Transcript Non-obstetrical Surgical Emergencies ion Pregnancy

Non-obstetrical Surgical
Emergencies in
Pregnancy
Steven Stanten MD
Rupert Horoupian MD
Non-Obstetrical
Surgical Emergencies in
Pregnancy
Steven Stanten M.D.
Rupert T. Horoupian M.D.
OBJECTIVES
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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
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Appendicitis
Biliary disease
Ovarian disorders
Breast disease
Cervical disease
Bowel obstruction
Introduction
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1-2% of pregnancies complicated by nonobstetrical surgical problem
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Adenexal masses
Appendicitis
Biliary tract disease
Small bowel obstruction
Diverticular disease
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
Challenges
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Physiologic changes
Diagnostic imaging limitations
Anesthesia issues
Delay in diagnosis
Communication
Fetal issues
Maternal issues
Teratogenicity of Irradiation
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Etiology of most birth defect unknown
Drugs and chemicals 3% of risk
Embryogenesis at 8-9 weeks
Nervous system develops beyond
ACOG – exposure , 5 rads is not
associated with increase in fetal anomalies
or prgnancy loss
Teratogenicity of Irradiation (con’t)
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ACR – No single diagnostic procedure
results in a radiation dose that threatens
the well being of the developing embryo
and fetus
Physiologic Changes During
Pregnancy That Effect Surgery
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Respiratory System
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Increase in minute ventilation
Decrease in functional residual capacity
Oxygen consumption increase greater than
cardiac output increase
Decrease in Sv O2
Aortocaval compression
Physiologic Changes During
Pregnancy That Effect Surgery
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Cardiovascular changes
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Cardiac output increases 30%
Aortocaval compression with increase in
abdominal pressure
Decrease in BP with reverse trendelenberg
Increase in blood volume
Surgical Considerations
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Pneumoperitoneum
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Increase in peak airway pressures
Decrease in total lung compliance
Hypoxic episodes possible
Supine position causes decrease in PaO2
Hyperventilation to keep PaCO2 down can
cause decrease uteroplacental perfusion
Decrease PaO2 +/or increase in PaCO2 can
cause fetal harm
Other Risks
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Pneumoperitoneum
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Animal studies indicate
decreased unteroplacental
blood flow with CO2
pressures >15mmHg
Also, some infants
developed acidemia
Barnard et al 1995
Hunter et al 1995
Adenexa
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1 in 200 pregnancies complicated by
adenexal mass greater than 6cm
Treatment depends on trimester
Williams Obstetrics Concludes:
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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?
The Adnexa
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Estimated 1:200
deliveries (adnexal
masses)
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Based on two studies
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Katz 1993
Koonings 1988
Est. 1:1300 adnexal
masses require
surgery
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Whitecar 1999
MRI?
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1990 Kier et al
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Correctly identified 17
of 17 adnexal masses
with MRI vs. 12 out of
17 with ultrasound
Axial SSFSE T2W image
Adnexal Masses Cont…
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1990 Study
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Whitecar 1990
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130 pregnancies
5% malignant rate
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½ Serous
Carcinomas of low
malignant potential
30% cystic teratomas
28% serous/mucinous
cystadenomas
13% corpus luteal
7% benign
30
25
20
15
% Mass
10
5
0
C.Ter.
S/M Cys C. Luteal Benign
Adnexal Masses cont….
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2 additional studies support percentages:
Sunoo 1990
 Hopkins 1986
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1/3 Teratomas
1/3 Cystadenomas
Complications
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Whitecar study cont..
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Ovarian Torsion
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most common and
serious sequelae
5% occurrence
rupture most common
in 1st trimester
Management
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Multiple Studies
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Thornton 1987
Whitecar 1999
Fleischer 1990
Caspi 2000
Hess 1988
Platek 1995
Parker 1996
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Best Approach:
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(<5cm) Exp. Mgmt
(5-10cm) Watch
unless complex on
sonography
If >6cm after 16 WGA,
operate
Biliary Tract Disease
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Complicates 25 out of 1000 pregnancies.
Biliary colic
Acute cholecystitis
Causes
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Increased bile viscosity
Decreased bile flow
Symptoms
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May be asymptomatic
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2.5-10% of pregnant
patients
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RUQ Pain – most reliable
symptom
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(Maringhini et al 1987)
(pain may radiate to back)
Vomiting approx 50%
Can mimic appendicitis in
3rd trimester
Gall Bladder
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Biliary Disease
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Increased biliary sludge in
pregnancy
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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)
Biliary Tract Disease (con’t)
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Treatment
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Symptomatic
Pain meds
 Nausea meds
 IV fluids
 Surgical consultation
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Individual Based
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No solid consensus on management
If Medically treated
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Demerol over morphine for pain
IVF
NG suction
Low fat diet
Asymptomatic Stones- surgery not
recommended
Management
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Several studies – Conservative vs. Surgical
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Landers et al 1987
Glasgow et al 1998
Dixon et al 1987
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15-50% of pts treated medically reported
continued symptoms throughout pregnancy.
