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Surgery During Pregnancy: Using Radiographic Studies in the Diagnostic Work Up of the Pregnant Patient

Posted Mar 15 2011 6:37pm

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. Optimal maternal outcome may require radiologic imaging, sometimes with ionizing radiation. A risk-benefit discussion with your physician should occur prior to any diagnostic study.

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 first of a two part series focusing on recommendations from the most recent literature regarding the diagnostic work-up and radiological imaging of surgical problems in pregnant patients. Recommendations are based on guidelines provided by the Society of American Gastrointestinal Endoscopic Surgeons.

Imaging Studies

Ultrasound

 Ultrasound imaging during pregnancy is safe and useful in identifying the source of acute abdominal pain in the pregnant patient. There have been no adverse effects to the mother or fetus reported from the use of ultrasound. This has made it the initial radiographic test of choice for most gynecologic causes of abdominal pain including ovarian masses, torsion, placental abruption, placenta previa, uterine rupture and fetal demise. Ultrasound is also a useful study for many non-gynecologic causes of abdominal pain, including symptomatic gallstones and appendicitis.

CT Scan

 The newest generations of Computed tomography (CT) Scanners are designed to deliver a low radiation dose and may be used with caution in the evaluation of abdominal pain during pregnancy. In general, radiation doses for CT scans of both the abdomen and pelvis are considered safe, with only a slight risk in affecting organ development of the fetus. However, each institution has its own CT scan protocols and radiation doses, and it is important to ensure that everyone involved in the patients’ care makes every attempt to minimize fetal radiation exposure.

Magnetic Resonance Imaging

Magnetic Resonance Imaging (MRI) without the use of intravenous Gadolinium can be performed at any stage of pregnancy. MRI provides excellent soft tissue imaging without ionizing radiation and is safe to use in pregnant patients. No specific adverse effects of MRI on fetal development have been reported. Intravenous Gadolinium agents cross the placenta and may be detrimental; therefore their use during pregnancy should be confined to select cases where it is considered essential.

The bottom line with radiological imaging during pregnancy is that prompt and accurate diagnosis should take priority over concerns for ionizing radiation. Fetal mortality is greatest when exposure occurs within the first week of conception. Routine radiographs should always be avoided; however under emergent situations imaging studies may be performed during any trimester with minimal radiation doses.

Part two of the article series continues with Surgical Intervention in the pregnant patient…..


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