PREGNANCY AND COMMONSURGICAL DISEASES

BY

DR. SEFEEN SAIF ATTYASOHAG TEACHING HOSPITAL

TOPICSIntroductionAcute appendicitisCholecystitis and cholelithiasisIntestinal obstructionHerniasThyrotoxicosisCancer breast

INTRODUCTIONThe incidence of surgical illness is the same in

pregnant women as in nonpregnant women of the same age group

Pregnancy may alter or mask the signs and symptoms of the disease

The fetus must be considered in planning a surgical prcedure

Pregnancy may modify the timing of a semiselective operation or the surgical approach of an emergency abdominal procedure

Purely elective surgery should be deferred until the postpartum period

Any major operation represents a risk not only to the mother but to the fetus as well

During the first trimester ,congenital anomalies may be induced in the developing fetus by hypoxia ,therefore if surgery does become necessary the greatest precaution must be taken to prevent hypoxia and hypotension

The second trimester is usually the optimum time for operative procedures

Diagnostic radiologic examinations of the lower abdomen and pelvis should be avoided during pregnancy ,if possible ,especially during the first 6 weeks of gestation ,when the fetus is particularly susceptible to irradiation

Radioactive isotopes pose a particular hazard to the fetus when they are used in the pregnant patient

Radioactive iodine for thyroid scanning ,selenomethionine for imaging of the pancreas bone scanning with radioactive strontium or calcium are contraindicated during pregnancy because these agents cross the placenta and are taken up by the fetal tissues

Sonography has proven to be useful diagnostic method in many circumstances and avoids the pitfalls of x-ray exposure , at present it is considered safe for use during pregnancy

ACUTE APPENDICITIS Acute appendicitis occurs about once in every 2000

pregnancies The signs and symptoms are the same as in nonpregnant

women ,but they may be considerably modified Because Nausea and vomiting Lower abdominal discomfort Moderate leucocytosis Elevated sedimentation rateAre seen frequently in the first and second trimester therefore errors in diagnosis are more frequently made

The enlarging uterus often carries the appendix higher in the abdomen ,so that McBurney’s point can no longer be used as a point of reference ,and maximal tenderness is proportionately higher

The presence of the gravid uterus may effectively block off the omentum and loops of small intestine and thus hinder the walling off process particularly in the third trimester .therefore ,rupture of the appendix is more often associated with widespread dissemination of infection ,generalized peritonitis and higher death rate

Because of the flaccidity of the anterior abdominal wall in the last trimester ,there may be little rigidity assocciated with inflammation of the appendix and rebound tenderness may be hard to define ,so that one cannot rely upon these physical findings

Treatment of acute appendicitis during pregnancy is by immediate operation

Because of the extreme seriousness of perforation when it occurs ,it is better to remove a normal appendix when the diagnosis is in doubt than to wait for typical signs or symptoms and risk of consequences

Regional anaesthesia is preferred ,and the transverse or oblique muscle –splitting incision should be placed somewhat higher than in the non pregnant woman

In fact ,late in the third trimester the appendix may be in the right upper quadrant of the abdomen and a right paramedian incision is more appropriate

Premature labour is not common following an uncomplicated appendectomy

Appendicular abscess

In appendicular abscess following perforation ,the gravid uterus forms the medial wall of the abscess

This intense inflammatory process initiates uterine contractions ,with premature labour ,with evacuation there is a sudden reduction in the size of the uterus and the abscess ruptures into the general peritoneal cavity

CHOLECYSTITIS AND CHOLELITHIASIS

pregnancy may contribute to the formation of gall stones by:

Encouraging bile stasis Increasing the concentration of cholesterol in

the bile Fostering changes in bile solubilityTherefore cholelithiasis is more common in

women who have borne children

Acute cholecystitis in pregnancy occurs less often than acute appendicitis ,the prevalence being about one in 3500-6500 pregnancies and is associated with gallstones in 50% of cases

The symptoms are the same as in nonpregnant patient with :

abrupt onset of colicky pain in the right upper quadrant of the abdomen

Low grade fever Nausea and vomiting

Acute chlecystitis may be difficult to distinguish from acute appendicitis ,with the high position of the appendix associated with the third trimester of pregnancy

ultrasound is helpful in making the diagnosis

Unlike appendicitis ,however ,acute cholecystitis in the first trimester of pregnancy is best managed conservatively with:

Hospitalization Parenteral fluids Nasogastric suction Antispasmodics Analgesics And broad –spectrum antibiotics

In 3 out of 4 patients treated ,there will be a definite improvement within 2 days ,and a definitive surgical procedure can be deferred until the second trimester or the postpartum period

Surgery should be done whenever there is doubt regarding the differentiation from acute appendicitis or if there is no response to conservative therapy as manifested by

Enlarging mass (empyema) jaundice(common bile duct obstruction) Evidence of rupture Or associated pancreatitis Gallstone-induced pancreatitis increases both fetal and

maternal death rate

INTESTINAL OBSTRUCTION

intestinal obstruction occurs infrequently during pregnancy ,but it should be considered in the differential diagnosis of any pregnant patient with an abdominal scar who develops abdominal pain and vomiting