Management (con’t)
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Davis et al 2000
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77 cases
Primary surgical management
Reported better outcomes with surgical
management
 Less risk to fetus if performed in 2nd trimester
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Biliary Tract Disease (con’t)
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Laparoscopic cholecystectomy
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Antibiotics
NG or OG Tube
Compression stockings
Open trocar vs. Verees needle
Pressure to 12 mm Hg or lower
Coagulation is OK
Cholangiogram is OK
Do not move patient position rapidly
Biliary Tract Disease (con’t)
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Treatment
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Laparoscopic cholecystectomy is feasible
during pregnancy
Even in 3rd trimester
Upper gestational age not defined
Intra-op fetal minitoring
Post-op fetal monitoring
Biliary Tract Disease (con’t)
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Treatment
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SAGES Guidelines
“Laparoscopic surgery in pregnancy when
possible should be deferred to the 2nd
trimester or after delivery”
Decreased rate of spontaneous Abortion
Decrease likelihood of pre-term labor
Biliary Tract Disease (con’t)
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Laparoscopic cholecystectomy
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Less invasive
Earlier recovery
Less scarring
Less hospital costs
Surgical Management
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Laparascopic
approach safe,
generally to 3rd
trimester
Remember M/F Risks
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Slight increase of low
birth weights
Slight increase of
infant death within 7
days
Increase in
contractions,
especially >24 weeks
Surgical Recommendations
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Late 1st or 2nd trimester is best
Reports out that 3rd trimester is OK
Evaluate fetal HR and uterine contractility
pre and post if >16 weeks gestation
Open trocar insertion
Avoid high intra-abdominal pressures
Open trocar insertion
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The obvious
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Minimize
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Aspiration
Sedatives – GERD and decreased gastric emptying
Hypoxia
Hypercarbia
Hypocapnia
Hypoxia
Hypotension
Aortocaval compression
Nitrous oxide
Pancreatitis
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1:3000 – 1:4000 pregnancies
High incidence of Gallstones
Elevated Amylase, Lipase
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Medical management
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NG tube
NPO
IVF, Pain control
Parkland Study 1995
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43 patients, all tx. medically
All did well – Avg stay 8 days
(Ramin eta al 1995)
Appendicitis
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1:2000 to 1:6000
pregnancies
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Incidence 0.05%
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Difficult diagnosis??
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Immediate intervention
a must
Appendicitis
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The most common surgical condition of
the abdomen
Lifetime occurrence of 7%
Peak incidence 10-30y
The most common non-obstetric surgical
intervention during pregnancy
Occurrence
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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
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(Tamir 1990, Mourad 2000)
5
0
1st
2nd 3rd
Mazze and Kallen
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5405 pregnant women undergoing surgery 1973-1981
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41% 1st
35% 2nd
24% 3rd
 16% Laparascopic
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54% General anesthesia
Increased risk of:
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Death by 7 days 1.4 – 3.2 – 1.9 (2.1)
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Birthweight <1500 gms 1.7 – 3.2 – 1.5 (2.2)
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Birthweight <2500 gms 1.4 – 1.8 – 2.2 – (2.0)
 (No increased risk of stillborn or congenital malformation)
Acute Appendicitis
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Extensive differential diagnosis
Displacement of the appendix
Fever and tachycardia may not be present
No rectal tenderness
+/- anorexia
Leads to delay in diagnosis
Differential Diagnosis
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Renal stone / APN
Gastroenteritis
Pancreatitis
Cholecystitis
Mesenteric adenitis
Hernia
Bowel obstruction
Preterm labor
Placenta abruptio
Chorioamnionitis
Adnexal torsion
Ectopic pregnancy
Pelvic inflammatory
Round lig. pain
Pathogenesis:
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Appendiceal lumen obstruction:
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Fecaliths
Parasites
Foreign bodies
Lymphoid hyperplasia
Metastatic cancer
Carcinoid tumor
Symptoms
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Normal Pregnancy
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Abdominal tenderness
Nausea
Vomiting
Anorexia
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Acute Appendicitis
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Abdominal tenderness
Nausea
Vomiting
Anorexia
Symptoms
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Pain
Anorexia
Nausea / vomiting
Pain migration – RLQ / RUQ / Flank
Fever
Symptoms cont….
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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.
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(Cunningham 1975)
Appendix Location
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1932 Baer described
location of appendix
during pregnancy.
Since, most agree
there is a shift in
location.
Physical Examination
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Tenderness – RLQ
Rebound & Guarding (peritoneal signs)
Rovsing sign
Dunphy’s sign
Psoas sign (retroperitoneal retrocecal appendix)
Obturator sign (pelvic appendix)
Rectal examination tenderness (cul-de-sac)
Low grade fever
Psoas and Obturator signs. Sensitivity/specificity??
Lab Values
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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
Ultrasound
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1992 Study
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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)
Graded Compression Ultrasound
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Normal appendix: < 6 mm diameter
Non-pregnant: Sensitivity 85%
Specificity 92%
Pregnant: cecal displacement & uterine
imposition makes precise examination
difficult
Can we do better than 50%?
