Surgical Problems in Pregnancy

Surgical problems in pregnancy
Introduction
The approach to surgery is different in pregnancy than in the nonpregnant state.
A central focus is balancing the health and well-being of the fetus against the
mother's need for surgery.
The effect of surgery on the fetus and the pregnancy in general often is difficult
to discern from the effects caused by the pathologic process (e.g., appendicitis)
that created the need for surgery.
However, there is a demonstrable increase in risk from surgery alone, and that
risk to the fetus is greatest in the first and third trimester.
Physiological changes and risk of surgery

to the mother
Cardiovascular
Aortocaval compression (due to enlarged uterus compressing IVC and lower

aorta
Decrease the venous return and cardiac output
However most women are able to compensate.
Surgical and anaesthetic implication:
During anaesthesia, compensatory mechanism is abolished.
Reduces blood flow to kidney, uteroplacental unit and lower extremities
Physiological changes and effect of

surgery to the mother
Respiratory
Increase minutes ventilation
Respitarory alkalosis
Upward displacement of diaphragm
Increase thoracic diameter
Mucosal edema
Faster inhalation induction
Potential hypoxaemia in supine and Trendelenburg position
Breathing more diaphragmatic than thoracic

Central nervous system
Epidural vein engorgement
Decrease in epidural space volume
Increase sensitivity to opioids and sedatives.
Higher incidence of dural puncture and intravascular injection
More extensive anaesthetic spread.

Haematological
Increase red cell volume, white cell count, plasma volume.
Increase coagulation factors
Decrease albumin and colloid osmotic pressure
Dilutional anaemia
Thromboembolic complications
Oedema
Decrease protein binding of drugs

Gastrointestinal
Increase intragastric pressure
Decrease barrier pressure
Increase aspiration risk
Renal
Increase renal plasma flow
Increase GFR
Effect of surgery to the foetus
Spontaneous abortion
Prematurity
Compromised utero-placental circulation
Teratogenicity
Intrauterine growth retardation
Low birth weight
Non-Obstetric Causes of
Acute Abdomen in
Pregnancy
Acute Appendicitis
Intestinal obstruction with pain (Ileus)
Torsion of the ovarian cyst
Haemorrhaging of an ovarian cyst
Acute Cholecystitis
Cholangitis
Acute Pancreatitis
Ureteric stone
Peritonitis
Pelvic Inflammatory Disease
Peptic Ulcer
Hepatitis
Diabetic Ketoacidosis
Mesenteric Vein Thrombosis
Differential Diagnosis of
an Acute Abdomen in
Pregnancy
Ruptured ectopic pregnancy
Septic miscarriage (with or without Peritonitis)
Acute urinary retention due to retroverted gravid uterus
Torsion of a pedunculated fibroid
Placental abruption
Placental percreta
Uterine rupture
Chorioamnionitis
Cholecystitis
Cholecystitis
Inflammation of the gallbladder that occurs most commonly because of an

obstruction of the cystic duct from cholelithiasis
Second most common surgical cause of acute abdomen in pregnancy
Incidence : between 1:1600 and 1:10 000 pregnancies
May occur at any time in pregnancy
90% cases are caused by gallstones
Pregnancy promotes bile lithogenicity and sludge formation because estrogen

increases cholesterol synthesis and progesterone impairs gallbladder motility.
Most gallstones are asymptomatic during pregnancy
Clinical features
Symptomless gallstones in 2.5-11% of pregnancy
Clinical features similar to non-pregnancy state:
Epigastric or right upper quadrant pain
Colicky/ stabbing in nature
May radiate to the back and tip of the shoulder
Associated with nausea, vomiting and fatty food intolerance
Tenderness and guarding
Diagnosis
Ultrasound scan
o
Detect 95-98% of gall stones
Gallbladder thickening (>3mm)
Pericholecystic fluid
Dilatation of the intra and extra hepatic ducts
Full blood count

o
Raised in WBC
Liver function test

o
Serum level of direct bilirubin and transaminases, amylase may be raised
Alkaline phophatase is of limited use due to placental production
Complications
Pancreatitis
Other uncommon complications:
Retained intraductal stones
Cholangitis
Rupture of the cystic duct
Management
Conservative management
Analgesia
Fluids
Antibiotic if infected
Surgical management
Being delayed until delivery of baby
If being required, best done during second trimester
Risk of miscarriage low
Uterus not yet large enough to obscure the surgical field
Endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy
Choledocholithiasis
Presence of gallstone in common bile duct.
Clinical features
Pyrexia
Right upper quadrant pain
Intermittent Jaundice
Nausea and vomiting
Management
Endoscopic retrograde cholangiography and sphincterotomy with stone extraction
OVARIAN TUMOURS
Ovarian cysts are uncommon in pregnancy

Type:
Corpus luteum cysts
Simple ovarian cyst
Dermoid cyst
Ovarian cancer
Diagnosis
Bimanual palpation much easier in early
pregnancy before the uterus occupies most of the
pelvis
An ovarian cyst is more mobile than hydro or
pyosalpinx, less tender than a tubal pregnancy
Do ultrasound to confirm the pelvic mass
Complications in the Cyst

