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Chapter 25
Surgical Disorders in Pregnancy
44
Medical
Graduate
08/20/2013

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Term
What is the risk of non-obstetric surgery in pregnancy?
Definition
1.5-2%
Term
What are the most common surgical diseases in pregnancy?
Definition
1. Appendicitis - 0.1-1.4:1000
2. Biliary colic & cholecystitis - 1:1600-10000
3. Acute intestinal obstruction - 1-3:10000
Term
How is the natural history of appendicitis altered in pregnancy?
Definition
25% chance of rupture (2-3 times higher than normal).
Term
How is the clinical picture of appendicitis changed in pregnancy?
Definition
25% of patients are afebrile, atypical pain patterns are common.
Term
What is the most common misdiagnosis of appendicitis in pregnancy?
Definition
Pyelonephritis
Term
What is the chance of preterm labor in appendicitis?
Definition
25% in the 2nd trimester patients, 50% in the 3rd trimester.
Term
What are the maternal and fetal mortality rates of appendicitis in pregnancy?
Definition
Uncomplicated appendicitis: 0-1.5% perinatal loss (maternal death is negligible).
Ruptured appendicitis: 30% fetal loss, 4% maternal mortality.
Term
What is the treatment of appendicitis in pregnancy?
Definition
Surgical.
Term
What percentage of pregnant women have gallstones?
Definition
3.5%
Term
What is the diagnostic accuracy of U/S for gallstones in pregnancy?
Definition
95%
Term
What is the treatment of gallbladder disease in pregnancy?
Definition
Initial treatment is nonoperative (IV fluids, analgesia, NPO, correction of electrolyte imblanaces).
If not given routinely, Abx are started after 12-24hrs w/o improvement.
Term
What are the four indications for surgery in gallbladder disease in pregnancy?
Definition
1. Pancreatitis
2. Failure of medical therapy
3. Choledocholithiasis
4. Recurrence - 2nd event in pregnancy
Term
What is the chance of recurrence of biliary disease in pregnancy?
Definition
High - 60-92%
Term
What is the incidence of acute pancreatitis in pregnancy?
Definition
1:1000-5000, unaffected by pregnancy.
Term
How is the clinical presentation of acute pancreatitis change in pregnancy?
Definition
Patients may present with little of no abdominal pain.
Term
How are amylase levels interpreted in pregnancy?
Definition
In pregnancy, levels as high as twice the normal upper limit are considered normal.
Term
What are the acute complications of acute pancreatitis?
Definition
Hemorrhagic pancreatitis (hypotension + hypocalcemia), ARDS, pleural effusion, pancreatic ascites, abscess, liponecrosis.
Term
What is the treatment of acute pancreatitis in pregnancy?
Definition
Similar to treatment of the non-pregnant patient: NPO, IV fluids, analgesia. Abx may be given in evidence of acute infection.
Term
What are the perinatal and maternal mortality rates of acute pancreatitis in pregnancy?
Definition
Perinatal mortality - 3-20%, maternal mortality - <1%. Increased risk of preterm labor.
Term
How is the natural history of PUD (peptic ulcer disease) affected by pregnancy?
Definition
90% of patients experience significant improvement during pregnancy. Half will have recurrence within 3 months postpartum.
Term
How is the treatment of PUD (peptic ulcer disease) altered in pregnancy?
Definition
H2-receptor antagonists are preferable to PPIs. Triple therapy for H. Pylori is controversial - risks of not treating are low and risk of teratogenicity is not insignificant. Empiric treatment of H Pylori is not recommended.
Term
What is the classic triad of acute intestinal obstruction?
Definition
Abdominal pain, vomiting, obstipation
Term
What cause, uncommonly encountered in the non-pregnant patient, is more common in pregnancy women with acute intestinal obstruction?
Definition
Volvulus (25% of pregnant bowel obstructions).
