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

Surgical and anaesthetic implication:

Faster inhalation induction

Potential hypoxaemia in supine and Trendelenburg position

Breathing more diaphragmatic than thoracic

Physiological changes and effect of

surgery to the mother
Central nervous system

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

surgery to the mother
Haematological

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

Increase coagulation factors

Decrease albumin and colloid osmotic pressure

Surgical and anaesthetic implication:

Dilutional anaemia

Thromboembolic complications

Oedema

Decrease protein binding of drugs

Physiological changes and effect of

surgery to the mother
Gastrointestinal

Increase intragastric pressure

Decrease barrier pressure

Surgical and anaesthetic implication:

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