Torsion of the pedicle is the commonest and may lead to
rupture
Women will have acute abdominal pain, vomiting and
pyrexia .These symptoms will subside but can occurs again later
Cyst torsion is likelier in the puerperium when the involuting
uterus no longer limits movement of the cyst
Pressure symptoms may arise if the cyst is very large
Dysuria, abdominal distention, varicose veins
Infection most likely in the puerperium as a result of trauma
sustained during delivery
Complications in the Pregnancy

Increased tendency to miscarriage if the cyst is
large
A cyst in the pelvis will obstruct labour, causing
malpresentation or non-engagement of the head
Management
Removal of an ovarian cyst is done through
laparotomy
Need to distinguish a mass separate from the
uterus
Removal of an ovarian cyst is usually safe
However, it may induce miscarriage or labour
Laparotomy in early pregnancy is not usually a

problem as little handling if the uterus is required
to gain access to the cyst
If a cyst is discovered at term or near term and is
well clear of the pelvis (does not obstruct descent
and engagement), labour can be induced and the
cyst removed few days later
In mid-pregnancy when laparotomy to remove the

cyst might involve considerable uterine handling
The obstetrician must decide whether removal of
the cyst can safely be postponed until the fetus is
viable
LEIOMYOMAS (FIBROIDS)
Pregnancy in the presence of fibroids is rather rare

Usually found in older women
Majority of women with fibroids do not experience
mechanical cause of pregnancy loss
However, a uterus distorted by fibroids may be
unable to accommodate the growing fetus and can
cause miscarriage
There is tendency to increase in size during

pregnancy
But 10% will experience red degeneration or
infarction of the fibroids
Degenerating Fibroids
Fibroids are harder than any other pelvic mass and
more likely to be multiple
Usually symptomless and can be left alone
During pregnancy, fibroids will undergo red
degeneration or infarction
Degenerating fibroids can cause acute abdominal
pain, vomiting and pyrexia
The condition usually resolves in a few days with

rest and sedation
Operation is only likely to be indicated when there
is torsion of the pedicle of a fibroid
Sometimes laparotomy may have to be performed
to exclude appendicitis
Pressure Symptoms
If the fibroids are very big or when the fibroids are
impacted in the pelvis
Women can have dysuria, abdominal distension,
varicose veins
Treatment should always be conservative unless
an obstruction develops
Myomectomy in pregnancy is a very haemorrhagic

operation
Likely to be followed by miscarriage or labour
Even require hysterectomy if bleeding still persist
Management of labour
If the fibroid obstruct descent and engagement,
caesarian section should be done
If not, the labour should be proceed vaginally
If there is doubt about the obstruction, the labour
should be continued for some time, to see if
dilatation of the cervix causes the fibroids to be
moved aside
If delivery is by caesarian section, myomectomy

should not be done at the same time
Uterine incision may be placed anywhere, it can
be through the fundus, as long as avoid interfering
with the fibroids, which will bleed excessively

Surgical Problems in Pregnancy

Uploaded by

Copyright:

Available Formats

Surgical Problems in Pregnancy

Uploaded by

Document Information

Original Description:

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Surgical Problems in Pregnancy

Uploaded by

Copyright:

Available Formats

Surgical problems in pregnancy

The approach to surgery is different in pregnancy than in the nonpregnant state.

Physiological changes and risk of surgery

Aortocaval compression (due to enlarged uterus compressing IVC and lower

Decrease the venous return and cardiac output

However most women are able to compensate.

Surgical and anaesthetic implication:

During anaesthesia, compensatory mechanism is abolished.

Reduces blood flow to kidney, uteroplacental unit and lower extremities

Physiological changes and effect of

Increase minutes ventilation

Upward displacement of diaphragm

Increase thoracic diameter

Surgical and anaesthetic implication:

Faster inhalation induction

Potential hypoxaemia in supine and Trendelenburg position

Breathing more diaphragmatic than thoracic

Physiological changes and effect of

Epidural vein engorgement

Decrease in epidural space volume

Increase sensitivity to opioids and sedatives.

Surgical and anaesthetic implication:

Higher incidence of dural puncture and intravascular injection

More extensive anaesthetic spread.

Physiological changes and effect of

Increase red cell volume, white cell count, plasma volume.

Increase coagulation factors

Decrease albumin and colloid osmotic pressure

Surgical and anaesthetic implication:

Decrease protein binding of drugs

Physiological changes and effect of

Increase intragastric pressure

Decrease barrier pressure

Surgical and anaesthetic implication:

Increase aspiration risk

Increase renal plasma flow

Effect of surgery to the foetus

Compromised utero-placental circulation

Intrauterine growth retardation

Low birth weight

Intestinal obstruction with pain (Ileus)

Torsion of the ovarian cyst

Haemorrhaging of an ovarian cyst

Pelvic Inflammatory Disease

Mesenteric Vein Thrombosis

Ruptured ectopic pregnancy

Septic miscarriage (with or without Peritonitis)

Acute urinary retention due to retroverted gravid uterus

Torsion of a pedunculated fibroid

Inflammation of the gallbladder that occurs most commonly because of an

Second most common surgical cause of acute abdomen in pregnancy

Incidence : between 1:1600 and 1:10 000 pregnancies

May occur at any time in pregnancy

90% cases are caused by gallstones

Pregnancy promotes bile lithogenicity and sludge formation because estrogen

Most gallstones are asymptomatic during pregnancy

Symptomless gallstones in 2.5-11% of pregnancy

Clinical features similar to non-pregnancy state:

Epigastric or right upper quadrant pain