SURGERY IN THE PREGNANT PATIENT 1

References Stomach – diminished gastric tone and motility

- Sabiston Textbook of Surgery, 20th ED Small bowel – Motility is ↓ thus ↑ small bowel transit time
- British Journal of Anesthesia Colon – Pregnancy-related changes usually manifest as constipation
- ACOG Guidelines  ↓ motility and obstruction
↑ in portal venous pressure
SURGERY IN PREGNANT PATIENT - ↑ in pressure in collateral venous circulation
- Pregnant patient present unique clinical challenge - Dilation of veins of gastroesophageal junction
- 1-2% of pregnant women require surgical procedures - Most common result of ↑ pressure  dilation of the
- Non-obstetric surgery necessary in up to 1% of pregnancies hemorrhoidal veins
- Most indications are common for the patient’s age group and o Complaint of hemorrhoids
unrelated to pregnancy Gallbladder
o Acute appendicitis (1:2000) - Function is altered
o Symptomatic cholelithiasis (6:1000) - As well as chemical composition of bile
o Maternal trauma - During the second and third trimesters, the volume of
o Surgery for maternal malignancy gallbladder may be twice that found in non-pregnant state
- In the largest single series concerning surgery and anesthesia - Gallbladder emptying is markedly slower
during pregnancy - ↑ cholesterol saturation
o 42% - first trimester o Sludge and stone formation
o 35% - 2nd trimester o Up to 4% of pregnant patient have gallstones on routine
o 23% - 3rd trimester obstetric U/S
- Changes in maternal anatomy and physiology and safety of fetus - 1 in every 1000 pregnant patients develop symptoms
are among the issues which the surgeon must be cognizant Some changes resemble liver disease
- The presentation of surgical diseases in the pregnant patient - Spider angiomas and palmar erythema
may be atypical or may mimic signs and symptoms associated - From elevated estrogen levels
with normal pregnancy Cardiovascular
- A standard evaluation may be unreliable because of pregnancy - ↑ CO (by up to 40% or 1.5L/min)
associated changes in diagnostic tests or laboratory test results - ↑ baseline HR (10-15bpm above normal)
- Many physicians may be more conservative in regard to - ↑ plasma volume  mild dilutional anemia
diagnostic evaluation and treatment At 36th to 40th week of AOG
- Any of these factors may result in delay in diagnosis and - Cardiac output falls back to almost normal
treatment  adverse effects on maternal and fetal outcome During 3rd trimester, CO is dramatically ↓ when mother is lying
supine
CHANGES IN PREGNANCY - ↑ portal venous pressure
ANATOMIC CHANGES - Caused by compromised venous return from lower extremity
- Breast changes - caused by compression of IVC by gravid uterus
- The diaphragm can be elevated in pregnancy up to 4cm - 30o lateral decubitus position  relieve compression
- The lower chest wall can widen up to 7cm Respiratory
o “barrel chested” appearance during pregnancy - ↓ respiratory function and oxygen reserve as a result of:
- Reduced lung capacity o ↑ O2 consumption
- Bowels are displaced upward and to the periphery d/t enlarging o ↓ residual volume and functional residual capacity
gravid uterus o ↑ RR, tidal volume and minute ventilation
- Inguinal swelling secondary to varicosities of the round ligament o ↑ airway edema
o Often mistaken for inguinal or femoral hernia o ↑ Chest wall compliance
o Careful PE and U/S needed Hematologic Changes
- Changes in uterine size - Blood vol – ↑ 30-50% volume
- Changes in position and orientation of abdominal viscera from - WBC (mm3) – ↑ 5,000 – 14,000
enlarging uterus  modify the perception or manifestation of an - Hemoglobin (g/dL) - ↓ 100-140
intra-abdominal process - Hematocrit (%) – 32-42
o Be mindful of the area of maximal area of tenderness (d/t - Plasma volume (mL) - ↑ 30-50%
displacement of viscera)
PHYSIOLOGIC CHANGES Physiologic Changes in Pregnancy
- Many changes to the maternal body through mechanical and (Sabiston) – Read and Study this
hormonal alterations
- Progesterone and Estrogen SAFETY CONCERNS IN SURGERY
o 2 of the principal hormones of pregnancy RADIOLOGIC CONCERNS
o Mediate many of the maternal physiologic changes in - Primary organogenesis occurs during this time and the
pregnancy teratogenic effects of radiation, particularly to the developing
- ↑ progesterone, and ↓ serum motilin = smooth muscle CNS, are at the highest
relaxation - Greatest concern with radiation exposure is the risk to the fetus
o Producing multiple effects on several organ systems from exposure
Esophagus - Accepted maximum dose of ionizing radiation during entire
- The lower esophageal sphincter (LES) tone is ↓ pregnancy is 5 rads (0.05 Gy; 5 cGy; 50 mGy)
- When combined with ↑ intra-abdominal pressure  ↑ in - The fetus is at the highest risk from radiation exposure  from
incidence of GERD pre-implantation period to approximately 15 weeks’ gestation
(organogenesis)
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SURGERY IN THE PREGNANT PATIENT 2
- Perinatal radiation exposure has been associated w/ childhood C Animal reproduction studies Tramadol
leukemia and childhood malignancies have shown an adverse effect Gabapentin
- Higher than 10 cGy (100 mGy)  Congenital malformation on the fetus and there are no Amlodipine
- Avoid unnecessary fetal exposure to ionizing radiation, esp. adequate and well-controlled Trazodone
during the 1st and early 2nd trimesters studies in humans but Prednisone
FETAL RADIATION EXPOSURE WITH RADIOGRAPHIC IMAGING potential benefits may Pseudophidrine
warrant use of the drug in Fluconazole
pregnant women Ciprofloxacin
D Positive evidence of human Lisinopril
fetal risk based on adverse Alprazolam
reaction but potential Losartan
benefits may warrant use of Clonazepam
drug in pregnant women Lorazepam
despite potential risks Alcohol
Lithium
Phenytoin
Most forms of
chemotherapy
X *Fetal abnormalities and/or Atorvastatin,
there is positive evidence of Simvastatin,
MAGNETIC RESONANCE IMAGING (MRI) human fetal risk based on Thalidomide,
- Avoids exposure to ionizing radiation adverse reaction data Warfarin,
- Poses an unknown risk to the fetus *Risks outweigh potential Methotrexate,
o Theoretically, the gradient magnetic fields may produce benefits Finasteride,
electric currents and the high frequency currents induced Isoretinoin
by radiofrequency fields may cause local generation of heat N Has not classified drug
- The National Radiological Protection Board has advised against
the use of MRI during 1st trimester of pregnancy
- Animal studies have shown no teratogenic effect or ↑ incidence
of fetal death or congenital malformations from electromagnetic
radiation, static magnetic field, radiofrequency magnetic fields,
or IV contrast agents used during MRI

