Surgical diseases in

pregnancy

Surgical disease in pregnancy 1

Surgical disease in pregnancy

1 in 500 (2%) women in each year will require non obstetrical

surgery during pregnancy.

Annual incidence (USA) -75,000–80,000

Surgical disease in pregnancy 2

Surgical disease in pregnancy

• This care requires a multidisciplinary approach involving the

obstetrician, surgeon, anesthesiologist, and pediatrician

Surgical disease in pregnancy 3

Surgical disease in pregnancy

ACOG-It is important to have obstetric consultation before

performing nonobstetric surgery b/c obstetricians are
uniquely qualified to discuss aspects of maternal physiology &
anatomy that may affect intraop maternal-fetal well being

Surgical disease in pregnancy 4

Surgical disease in pregnancy 5
Principles of Non-Obstetric
surgery

1. Elective, non-obstetric surgery should be avoided, if possible, during

pregnancy.

2. When possible, regional analgesia is favored over GA, as the MMR is

16 times higher

3. Unless clinically necessary, defer surgical intervention until 2nd Tx

Surgical disease in pregnancy 6

Surgical disease in pregnancy

Surgical disease in pregnancy 7

CONT...

4. Avoid hypotension during the surgery

• 15% left lateral tilt can be accomplished by placing a wedge under

the right hip

5. Surgery should be done with obstetrical care provider, AND in

institution with neonatal care service is available

Surgical disease in pregnancy 8

PREGNANCY OUTCOME

• pregnancy outcome depends on:

-underlying indication for surgery

-type of surgery,
-type of anesthesia

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 Surgical disease in pregnancy

• Risks- Congenital anomaly and Prematurity

Surgical disease in pregnancy 10

 ANESTHESIA

Physiologic changes

• Pharmacokinetic & pharmacodynamic profiles are altered in

pregnancy; therefore, drug administration must be titrated
accordingly.

Surgical disease in pregnancy 11

Risk of anestesia

• 1. Difficult intubation

• 2. Hypoxia

• 3. Risk for aspiration

• 4. Hypotension

• 5. Miscarriage

• 6. Preterm labor, IUGR

• 7.TERATOGENECITY
Surgical disease in pregnancy 12
• ACOG, ASA- No currently used anesthetic agents have
any teratogenic effects in human when using standard
concentration at any gestational age.

Surgical disease in pregnancy 13

 FETAL MONITORING
• ACOG - decision to use intermittent or continuous intraoperative
fetal monitoring should be individualized based on GA, type of
surgery, and available resources

• Recommendation -monitoring should occur before and after

operation

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 Tocolytics

• ????controversial, generally not used

• Could be considered perioperatively when signs of preterm labor are

present

• Minimizing uterine manupilation reduce uterine contraction & risk of

preterm labor

If a pregnancy continues beyond the 1st postop week the incidence
of preterm labour is no higher than the non-surgical pregnant patient

Surgical disease in pregnancy 15

 Thromboprophylaxis

1. Pneumatic compression devices:- for all cases

2. Pharmacologic thromboprophylaxis:-
-For those have risk factors for venous thrombosis in addition to
the pregnancy
.Thrombophilia
.Prolonged immobilization
.Obesity
.Previous DVT
.Malignancy
.Diabetes mellitus
.Varicose veins,
Surgical disease in pregnancy 16
 Glucocorticoids

• If the procedure is semi-elective & GA is b/n 24-34 wks, administering

glucocorticoids reduce perinatal morbidity &mortality related to
preterm birth

• corticosteroids should be avoided in the setting of systemic infection

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 Delivery

• C/S -is reserved for standard obstetrical indications

• the presence of a recent abdominal incision does not preclude

pushing in the 2nd stage of labor if the fascia properly approximated

Surgical disease in pregnancy 18

 Postoperative care

Recovery from anesthesia

• A review of anesthesia-related maternal mortality in Michigan from
1985-2003 found that no maternal death occurred during induction
or maintenance of anesthesia; all of the deaths occurred shortly
after, extubation

• The importance of effective and safe reversal of muscle relaxation

should not be underestimated

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LAPAROSCOPY IN PREGNANCY

• Advantage
-Decreased post-op pain
-Shorter recovery times
-Lower risk of thromboembolic events.

• Disadvantage
-Pneumoperitoneum further decreases
functional residual capacity and can cause
ventilation-perfusion mismatch & hypercapnia.

Although lower insufflation pressures limit surgical visualization, it

is important keep below 15mm Hg
Surgical disease in pregnancy 20
CONT...

