Surgery During Pregnancy: Operating on the Pregnant Patient
Posted Mar 18 2011 12:26am
It is common for women to experience abdominal pain during their pregnancies. In some pregnant women, this abdominal pain may progress to a severe intensity, possibly requiring surgical intervention. Abdominal pain in the pregnant patient can be separated into obstetrical and non-obstetrical causes. Approximately 1 in 500 to 1 in 635 women will require non-obstetrical abdominal surgery during their pregnancies. The most common non-obstetrical surgical emergencies complicating pregnancy are acute appendicitis, inflammation of the gallbladder (cholecystitis), and intestinal obstruction. Other conditions that may require operations during pregnancy include ovarian cysts, masses or torsion, symptomatic gallstones, adrenal tumors, symptomatic hernias, complications of inflammatory bowel diseases, and abdominal pain of unknown cause.
No matter the etiology of the condition the goal of all surgical interventions during pregnancy should be to minimize fetal risk without compromising the safety of the mother. In pregnant women with surgical issues, fetal outcome depends on the outcome of the mother. The first article in this series described how optimal maternal outcome may require radiologic imaging, sometimes with ionizing radiation.
Given the wide variety of details in any health care problem, the surgeon must always choose a course of treatment which is best suited to the individual patient given the circumstances in each clinical situation. This is particularly true in pregnant patients who often present with atypical clinical signs and symptoms, leading to a delay in diagnosis. Therefore, it is important that both surgeons and their pregnant patients are aware of the latest evidence based techniques in diagnosis and management of surgical conditions during pregnancy which lead to the best possible outcomes, and that this information is communicated effectively between both parties.
The following is the second part of a two part series focusing on recommendations from the most recent literature regarding the operative treatment of surgical problems in pregnant patients. Recommendations are based on guidelines provided by the Society of American Gastrointestinal Endoscopic Surgeons.
Once the decision to operate has been made, the surgical approach (open laparotomy versus laparoscopy) should be determined based on the skills of the surgeon and the availability of the proper staff and equipment. A detailed discussion regarding the risks and benefits of surgical intervention should be undertaken with the patient. The benefits of laparoscopy during pregnancy are the same as those in non-pregnant patients and include less postoperative pain, decreased length of hospital stays, and faster return to work.
Surgery may be performed in any trimester of pregnancy. General practice has been to delay surgery until the second trimester in order to reduce the rates of spontaneous abortion and preterm labor. However, recent literature has shown that pregnant patients may undergo laparoscopic surgery safely during any trimester without any increased risk to the mother or fetus. Postponing necessary operations until after childbirth may, in some cases, increase the rates of complications for both mother and fetus.
During its infancy, some argued that laparoscopy was contraindicated during pregnancy due to concerns for uterine injury and fetal perfusion. As surgeons have gained more experience with laparoscopy it has become the preferred treatment for many surgical diseases in the gravid patient. Surgery for some of the more commonly encountered conditions are described below:
In the past non-operative management of symptomatic gallstones in pregnancy has been recommended. At present early surgical management is the treatment of choice. Early surgical management of pregnant patients with symptomatic gallstones is supported by data showing recurrent symptoms in 92% of patients managed non-operatively who present in the first trimester, 64% who present in the second trimester, and 44% who present in the third trimester. This delay in surgical management results in increased rates of hospitalizations, spontaneous abortions, preterm labor, and preterm delivery compared to those undergoing gallbladder removal.
Altogether, non-operative management of symptomatic gallstones in pregnant patients results in recurrent symptoms in more than 50% of patients, and 23% of such patients develop acute gallbladder inflammation or gallstone induced inflammation of the pancreas (gallstone pancreatitis). Gallstone pancreatitis results in fetal loss in 10% to 60% of pregnant patients.
The significant morbidity and mortality associated with untreated gallbladder disease in the pregnant patient favor surgical treatment. Laparoscopic cholecystectomy is preferred because of the beneficial outcomes and favorable side-effect profile. There have been no reports of fetal demise for laparoscopic cholecystectomy performed during the first and second trimesters. Furthermore, decreased rates of spontaneous abortion and preterm labor have been reported in laparoscopic cholecystectomy when compared to open surgery.
The laparoscopic approach is the preferred treatment for pregnant patients with presumed appendicitis, and a large number of studies have shown the technique to be safe and effective with very low rates of pre-term delivery and fetal demise.
Accurate and timely diagnosis of appendicitis in the pregnant patient may minimize the risk of fetal loss and optimize outcomes. In some circumstances clinical findings may be enough for diagnosis. When the diagnosis remains uncertain, prompt ultrasound, CT, or MRI are useful aids in diagnosing appendicitis, and decrease the rate of negative laparoscopy. Recent studies confirm the safety of laparoscopic appendectomy in the pregnant patient, compared to conventional open surgery for appendicitis.
The incidence of ovarian masses during pregnancy is 2%. Most of these masses discovered during the first trimester are functional cysts that resolve spontaneously by the second trimester. 80% to 95% of ovarian masses less than or equal to 6 cm in diameter in pregnant patients spontaneously resolve; therefore non-operative management is acceptable in such cases.
Persistent masses are most commonly functional cysts or mature cystic teratomas with the incidence of malignancy reported at 2% to 6%. Historically, the concern over the possibility of cancer and risks associated with emergency surgery have led to elective removal of masses that persist after 16 weeks and are larger than 6 cm in diameter. Recent literature supports the safety of close observation in these patients when ultrasound findings are not concerning for cancer, tumor markers are normal, and the patient is asymptomatic. In the event that surgery is indicated, reports support the use of laparoscopy in the management of ovarian masses in every trimester.