ULTRASONOGRAPHY
- Routinely used by obstetricians during pregnancy
- Although tissue heating and cavitation are theoretical effects of
ultrasound exposure, such effects have never been reported
- Deeper structures are difficult to visualize and may be obscured
by superficial structures that are more echo dense
Disadvantage:
- It has limited field of view
- Highly operator-dependent
- Despite these limitations, certain disease processes, such as ANESTHESIA CONCERNS
palpable breast mass, gallbladder stones, or suspected - Duncan study
appendicitis, may be evaluated effectively and safety - 2565 pregnant Canadian women
- Statistically significant increase in spontaneous abortion in both
MEDICATION CONCERN the 1st and 2nd trimesters
Category Description Examples - 6.5 to 7.1%
A Adequate and well-controlled Vitamin B6 Primarily
studies have failed to Levothyroxine - Safety of mother and fetus
demonstrate a risk to the Folic acid - Risk for spontaneous abortion
fetus in the 1st trimester of Magnesium Sulfate - Teratogenesis related to anesthetic agents is of major concern
pregnancy (and there is no Liothyronine For mother
evidence in later tri) - Hypotension
- Hypoxia
B Animal reproduction studies Metformin - Airway problem
have failed to demonstrate a Hydrochlorthiazide The fetus:
risk to the fetus and there Cyclobenzaprine - Exposure to teratogenic effects of anesthetic agents
are no adequate and well- Amoxicillin - Risk for preterm labor
controlled studies in Pantoprazole - Risk from changes in maternal physiology as a consequence of
pregnant women Insulin anesthesia
Acetaminophen
Aspartane
Famotidine Fetal CNS or CVS may be affected by:
Ibuprofen - Maternal hypotension or hypoxia