Laparotomy may be preferred in certain cases;

-Prior abdominal surgeries
-Large masses
-???late pregnancy (visualization compromised)

Surgical disease in pregnancy 21

ACOG & SAGES: laparoscopy is a
safe & effective approach in any
trimester with the same indications
as in nonpregnant women

Surgical disease in pregnancy 22

 COMMON INDICATIONS of
NONOBSTETRIC SURGERY
Indication Incidence in pregnancy

Appendicitis 1:1500

Cholecystitis 1:1500-1:10,000

Bowel obstruction 1:1500-1:3500

Adnexal torsion 1:3000-1:4000

Breast or cervical disease 1:3000-1:5000

Surgical disease in pregnancy 23

ADNEXAL MASSES IN
PREGNANCY
• Prevalence 1-25%

• Most adnexal masses in pregnancy are benign and spontaneously

resolve during the course of pregnancy (72-96%)

• Whether malignant or benign, most ovarian tumors complicating

pregnancy are unilateral

Surgical disease in pregnancy 24

• Common ovarian tumors In descending order:

-Functional ovarian cysts (follicular, corpus

luteum & theca-lutein),
-Benign cystic teratomas
-Serous cystadenomas
-Paraovarian cysts
-Mucinous cystadenomas
-Endometriomas
-Malignant tumors

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 Malignant ovarian tumors

• 2-5% of adenexial masses in pregnancy are malignant

• 1 in 18,000-56,000 pregnancies

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• In the largest series of adnexal masses in pregnancy, (9375 adnexal
masses)
-87 (0.93%) were found to be malignant.
-115 (1.25%) were found to be borderline
• Taken together the prevalence of clinically significant ovarian tumors
were 1 in 23,800 deliveries.

Surgical disease in pregnancy 27

CONT...

• Majority of cases are dx in early stages, b/c of young age &

incidental diagnosis while assymptomatic, resulting in favorable
outcome

• Tumor markers during pregnancy have limited value due to

physiologic increases in β-hCG, AFP, & CA 125.

Surgical disease in pregnancy 28

 RELATIVE FREQUENCY

13%

17% 40%
EPITHELIAL
GERM CELL
SEX CORD
SECONDARY

30%

Surgical disease in pregnancy 29

 MANEGMENT

• Surgical intervention
-May favor a conservative approach
Border line & Low grade Gross metastatic disease

-Peritoneal washing -1st TX- aggressive surgical debulking

-Peritoneal bx (sacrifice of the pregnancy)
-Omentectomy
-Pelvic & paraaortic -2nd & 3rd Tx-
-preservation of the pregnancy
lymphadenectomy -chemotherpy
-Salphengo-ophorectomy

Surgical disease in pregnancy 30

CONT...

• Adjuvant therapy

-Based on the-tumor stage,

-Histologic type
-Grade

-Low stage: delay until after delivery

-Advanced: combination chemotherapy

Surgical disease in pregnancy 31

 Ovarian torsion

• 7% of adnexal masses

 Common=6-8 cm in diameter

Surgical disease in pregnancy 32

INCIENCE ACCORDING TO TRIMESTER

10%

1st TX
2ND TX
35% 55% 3RD TX

Surgical disease in pregnancy 33

Cont..

• C/F-lower abdominal pain

-nausea, vomiting
-fever.
-+/-adnexal mass

 Recurence- some pregnancy- 15%

-next pregnancy- unknown

MX- laparoscopy vs laparotomy

 The decision to untwist and preserve the torsed ovary individualized

based on intraoperative findings and risk factors for recurrence
Surgical disease in pregnancy 34
 Cont..
• In a series of 102 patients with adnexal torsion, of whom 25% were
pregnant, detorsion was undertaken, no documented cases of
pulmonary emboli

Surgical disease in pregnancy 35

 Cont…

• Before 8 wks of gestation, the corpus luteum is the primary source of

progesterone for the pregnancy. Therefore, progesterone
supplementation should be administered to patients who undergo
adnexal surgery before 8-10 weeks’ gestation

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 Uterine fibroids

• 2.7-4% of pregnancies

Effect of pregnancy on myoma Effect of myoma on pregnancy

-size -no change: 49-60% -Most no complications

-increase : 22-32%
-decrease: 8-27% -Miscarriage
-premature labor and delivery,
-Degenerative changes -abnormal fetal presentation
-RED DEGENERATION -Placenta previa & abruption
-torsion -PPH

Surgical disease in pregnancy 37

Cont..

MX -Conservative
.Short-term (48hr) indomethacin
.Bed rest

-Surgery -is rarely recommended

Surgical disease in pregnancy 38

 Cervical ca

• Most common gynecologic malignancy associated with pregnancy,

• 1 per 2200 pregnancies (3%)

• 1 in 34 cases, of all invasive cervical cancers occur during pregnancy.

• ½ dx prenatally & 1/2 within 12 months of delivery

Surgical disease in pregnancy 39

 Frequency of reproductive tract malignancy during
pregnancy
80%
70%
70%
60%
50%
40%
30% 23%
20%
10% 7%
0%
cervical ca ovarian ca uterus, vulva,vagina

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C/F

• asymptomatic
• vaginal bleeding
• discharge.
• Pressure symptoms

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SCREENING

• Visualization of the cervix

• Colposcopy
• Endocervical curettage (not recommended)
• Cone bx (ideally at 2nd TX, b/n 14-20 wks)

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MX

• Management should follow the 2006 Bethesda consensus guidelines

• Treatment options influenced by

-Gestational age
-Tumor stage
-Maternal expectation of the pregnancy.