Adhesive bands are the most common cause of intestinal obstruction

The most frequent causes of postoperative adhesions are appendectomies and gynecological operations

Other causes of intestinal obstruction during pregnancy are volvolus ,intussusception and large bowel cancer

The symptoms and signs of intestinal obstruction are the same as those in the nonpregnant woman,although the clinical picture may be obscured by the nausea and vomiting of early pregnancy ,round ligament pain, and abdominal distention already produced by pregnancy

When operation is indicated ,it should be performed without delay ,and pregnancy should be a second consideration

Near term ,a cesarean section may be required to obtain necessary exposure

HERNIAS

Hiatal hernias are common during pregnancy 15-20 % of pregnant women develop this condition as a result of pressure against the stomach by the enlarging uterus

The principal symptom is reflux esophagitis with severe heartburn ,aggravated by recumbency or the ingestion of a large meal and relieved by an upright position or antacids

Hematemesis may result from ulceration of the esophageal mucosa

Treatment is by: Elevation of the upper half of the body while

reclining Frequent small bland meals AntacidsMost hiatal hernias disappear following the

pregnancy surgical correction is required only for those

cases that persist and remain symptomatic

Umbilical, groin ,and ventral hernias are usually unaffected by pregnancy and can be repaired electively after delivery

Surgery during pregnancy is indicated only in the rare event of an incarcerated or strangulated hernia

THYROTOXICOSIS

Radioactive iodine is absolutely cotraindicated because of the risk to the foetus

The danger of surgery is miscarriageAntithyroid drugs cause goitre and

hypothyroidism to the baby

• Thyroidectomy for thyrotoxicosis during pregnancy should be reserved as a second line of treatment in specific situations such as:

a) persistent high ATD doses required to control maternal thyrotoxicosis ; b) patients who present serious side effects to ATD ,

c) non compliant patients; and finally d) rare cases with upper respiratory compressive symptoms due to goiter

size .

• Thyrotoxic pregnant women should be prepared for surgery by using beta-blocking agents and a 10-14 days course of super-saturated potassium iodide solution (50-100 mg/d) in order to reduce vascularity of the thyroid gland.

• Surgery in pregnancy is safest if it can be undertaken in the second trimester when organogenesis is complete, and thus the fetus is at minimal risk for teratogenic effects of medications, and the uterus is relatively resistant to contraction-stimulating events of drugs

CANCER BREASTCancer breast occurs infrequently during

pregnancy complicating one in 3000 pregnancies

The breast changes that occur during pregnancy make detection of early breast carcinoma much more difficult

In general breast cancers are detected earlier in women who perform breast self examination regularly

The disease is more malignant during pregnancy perhaps as a consequence of hormonal changes and suppression of the immune mechanism

As there is considerable procrastination in diagnosis ,most cases are advanced by the time the diagnosis is made

Needle aspiration will serve to distinguish cysts and galactoceles from solid tumors

Mammography is not very helpful during pregnancy ,because of the increased radiographic density of the breast

Biopsy and appropriate surgical treatment should be undertaken as soon as the cancer is suspected

If the cancer is confined to the breast ,the prognosis is good , if the axillary nodes are involved ,the outlook is poor

The overall cure rate for breast cancer developing during pregnancy or lactation is significantly lower than that of nonpregnant women of comparable age because of delay in diagnosis resulting in more advanced disease

Therapeutic abortion is not indicated in the patient with localized disease of a favorable microscopic type

Interuption of early pregnancy as part of estrogen ablation may be of some palliative benefit to the woman with advanced disease , but if the pregnancy has progressed beyond the 20th week the life of the fetus should take precedence

Pregnancies subsequent to treatment of breast carcinoma are best deferred for 3-5 years ,after the period of greatest risk of recurrence is past

JAUNDICE IN PREGNANCY

Jaundice in pregnancy may result from any liver disease that also affects nonpregnant women or from conditions unique to pregnancy .

The unique conditions include; 1-a generally modest and self-limited elevation in aminotransferase and

bilirubin levels during the first trimester, often in patients with hyperemesis gravidarum ;

2-intrahepatic cholestasis of pregnancy, which occurs during the second and third trimesters and resolves spontaneously after delivery ;

3 -acute fatty liver or 4 -HELLP syndrome (h emolysis, e levated l iver enzymes, and l ow p

latelets) in association with preeclampsia in the third trimester . Acute fatty liver may resemble fulminant hepatic failure, with early delivery being a prerequisite to maternal recovery; a defect in the oxidation of fatty acids is found in some infants born after these pregnancies

UTI IN PREGNANCY

-About 2% of women have acute symptomatic UTI in pregnancy

-Acute infection is associated with low biryh weight , prematurity and maternal anaemia

-Screening for infection in early pregnancy is justified because one -third of women with infection develop ascending UTI

-A seven day course of antibiotics is recommended and a 14 day course in presence of renal infection