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- Maternal hyperventilation - Intra-peritoneal surgeries and disease processes with intra-
- Placental passage of anesthetic agents that affect fetal CNS and peritoneal inflammation – most common reasons for preterm
cardiovascular system labor
Changes in uterine blood flow and maternal acid-base status and may
cause hypoxemia or asphyxia in fetus ABDOMINAL PAIN AND THE ACUTE ABDOMEN IN PREGNANCY
- The approach is very similar to that for non-pregnant patients
EFFECTS OF ANESTHESIA with acute abdomen
Direct or Active effects - Consider the physiologic changes associated with pregnancy
- Teratogenic or embryotoxic properties when interpreting findings from history and physical exam:
Indirect effects or Passive o May be part of normal changes in pregnancy
- Mechanisms whereby an anesthetic agent or surgical procedure o When pregnant patients present with abdominal pain, it
may interfere with maternal or fetal physiology may be difficult to distinguish a pathophysiologic cause
- More common from normal pregnancy-associated symptoms
Notes: - On PE, findings may be less prominent than those in non-
- When treating maternal hypotension, vasopressors such as pregnant
dopamine and epinephrine, although increasing maternal - Some very commonly used laboratory tests have altered
systemic pressure, have little or no effect on uterine circulation reference ranges in pregnancy
- Phenylephrine and metaraminol are alpha agonists that are - Changes can make initial evaluation process somewhat more
effective maintaining maternal blood pressure and preventing difficult
fetal acidosis o Appendicitis would be expected to produce an elevated
MANEUVERS THAT INCREASE UTERINE BLOOD FLOW WBC. Yet pregnancy alone can produce WBC ranging from
- Fluid bolus 6,000-16,000mm3 in the second and third trimesters and
- Trendelenburg position from 20,000-30,000/mm3 in early labor
- Use of compression stockings - Changes in the position and orientation of abdominal viscera
- Leg elevation from enlarging fetus – may modify perception or manifestation
of intra-abdominal process
SURGICAL PROCEDURES Peritoneal signs may be absent because of:
Delaying semi-elective surgical procedures until after the first 1. Lifting and stretching of anterior abdominal wall
trimester may reduce the risk for teratogenicity 2. Underlying inflammation has no direct contact with parietal
peritoneum
Surgical procedures a. Precludes any muscular response or guarding
- ↑ risk of spontaneous abortion that would otherwise be expected
- IGR
- ↓ birthweight neonates
Elective surgical procedures are DELAYED until at least 6 weeks after
delivery
- Does not produce harm to fetus
- 6 weeks – back to normal physiology of mother
A large survey was done, and showed the ff in women who require
surgery during pregnancy
- Studies lacked information on indications for nonobstetric
surgical procedures when maternal physiology has returned to
NONPREGNANT STATE and when impact on fetus is no longer a
concern
Emergent procedures  the life of mother takes priority
- An experienced anesthesiologist will be able to modify the
anesthesia
During the 2nd trimester, after organ system differentiation has
occurred, there is almost no risk for anesthetic-induce malformation
or spontaneous abortion
Later in pregnancy, during the 3rd tri:
- Risk for preterm delivery at its highest
- When the pregnant patient requires surgical intervention,
consultation with obstetrician and possibly perinatologist is
essential

