59.Pregnancy complicated by surgical diseases (appendicitis, ileus, cholelythiasis)

Question 1

when is the safest time to perform a surgery that must be done (not elective)?

Answer 1

2nd trimester

the risks of teratogenesis and miscarriage are much lower than in the 1st trimester, and the risk of preterm labor is lower than in the 3rd trimester

Question 2

what concern is associated with laparoscopy?

Answer 2

that CO2 used for insufflation of the abdominal cavity can be absorbed across the peritoneum into the maternal bloodstream and cross the placenta, leading to fetal respiratory acidosis and hypercapnia.

Question 3

Antibiotics of choice for abdominal pathologies during pregnancy

Answer 3

Piperacillin/tazobactam OR ceftriaxone + metronidazole

Question 4

when is prophylactic anticoagulation with LMWH given?

Answer 4

in any surgical procedure during pregnancy

Question 5

common during pregnant women going through surgery

Answer 5

pulmonary aspiration

Question 6

what is the most common surgical emergency during pregnancy?

Answer 6

Appendectomy for acute appendicitis

Question 7

what is the incidence of acute appendicitis in pregnancy?

Answer 7

0.05-0.1%

Question 8

recommended imaging studies for appendicitis in pregnancy

Answer 8

US and/or MRI (currently 1st-line if available).

Question 9

what type of appendectomy is performed in pregnancy?

Answer 9

laparotomy

laparoscopic approach is 2nd line

Question 10

how are the usual symptoms for appendicitis confused in pregnancy?

Answer 10

increased WBC is normal in pregnant
The usual symptoms of acute appendicitis (epigastric pain, N/V, lower abdominal pain) are less apparent during pregnancy, although RLQ pain is still the most common presentation.

Question 11

what is the 2nd most common surgical procedure during pregnancy?

Answer 11

Cholecystitis and Cholelithiasis

Question 12

Predisposing factors to stone formation during pregnancy

Answer 12

1. An increase in serum cholesterol and lipid levels during pregnancy, along with biliary stasis, leads to a higher incidence of cholelithiasis, biliary obstruction, and cholecystitis.
2. High levels of estrogens in pregnancy increase the saturation of cholesterol in the bile.
3. Progesterone (as a smooth muscle relaxant) decreases biliary tract motility, contributing to biliary stasis.

Question 13

Common symptoms of biliary tract disease

Answer 13

N/V, right upper quadrant tenderness, and guarding.

Further findings may include ↑ WBC, ↑ ALP, ↑ bilirubin, and jaundice

Question 14

differential diagnosis of biliary tract disease in pregnancy

Answer 14

HELLP syndrome, viral hepatitis (see elevated ALT, AST with normal WBC count), intrahepatic cholestasis of pregnancy (ICP).

Question 15

Diagnosis of cholecystitis and cholelithiasis is made by

Answer 15

clinical presentation, US findings, and complete differential diagnosis.

Question 16

treatment for cholecystitis and cholelithiasis during pregnancy

Answer 16

medical (IV fluids, gastric decompression, dietary measures),
ERCP (if stone is visible in the common bile duct),
surgical (if signs and symptoms persist or peritonitis develops).

Question 17

when does intestinal obstruction usually occur in pregnancy?

Answer 17

It generally occurs in late pregnancy and is associated with traction on adhesions as the uterus enlarges

Question 18

what confirms the diagnosis of intestinal obstruction in pregnancy?

Answer 18

Erect abdominal x-ray (showing characteristic dilated loops of bowel and air-fluid levels)

Question 19

does the management of intestinal obstruction in pregnant women differ from an nonpregnant women?

Answer 19

no

Question 20

Management of intestinal obstruction in pregnancy (same as non pregnant)

Answer 20

Nasogastric suction should be started and fluid and electrolyte balance carefully monitored. If the obstruction does not resolve after 48-96 hours, an exploratory laparotomy should be carried out through an appropriate vertical incision.