Surgival Diseases in Pregnancy

The incidence of surgical disease is the same in pregnant and nonpregnant patients. A total of 1.5–2% of
all pregnancies undergo nonobstetric surgical intervention. Presenting symptoms of surgical diseases are
often similar in pregnant and nonpregnant patients. The most common surgical disorders in pregnancy
are appendicitis, cholecystitis, intestinal obstruction, adnexal torsion, trauma, and cervical and breast
disease. Limited imaging can be performed during pregnancy if results would significantly alter
management. The second trimester is the preferred time for nonurgent surgery. Surgery should not be
delayed in any trimester if systemic infection or severe disease is suspected, as this is associated with
higher risk to mother and fetus. Whenever possible, regional anesthesia should be performed.
Pregnancy does not change prognosis, which depends largely on the extent of disease at diagnosis. A
multidisciplinary approach with maternal–fetal medicine, surgery, anesthesia, and neonatology during
treatment planning is invaluable to ensure optimal outcomes for both the mother and fetus.

Altered anatomy and physiology and potential risks to the mother and fetus make diagnosis and
management of surgical disorders more difficult during pregnancy.

Surgical disorders can be either incidental to or directly related to the pregnancy. Diagnostic evaluation
requires gentle, sensitive elicitation of physical signs, at times without sophisticated diagnostic aids that
involve risk to the developing fetus. Good judgment regarding the timing, methods, and extent of
treatment is important. In the absence of peritonitis, visceral perforation, or hemorrhage, surgical
disorders during gestation generally have little effect on placental function and fetal development.

Acute Pancreatitis

AP during pregnancy is a rare but severe disease with a high maternal–fetal mortality.

Although the diagnostic criteria for AP are not specific for pregnant patients, Ranson and Balthazar
criteria are used to evaluate the severity and treat AP during pregnancy. The fetal risks from AP during
pregnancy are threatened preterm labor, prematurity and in utero fetal death.

Cholecystitis

The diagnosis is usually suspected based on classic symptoms of nausea, vomiting, and right upper
quadrant pain, usually after meals, and is confirmed with right upper quadrant ultrasound.

Cholecystectomy has successfully been performed in all trimesters of pregnancy and should not be
withheld based on the stage of pregnancy if clinically indicated. Laparoscopy is preferred in the first half
of pregnancy, but becomes more technically challenging in the last trimester due to the enlarged uterus
and cephalad displacement of abdominal contents.

acute appendicitis

Acute appendicitis is the most common general surgical problem encountered during pregnancy.

As opposed to most of the non-pregnant patients with appendicitis who have a preoperative
leukocytosis (greater than 10000 cells/microL) and a neutrophilic predominance, leukocytosis as high as
16900 cell/microL may be a normal finding in pregnant women, and during labor, the count may rise as
high as 29000 cells/microL, with a slight neutrophilic predominance. Therefore the presence of
leukocytosis is an unreliable indicator in the workup of appendicitis.

An elevated c-reactive protein level occurs in appendicitis, but it is a nonspecific sign of inflammation.
Some studies evaluated the use of neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio
(PLR) to be added to the routine diagnostic methods in the diagnostic course of acute appendicitis
during pregnancy, and the results were suggestive of increased accuracy of the diagnosis of acute
appendicitis in this group of patients.

Due to the risks of negative appendectomies, routine imaging is recommended in all pregnant patients
with suspected appendicitis to obtain accuracy in diagnosis. The initial study of choice is ultrasound with
graded compression of the right lower quadrant starting at the point of maximal tenderness and
scanning between the border of the pelvis, iliac artery, and psoas muscle. Ultrasound has the advantage
of being pregnancy-safe and easily available.

If ultrasound findings are inconclusive, magnetic resonance imaging (MRI) without gadolinium contrast
remains a safe alternative for confirmation or exclusion of appendicitis during pregnancy, as it provides
good soft-tissue resolution and lacks ionizing radiation with excellent sensitivity and specificity that
remains intact in the pregnant patient.

Although debatable, the use of CT scanning might be permissible when ultrasound is inconclusive, and
MRI is not available.

The differential diagnosis of suspected acute appendicitis during pregnancy includes disorders typically
considered in non-pregnant individuals.

Also, and more importantly, pregnancy-related causes of lower abdominal pain, fever, leukocytosis,
nausea/vomiting, and changes in bowel function need to be considered, such as placental abruption,
uterine rupture, preeclampsia, HELLP (hemolysis, elevated liver function tests, low platelets) syndrome.

diverticulitis

Because of its rare presentation in pregnancy there are no good defined protocols for diagnosis and
treatment of diverticulitis during pregnancy. Imaging modalities should include those that are used in
the diagnosis of appendicitis: ultrasonography, CT, and MRI.

The inflammatory response may trigger preterm labor and delivery if not treated.

Surgery

It is important for a physician to obtain an obstetric consultation before performing nonobstetric surgery
and some invasive procedures (eg, cardiac catheterization or colonoscopy) because obstetricians are
uniquely qualified to discuss aspects of maternal physiology and anatomy that may affect intraoperative
maternal–fetal well-being.

No currently used anesthetic agents have been shown to have any teratogenic effects in humans when
using standard concentrations at any gestational age.

There is no evidence that in utero human exposure to anesthetic or sedative drugs has any effect on the
developing fetal brain; and there are no animal data to support an effect with limited exposures less
than 3 hours in duration.

Fetal heart rate monitoring may assist in maternal positioning and cardiorespiratory management and
may influence a decision to deliver the fetus.

A pregnant woman should never be denied medically necessary surgery or have that surgery delayed
regardless of trimester because this can adversely affect the pregnant woman and her fetus.

Elective surgery should be postponed until after delivery.

Given the potential for preterm delivery with some nonobstetric procedures during pregnancy,
corticosteroid administration for fetal benefit should be considered for patients with fetuses at viable
premature gestational ages, and patients should be monitored in the perioperative period for signs or
symptoms of preterm labor.

Pregnant women undergoing nonobstetric surgery should be screened for venous thromboembolism risk
and should have the appropriate perioperative prophylaxis administered.

Surgery should be done at an institution with neonatal and pediatric services.

An obstetric care provider with cesarean delivery privileges should be readily available.

A qualified individual should be readily available to interpret fetal heart rate patterns.

When possible, the woman has provided informed consent that allows for emergency cesarean delivery
for fetal indications.

The nature of the planned surgery will allow the safe interruption or alteration of the procedure to
provide access to perform emergency delivery.

In select circumstances, intraoperative fetal monitoring may be considered for previable fetuses to
facilitate positioning or oxygenation interventions.

The decision to use fetal monitoring should be individualized and, if used, should be based on
gestational age, type of surgery, and facilities available. Ultimately, each case warrants a team approach
(anesthesia and obstetric care providers, surgeons, pediatricians, and nurses) for optimal safety of the
woman and the fetus.