bowel obstruction

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Rate of non-obstetric surgery

0

5

10

15

20

25

30

35

40

45

AdnexalMass

Appendicitis Gallstones Other

% Cases

Rate – 1:527 pregnancies, 77 surgeries total

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Appendicitis

– 1:2000 to 1:6000 pregnancies

– Incidence 0.05%

– Difficult diagnosis??

– Immediate intervention a must

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Pathogenesis:

• Appendiceal lumen obstruction:– Fecaliths– Parasites– Foreign bodies– Lymphoid hyperplasia– Metastatic cancer

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Occurrence

• Retrospective studies (1990 UCLA, 1995 Good Sam, Phoenix)

• 151 patients• No significant change

in occurrence between trimesters

• (Tamir 1990, Mourad 2000) 0

5

10

15

20

25

30

35

40

1st 2nd 3rd

UCLA

G.Sam

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Diagnosis

• Sometimes difficult in Pregnancy!– Displaced appendix?

– Distorted lab values

– Vague Symptoms

– Fever? Tachycardia?

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Appendix Location

• 1932 Baer described location of appendix during pregnancy.

• Since, most agree there is a shift in location.

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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)

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Similar Study

• Year 2000

• Mourad and associates reported 80% of 45 patients studied to have RLQ pain.

• …..consistent with Study in Iran

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Symptoms

• Normal Pregnancy– Abdominal tenderness

– Nausea

– Vomiting

– Anorexia

• Acute Appendicitis– Abdominal tenderness

– Nausea

– Vomiting

– Anorexia

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Symptoms cont….

• 1975 Study Parkland:34 pts over 15 years.– Direct abdominal

tenderness is rarely absent.– Rebound tenderness 55-

75%– Rectal tenderness,

especially 1st trimester– Anorexia in only 1/3-2/3

pts, vs. almost 100% non pregnant.

– (Cunningham 1975)

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Psoassign

Obturatorsign

Psoas and Obturator signs. Sensitivity/specificity??

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Lab Values

• WBC often as high as 15,000/mm3 in normal pregnancy.

Bailey et. Al 1973-8341 cases of acute appendicitis in pregnancy57% accurate initial diagnosis based on P.E., labs, & Sx.

Mazze and Kallen 1991778 cases with 65% accurate diagnosis

Sharp 1994-50% accuracy reported

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Can we do better than 50%?

• CT Scan• Numerous reports in

surgical literature suggesting accuracy of >97% in non-pregnant patients.

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CT scanning, cont….

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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).

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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)

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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)

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Risks if untreated

• Preterm contractions/labor

• Rupture leading to peritonitis

• Sepsis

• Fetal tachycardia

• Maternal/fetal death

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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)

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“The mortality of appendicitis complicating pregnancy is the mortality of delay”

Babler 1908

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Treatment

• Suspicion:– Immediate surgery

• Delay– Generalized peritonits

• Antibiotics– Perioperative 2nd cephalosporin. May be discontinued

post-op, minus perforation, gangrene or phlegmon

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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)

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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)

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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

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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

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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.

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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

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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)

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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

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Workup

• Ultrasound– Effective rate 90%

• Liver enzymes• Amylase, Lipase • CBC

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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.

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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

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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

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Surgical Management

• Laparascopic approach safe, generally to 3rd trimester

• Remember M/F Risks

• Slight increase of low birth weights

• Slight increase of infant death within 7 days

• Increase in contractions, especially >24 weeks

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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)

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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

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Adnexal Masses Cont…

• 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 0

5

10

15

20

25

30

C.Ter. S/M Cys C. Luteal Benign

% Mass

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Adnexal Masses cont….

• 2 additional studies support percentages:

• Sunoo 1990

• Hopkins 1986– 1/3 Teratomas

– 1/3 Cystadenomas

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Complications

• Whitecar study cont..

• Ovarian Torsion– most common and

serious sequelae

– 5% occurrence

– rupture most common in 1st trimester

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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

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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?

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MRI?

• 1990 Kier et al

– Correctly identified 17 of 17 adnexal masses with MRI vs. 12 out of 17 with ultrasound

Axial SSFSE T2W image

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“No single diagnostic procedure results in a radiation

dose that threatens the well-being 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)

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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

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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

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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.”

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Bowel Obstruction

• Est. 1:17000 deliveries» (Meyerson 1995)

• Increasing secondarily to increased PID prevalence and increased surgeries resulting in more adhesions

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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

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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.”

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SUMMARY

• See Handout

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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

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*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):539-42.

*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