Afectiuni chirurgicale si sarcina

Principles of surgical treatment in pregnancy = same

treatment as non-pregnant: DO x-ray, anesthesia and surgery
Diagnostic problems Digestive symptoms of pregnancy nausea heartburn epigastric pain constipation Uterine problems broad ligament stretch pain abruptio placentae degenerated fibroids enlarged uterus obscures lower abdominal signs
difficult palpation diminished peritoneal findings physical findings displaced to unusual locations

Optimal timing

second trimester

Risks abortion or premature delivery intrauterine death

uterus not too big low uterine irritability

Acute apendicitis
Increased perforation rate due to: 1.Difficulty in diagnosis 2.Increased vascularity and lymphatic drainage 3.Lack of omental protection 4.Uterine contractions prevent adhesion forming 5.Increased steroids: immunosuppression Diagnosis Classical signs Right upper quadrant displacement Laboratory not helpful

Differentials
Gynecology

salpingitis ovarian cyst torsion fibroid degeneration Intestinal problems mesenteric adenitis cholecystitis CROHN disease Medical problems hepatitis pulmonary embolus pneumonia pancreatitis Pregnancy problems round ligament strain abruptio placentae Renal problems pyelonephritis kidney stones Surgical problems splenic rupture

Prognosis worsens in perforation

Therapy big incision at maximal tenderness point gentle handling drain if necessary avoid appendectomy with C-section

Gallblader disease
Same symptoms Indications for surgery Lack of response to medical treatment Unrelenting pain in biliary colic Therapy cholecystectomy

Perforated ulcer
Ulcer improves during pregnancy (decreased acidity) Frequent near term X-ray-air under the diaphragm Good prognosis if treated early

Intestinal obstruction Diagnosis difficulties Vomiting and constipation typical in pregnancy Pain confused with labor Abdominal distension difficult to evaluate Reasons adhesions volvulus incarcerated hernias ileo- and colostomies intussusception pseudoobstruction of the colon

Increased risk 4th-5th month (uterus moves to abdomen) prior to delivery (fetal head descent) immediately postpartum Therapy laparotomy with C-section if necessary in 3rd trim Splenic rupture Immediate splenectomy