Surgical disease in pregnancy 43

CONT...

1.High grade preinvasive disease — Treatment deferred to the

postpartum period
- Progression to invasive carcinoma 0-0.4 %

2.Microinvasion ca- conservative till delivery

5 year survival >95%

Surgical disease in pregnancy 44

CONT...

3. Invasive, Early-Stage Disease

(stages IA2, IB, IIA)

• Surgery - radical hysterectomy, pelvic

lymphadenectomy, and aortic lymph
node sampling.

1st TX-surgery carried out with the fetus in utero.

 2nd Tx- ???controversial
3rd TX- surgery performed after completion of a high classic cesarean
delivery.

 5 year survival= 80-90%

Surgical disease in pregnancy 45
CONT...

4. Invasive, Locally Advanced Disease

(stage IIB, III,& IVA)

1st TX - treated in the standard fashion

- chemotherapy & Radiothderapy
- spontaneous abortion within 2-5 wk

• 2nd or 3rd TX- high classic C/S before starting standard chemotherapy &
irradiation.
-neoadjuvant chemotherapy can be
considered if there is opportunity for further
fetal maturation

 5 year survival 65, 40, 20%

Surgical disease in pregnancy 46
CONT...

5.Invasive, Distant Metastasis

(stage IVB)
• poor prognosis.

• TREATMENT- based on patient choices and ethical considerations

-Palliative chemotherapy

• pregnancy preservation is not recommended.

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Method of Delivery

Stage I, II are candidates for vaginal delivery

• Whether vaginal delivery promotes systemic dissemination of tumor

cells is unknown

• Episiotomy nodules must be evaluated by bx, for early curative

therapy.

vaginal delivery should be avoided if tumor is bulky or friable -There

may be risk of hemorrhage, obstructed labor and delivery

With cesarean delivery, a classical incision is preferred

Surgical disease in pregnancy 48

 Appendicitis

• Most common reason for non obstetrical surgical intervention

• 1 in 1500 pregnancies

• Slightly higher rate in the 2nd tx than in the 1st or 3rd tx or

postpartum

Surgical disease in pregnancy 49

CONT...

• Pregnant women appear to be less likely to have appendicitis than

age-matched, nonpregnant women

• An infected appendix is more likely to rupture during pregnancy, b/c

of delay in diagnosis & intervention

COMPLICATIONS UNRUPTURED RUPTURED

Risk of fetal loss 1.5% 36%

MMR 0% 4%

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 Location of appendix

• Prospective study comparing the location of the appendix

-In women undergoing C/S at term,
-In pregnant women undergoing
appendectomy,
-In nonpregnant women undergoing
appendectomy,

There was no difference in appendix location among the three

groups

Surgical disease in pregnancy 51

 C/F

-Anorexia, nausea, vomiting

-Periumbilical pain then RLQ pain

Investigation
-Similar to nonpregnant women

Management
-Laparatomy vs Laparascopy

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 Gallbladder disease

• Gallstone occur in 2% of pregnancies

• Due to delayed gallbladder emptying

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 CONT...

INVESTIGATIONS
C/F
• U/S
• RUQ pain
• Anorexia,
• Endoscopic retrograde
• Nausea, vomiting, cholangiopancreatography (ERCP)
• Fever.
• RUQ tenderness
• Positive Murphy’s sign

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Management
1.Conservative 2. SURGERY

-IV antibiotics, -Laparoscopic vs Laparatomic

-adequate hydration
-keep NPO

Conservative MX of acute cholecystitis is championed in pregnancy

unless evidence of pancreatitis, ascending cholangitis, or common
bile duct obstruction is noted

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Small bowel obstruction

• 1 in 3000 pregnancies

• Common causes
-Adhesions
-Volvuluses
-Intussusceptions
-Hernias

Surgical disease in pregnancy 56

CONT...

• C/F-Nausea
-Vomiting
-Abdominal distension

MX
- Fluid, electrolyte, and nutritional balance
- A midline vertical incision to expose the
peritoneal cavity
- There is no place for laparoscopy

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 Pancreatitis

• 1 in 3000 pregnancies

• C/F
-Upper abdominal pain
.Radiation to the back
.Relieved by leaning forward
-Nausea, and vomiting

Surgical disease in pregnancy 58

CONT...

• DX –Clinical feature
-Elevated pancreatic amylase & lipase.
-Ultrasound
-CT scan

• MX-Conservative
.Bowel rest
.Nasogastric suction
.Pain medicine,
.Fluid & electrolytes balance

- Surgical intervention
.For gallstone pancreatitis
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REFERENCES

Surgical disease in pregnancy 60

THANK YOU

Surgical disease in pregnancy 61