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CT Scan
Numerous reports in
surgical literature
suggesting accuracy
of >97% in nonpregnant patients.
CT Scan
CT Scan
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Teratogenicity
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Hiroshima
Studied 45 years later
 Perinatal exposure
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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
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*No evidence of any increased risk with
exposure of up to 5 Rads.
Maximal risk at 1 rad is 0.003%
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15% embryos naturally abort
2.7-3.0% have genetic malformations
4% IUGR
8-10% late onset genetic abnormalities
(
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(Brent RL 1989)
Risks if untreated
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Preterm contractions/labor
Rupture leading to peritonitis
Sepsis
Fetal tachycardia
Maternal/fetal death
Risks (con’t)
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Increased Gest age = increased complication
rate
Uterine contractions – as high as 80% of pts
>24 WGA
Appendiceal perforation
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4-19% non-pregnant patients
57% pregnant patients
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(Innability to isolate infection by omentum)
(Am Sur 2000 Jun: 66)
Diagnostic Problem
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Position of appendix - Normally
~ 70% intraperitoneal
~ 30% pelvic, retroileal, retrocolic
Pregnancy – anatomical changes
Gravid uterus - displacement upward & outward
Flank pain (3rd trimester) (Baer,1932)
Increased separation of peritoneum causes
decreased perception of somatic pain and
localization
Diagnosis
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“Pain in RLQ is the most common presenting
syndrome of appendicitis in pregnancy regardless
of gestational age “
(Am J Obstet Gynecol 2001 Jul;185(1):259-60)
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“Physical examination is the most reliable tool for
diagnosis” (Am Surg 2000 Jun;66(6):555-9)
“Fever and WBC are not clear indicators”
(Am J Obstet Gynecol 2001 Jul;185(1):259-60
“The mortality of appendicitis complicating
pregnancy is the mortality of delay”
Babler 1908
Treatment
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Suspicion:
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Delay
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Immediate surgery
Generalized peritonits
Antibiotics
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Perioperative 2nd cephalosporin. May be discontinued
post-op, minus perforation, gangrene or phlegmon
Surgical Considerations
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Pneumoperitoneum
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Increase in peak airway pressures
Decrease in total lung compliance
Hypoxic episodes possible
Supine position causes decrease in PaO2
Hyperventilation to keep PaCO2 down can
cause decrease uteroplacental perfusion
Decrease PaO2 +/or increase in PaCO2 can
cause fetal harm
Laparoscopy
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Advantage
Less post-op complication
Better visualization
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Disadvantage
Co2 pneumoperitoneum:
– Dec. uterine blood flow
– Fetal acidosis
– Premature labor
Safe especially in 1st half of pregnancy (size
of gravid uterus)
Similar perinatal outcomes compared to
laparotomies (Reedy and colleagues,1997)
Laparoscopy
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Safe – especially in
the first 20 weeks
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(Reedy et al. 1997)
Risks:
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Low birth weight
infants
Preterm labor
Fetal growth
restriction
(no diff. Vs.
laparotomy)
(Mazze and Kallen 1989)
Incidence During Pregnancy
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Incidence 0.05%
1:1000 pregnant women - appendectomy
1:1500 proved appendicitis (Mazze &
Kallen,1991)
1st trimester – 30% / 22%
2nd trimester – 45% / 27%
3rd trimester – 25% / 50%
(Mourad,2000)
Complications
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Abortion , Fetal loss ~ 15% (1st trimester)
Decreased birth weight
Other surgical complication – wound
infection, atelectasis etc.
No increased infertility – (Viktrup and Hee,1998)
No congenital malformation
No stillborn infants
Appendectomy Review
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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
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General Anesthesia
acceptable
No sig. Diff in
morbidity/mortality with
Laparascopy vs
laparotomy
Extended monitoring for
labor pattern necessary
post operatively.
Acute Appendicitis
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Delay in diagnosis
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Fetal mortality
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Increase in morbidity
Increase in mortality
Non-perf = 3-5%
Perf = as high as 30%
Maternal mortality
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Non-perf = ~0%
Perf = as high as 4%
“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)
Bowel Obstruction
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Est. 1:17000 deliveries
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(Meyerson 1995)
Increasing secondarily to increased PID
prevalence and increased surgeries
resulting in more adhesions
Bowel Obstruction cont…
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60-70% adhesions
15-20% volvulus
Diagnosis:
Abdominal pain, nausea & vomiting
 Abdominal X-ray 38/42 (Perdue 1992)
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Treatment:
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Open laparotomy- Prompt
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Maternal mortality – 6%
Fetal Mortality – 26%
Williams 20th edition
Diverticular disease
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Very unusual
Case reports only
Difficult dx
-Young patients
-other causes more likely
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Medical treatment the same
Surgical treatment the same
-antibiotics
-resect and anastamose
-resect with colostomy
Conclusions
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Surgical emergencies happen
Call consultants early
Delay in diagnosis can cause serious
problems
Better diagnostic modalities available
Surgical care has improved
All resulting in improvement in maternal
and fetal outcome