11- Surgical Conditions and Infectious Disease In Pregnancy

Question 1

What is the most common surgical emergency in pregnancy?

Answer 1

Appendicitis
Has a higher mortality rate in pregnancy due to delay diagnosis and perforation of appendix
Most common perinatal complication

Question 2

How is the diagnosis of appendicitis ?

Answer 2

Anorexia and peri umbilical pain preceded by nausea and vomiting
DDX in 1st trimester: ectopic pregnancy, ovarian cysts
DDX in later pregnancy: round ligament, abruption

Question 3

How is appendicitis treated?

Answer 3

Appendectomy with or without antibiotics
External fetal monitoring during and after surgery
Tocolysis may be needed to prevent preterm labor

Question 4

What is the second most common surgery in pregnancy?

Answer 4

Gallbladder disease
Increased estrogen increases concentration of cholesterol and rate of stone formation
There is increase comorbidity with pancreatitis which increases need for cholecystectomy

Question 5

How is gallbladder disease diagnosed?

Answer 5

Food associated colic
Sonogram to visualize stones
Elevated liver enzymes and bilirubin

Question 6

How is gallbladder disease treated?

Answer 6

If asymptomatic- no surgery but caution patient about fatty food intake
Biliary colic- nasogastric suction, hydration, analgesia and antibiotics if needed
If no improvement with conservative measures or presence of pancreatitis- surgery

Question 7

How does pregnancy increases the risk of gallstone?

Answer 7

Increased gallbladder motility and increased cholesterol saturation of bile

Question 8

What are the precautions to take in abdominal surgery?

Answer 8

Fully evaluate patient- xray with shield if needed
Monitor fetus before, during and after hospitalization
Keep patient in lateral position as much as possible to avoid hypotension and compression of great vessels

Question 9

What are some common causes of abdominal trauma?

Answer 9

Auto accidents
Falls
Interpersonal violence

Question 10

What are the steps to do in abdominal trauma?

Answer 10

Screen for abruptio by exam and sonogram
Monitor patient in lateral position
Screen and give RhoGam as needed also tetanus toxoid

Question 11

What are the complications of abdominal trauma?

Answer 11

Abruptio placenta
Uterine rupture associated with severe, direct abdominal trauma
Fetal injury is rare
Fetal death usually associated with impaired maternal status or abruption

Question 12

What are the TORCH infections?

Answer 12

Toxoplasmosis
Other- syphilis
Rubella
Cytomegalovirus 
Herpes simplex virus

Question 13

How is toxoplasmosis contracted?

Answer 13

Consumption raw/ undercooked meat
Contact with cat feces
Tachyzoite invade all mammalian cells except RBC

Question 14

What are the complications of Congenital toxoplasmosis early in Pregnancy?

Answer 14

Chorioretinitis
Cerebral calcification
Hydro/microcephalus

Question 15

What are the complications of congenital toxoplasmosis late in pregnancy?

Answer 15

Chorioretinitis
Hepatosplenomegaly
Jaundice, rash

Question 16

What are the characteristics of syphilis?

Answer 16

Caused by treponema pallidum that can cross the placenta
Vertical transmission occurs after 16 weeks
Greater risk when in early stages but can occur at any time

Question 17

How is syphilis diagnosed?

Answer 17

RPR/VDL screen in all pregnant women early in pregnancy and at time of birth

Question 18

What are the complications with syphilis?

Answer 18

Spontaneous abortion
Stillbirth
Non immune hydrops
Perinatal death 
IUGR
Any woman delivering still birth after 20 weeks gestation should be evaluated for syphilis

Question 19

What is the treatment for syphilis?

Answer 19

Penicillin G

Maternal pregnancy during pregnancy very effective

Question 20

What are the clinical manifestations of congenital rubella?

Answer 20

Sensorineural deafness
Cataracts
Cardiac malformations
Neurologic and endocrinologic sequelae
Growth retardation
Radiolucent bone disease
Hepatosplenomegaly
Purpuric lesions- blueberry muffin lesions

Question 21

What is the epidemiology of congenital rubella?

Answer 21

Rare in developed countries with immunization programs

Postpartum vaccination is recommended if not rubella immune

Question 22

What are the characteristics of cytomegalovirus?

Answer 22

Ost common congenital viral infection
Transmission via body fluids
DNA virus
Vertical transmission has greater risk than horizontal transmission especially in utero

Question 23

What are the clinical manifestations of CMV?

Answer 23

Malaise
Fever
Lymphadenopathy 
Hepatosplenomegaly 
More severe manifestations if immune suppressed

Question 24

What are the determinants of fetal risk with CMV?

Answer 24

Primary vs recurrent maternal infection
Trimester of exposure
Greater risk is associated with primary maternal infection in the first half of pregnancy
Fetal infection by reactivation is less likely

Question 25

How to prevent CMV infection?

Answer 25

Vaccine is not available
Antiviral drugs do not prevent fetal injury
Key to prevention is universal precautions

Question 26

When is congenital herpes infection more likely?

Answer 26

Intrauterine infection is rare and follows primary infection

Perinatal infection are ,mostly due to 75% of HSV2

Question 27

How is herpes simplex virus diagnosed?

Answer 27

History and physical exam
Vesicle fluid
Serology- difficult to distinguish between hsv1 and 2

Question 28

What is the treatment for herpes?

Answer 28

High dose acyclovir 60mg/kg/day every 8 hours

Ocular involvement requires topical therapy as well