Surgical disease in pregnancy Flashcards
Appendicitis
Treat surgically
Features:
- Incidence same as non-pregnant individuals
- Evenly distributed across 3 trimesters
- Poorly localised especially late in pregnancy
- Adler sign: roll patient to left - persistent RIF pain = appendicitis, shifting pain to midline = tubo-ovarian
- Bryan sign = shifting uterus to right increases pain = appendicitis
Investigation:
- MRI >90% sensitive and specific
- USS may be useful
Management:
- Laparoscopy if possible - place first port high
Risk of foetal loss:
- 2.5% without peritonitis, 10% with
Increased risk of complications with medical management
Biliary Colic
Surgery if intractable/recurrent, in any trimester
- delaying surgery has high rate of recurrences and complications
Gallstones more common in pregnancy
- Estrogen increases cholesterol synthesis
- Progesterone decreases bile acid production and GB motility
- Leads to supersaturation of bile with cholesterol and biliary stasis
Cholecystitis
Treat surgically, as per non-pregnant patient
Increased risk of maternal (4 vs 16%) and foetal (6 vs 16%) complication rates with medical management in a non-randomised study
Breast Cancer
3% of all breast cancers
General
- Discuss at MDT
- Involve obstetrician
- Shield abdo during mammography
1st trimester
- Start Chemo during second trimester (neo/adj)
- Then Mastectomy, can consider SLNB (no methylene blue) or ALND
….Can do WLE and radiotherapy potentially (in discussion with radonc) as uterus easier to shield
2nd/3rd trimester options
- Mastectomy and SLNB, or
- Neoadj chemo (AC only, no Taxane) with BCS/Mx and axillary staging postnatal
SNB
- Use Tc99 radiocolloid only
- Methylene blue is potentially teratogenic
Contraindications
- Radiotherapy (relative)
- Taxane chemo (so give AC, not T)
- Herceptin
- Tamoxifen
- Aromatase inhibs
Chemotherapy
Taxanes contraindicated
Fertility
- Gonadotoxicity may lead to infetility
- 20 - 70% of women post breast cancer treatment - variable with age and treatment regime
Grave’s disease
Radioiodine contraindicated
Carbimazole contraindicated in first trimester - ok in second and third
Treat initially with PTU and propranolol for symptoms
Thyroidectomy for intractable disease
Thyroid Cancer
Radionuclide scanning and radioiodine contraindicated
Nodules can otherwise be worked up in same way
Radiotherapy
Contraindicated
Trauma
Management
- Left lateral tilt
- Send Kleihauer Betke test
- Anti-D if mother Rh negative
- Consult obstetrics & Speculum exam
- Foetal HR monitoring
- CT is fine if indicated
Indications for immediate delivery
- Hypotensive/needing trauma laparotomy
- Maternal arrest
- Suspected major abruption
- Fetal bradycardia <70 for >8 mins
- Other ominous FHR – late decels etc
Considerations:
- Health of mother > foetus
- Laparotomy for maternal injuries is not indication for routine C-section
- Tachycardia and hypotension are late signs in pregnancy
due to hypervolaemia
- Pregnancy is protective in penetrating trauma
Physiological changes of pregnancy
CVS
- Circulating volume increased 50%
- CO increased 50%
- HR increased 15-20 bpm
- SVR decreased
- Arterial BP decreased
- Venous return decreased (pressure of uterus on IVC)
Resp
- RR increased
- O2 consumption increased
- Chronic respiratory alkalosis
Haem
- Prothrombotic (increased clotting factors)
- Leucocytosis
- Thrombocytopaenia
GI
- Decreased motility
- Decreased smooth muscle tone - aspiration risk
- Biliary stasis
- Increased intra-abdo pressure
Anaesthetic considerations
No strong evidence of teratogenesis from anaesthetic agents
Position patient in slight left tilt later in pregnancy
Foetal heart rate monitoring
Pre-oxygenate patient - desaturate faster
No indication for prophylactic tocolytics
Ensure adequate VTE prophylaxis - clexane safe
Baseline risk of miscarriage
First trimester = 10%
Second trimester onward = <1%
Risk of surgery
Risk of stillbirth is low - 0.9% with surgery cf 0.6% without
Risk of preterm delivery - 11% vs 7.5%
Surgical considerations
Urgent surgery thought best performed in 2nd trimester (not much evidence for this, probably fine any time)
Delay elective surgery until after delivery
Laparoscopy in pregnancy?
Safe in any trimester
Keep pressures <12 mmHg if possible
Some risk of maternal acidosis due to CO2 absorption