Term
What is the maternal and perinatal mortality in acute intestinal obstruction in pregnancy?
Definition
Perinatal 20%, maternal 6%.
Term
How is the treatment of IBD changed in pregnancy?
Definition
Mostly, it isn't.
Term
What relationship does pregnancy bear with hemorrhoids?
Definition
Pregnancy is the most common cause of symptomatic hemorrhoids. 9-35% of pregnant women suffer from hemorrhoids.
Term
What relationship does rupture of a splenic artery aneurysm have to pregnancy?
Definition
0.1% of adults have a splenic artery aneurysm (more in women). 6-10% of these will rupture. 25-40% of ruptures occur in pregnancy. Maternal mortality is 75%, perinatal mortality - 95%.
Term
What is the prevalence of adnexal mass in pregnancy?
Definition
1-4%
Term
What is the risk of malignancy in a persistent adnexal mass?
Definition
10%
Term
What are the 5 indications for surgery of an adnexal mass?
Definition
1. Persistent post-14wks
2. Growing in size
3. Solid and complex components, internal papillae
4. Abdominal ascites
5. Symptomatic
Term
In relation to pregnancy, what are the common times for torsion of an adnexa?
Definition
Between 6-14 weeks and in the immediate puerperium
Term
Which ovary is more susceptible to torsion (in pregnancy)?
Definition
The right ovary
Term
How common are uterine leiomyomas in pregnancy?
Definition
0.1-3.9%
Term
How do uterine leiomyomas affect pregnancy?
Definition
Increased risk of C/S, and the 5 P's:
Presentation (breech)
Position (malposition)
Preterm delivery
Placenta previa
PPH, severe
Term
What are the 5 most common malignancies diagnosed in pregnancy (in the order of frequency)?
Definition
1. Cervical cancer (26%)
2. Breast cancer (26%)
3. Leukemias (15%)
4. Lymphomas (10%)
5. Malignant melanomas (8%)
Term
Does pregnancy affect prognonsis for women with cervical cancer? Is the fetus affected by the disease?
Definition
No, and no.
Term
Are cervical cancer and pre-malignant lesions contraindications for vaginal delivery?
Definition
Patients with cervical dysplasia and carcinoma in situ can be delivered vaginally. Patients with invasive carcinoma should be delivered via C/S.
Term
How is the surgical treatment of breast cancer different during pregnancy?
Definition
Modified radical mastectomy is preferred over breast-conserving surgery, due to the need for adjuvant RT. Breast-conserving surgery possible in late 2nd and 3rd trimester, with RT delayed till after delivery.
Term
How is the non-surgical treatment of breast cancer different during pregnancy?
Definition
Radiotherapy and hormone therapy are CI.
Chemotherapy is CI only in the 1st trimester, and should be stopped after 35weeks gestation to decrease the risk of neonatal neutropenia.
Term
What percentage of malignant melanoma patients are pregnant? How does this affect the fetus?
Definition
0.1-1%.
Malignant melanoma is the tumor that most frequently metastasizes to the placenta or fetus, accounting for more than half of all tumors with fetal involvement.
Term
What are the common causes of intracranial hemorrhage in pregnancy?
Definition
Aneurysm (70%)
AVM (25%)
Others: eclampsia, coagulopathy, trauma, tumors.
Term
How frequent is trauma in pregnancy? What are the common traumas?
Definition
7% of pregnancies are complicated by trauma.
Motor vehicle accidents (40%)
Falls (30%)
Direct assault (20%)
Other (10%)
Term
What is the most common non-obstetric cause of death in pregnant women?
Definition
Automobile accidents.
Term
How long should women with trauma during pregnancy be monitored?
Definition
At least 4 hours.
Monitoring should be extended to 24-48 hours if:
1. Severe trauma
2. Uterine contractions
3. Abdominal or uterine tenderness
4. Vaginal bleeding
5. Postural hypotension
6. Fetal heart rate abnormalities
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