CONCERNS OF PRETERM LABOR

- Rate of premature labor induced by non-obstetric intervention is
3.5%
- Incidence of preterm labor associated with non-obstetric surgery
is related to: LAPAROSCOPIC SURGERY
o Gestational age – the later the higher - Patients who underwent laparoscopic procedures had:
o Indication for surgery – severity of underlying disease are o ↓ pain
the most predictive indicators o Shorter hospital stays
o Quicker return to normal activity
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- Major concerns of laparoscopy in pregnancy:
o Injury to uterus
o ↓ uterine blood flow – from insufflation
o Fetal acidosis
o Preterm labor from increased intra-abdominal pressure
- During 2nd trimester, the uterus is no longer contained within the
pelvis
- The open technique for abdominal access can reduce the risk for
injury
o Usually use Hasson trocar (?)
o Really make an incision layer by layer
BREAST CANCER
- Evaluation in suspected:
o A PE with particular attention to the breast and regional
lymph nodes
o Mammogram of breast with shielding
o U/S of the breast and regional lymph nodes can be used to
assess the extent of disease and also guide biopsy
 Ultrasound has been reported to be abnormal in up to
100% of breast cancers occurring during pregnancy
 Physiologic changes of breast engorgement, rapid
cellular proliferation, and increased vascularity make a
reliable physical examination difficult
- Assessment of pregnancy should include a maternal fetal
medicine consultation
o Should include counseling regarding maintaining or
terminating pregnancy
- Documentation of fetal growth and development and fetal age
by means of ultrasonographic assessment is appropriate
- Medical Radical Mastectomy – the most common surgical
procedure
- However, breast-conserving surgery is possible if radiation
therapy can be delayed to the postpartum period
o Usually followed by radiotherapy
- When surgery is performed at 25 weeks of gestation or later,
obstetrical and perinatal specialists must be onsite and
immediately available in the event of precipitous delivery of a
viable fetus
- The indications of systemic chemotherapy are the same in
pregnant and non-pregnant
o Not given on 1st tri of pregnancy
 Fetal malformation risks in the 2nd and 3rd tri are
approx. 1.3% not different than that of fetuses not
exposed to chemotherapy during pregnancy
o Not given after week 35 of pregnancy or within 3 weeks of
planned delivery  hematologic complications
TRAUMA IN PREGNANCY
- Leading non-obstetric cause of maternal mortality
o Occurs in 5%
- Most common mechanisms of injury are:
o From falls
o From motor vehicle accidents
- Pregnant women who sustained trauma had a higher incidence
of:
o Spontaneous abortion
o Preterm labor
o Fetomaternal hemorrhage
o Abruptio placentae
o Uterine rupture
- The initial evaluation and tx is identical to non-pregnant
- Rapid assessment of the maternal airway, breathing, and
circulation, as well as ensuring adequate airway (ABC)
o Avoids maternal and fetal hypoxia
4
- Critical point – resuscitation of fetus is through mother
- As with primary survey, the secondary survey proceeds in a
fashion similar to non-pregnant
- Special attention is given abdominal examination
Important:
- All pregnant women with longer than 20 weeks gestation should
be managed in a left lateral tilt position (15-30 degrees) to
reduce impact of aortocaval compression
o Alternatively, the uterus may be manually displaced
- ↑ blood volume associated with pregnancy has important
implications in the trauma patient
- Signs of blood loss: tachycardia and hypotension  delayed until
patient loses almost 30% of her blood volume
o As a result, the fetus may be experiencing hypoperfusion
long before mother manifests any signs
o Early and rapid fluid resuscitation should be initiated even if
mother is normotensive
On PE
- Special attention is given to abdominal examination
- Uterus remains protected by pelvis until approximately 12
weeks’ AOG and is relatively well sheltered from the abdominal
injury until then
o As the uterus grows, it becomes more prominent and more
vulnerable to injury
- Measurement of fundal height provides a rapid approximation of
the gestational age. At 20 weeks’ gestation, it is at the level of
umbilicus and is approximately 1cm per week of gestation
- Intrauterine hemorrhage or uterine rupture may result in
discrepancy in measurement
- A pelvic exam is performed by obstetrician if possible, evaluate
for:
o Vaginal bleeding
o Ruptured membranes
o Bulging perineum
- Vaginal bleeding may indicate
o Abruptio placentae
o Placenta previa
o Preterm labor
BLUNT TRAUMA
- Most common cause of fetal death is Abruptio placenta
- Deceleration of fetal heart rate – earliest sign of abruption
PENETRATING TRAUMA
- Maternal death in fewer than 5% of cases
o From gunshot wounds and knife wounds
- The incidence of visceral injury w/ penetrating trauma during
pregnancy is 16-38% in comparison to 80-90% in non-pregnant
patients
- Fetal injury occurs in up to 70% of cases, with a 40-70% rate of
fetal death d/t direct injury or preterm labor
DIAGNOSTIC
- Supraumbilical diagnostic peritoneal lavage
- Diagnostic Laparoscopy
- CT scan
- Local wound exploration, and observation
- Treatment options include surgical exploration
EMERGENCY CESAREAN DELIVERY
- Emergency CS may indicated in:
o Maternal arrest after 4 minutes of unsuccessful
resuscitation
o Fetal compromise with a stable mother if the fetus is of
viable gestational age
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o Obvious impending maternal death
o When the gravid uterus interferes with trauma-related
surgical intervention
- May also improve chances of maternal survival by removing
aortocaval compression and increasing cardiac output
- No fetal survival has been documented when fetal heart tones
were absent before emergent delivery
- Fetus should be viable
- Delivery of the viable fetus may also improve chances of
maternal survival
- No fetal survival has been detected when fetal heart tones were
absent before emergent delivery
- But a 75% chance of fetal survival has been reported when fetal
heart tones were present and gestational age was at least 26
weeks
- Maternal and fetal survival rates as high as 72% and 45%
respectively
- Best chance for fetal survival with an intact infant is when
cesarean delivery occurs within 5 minutes of maternal death.
Four minutes of resuscitation followed by a 1-minute cesarean
delivery offers the best chance for survival

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