Download Surgery of the Pregnant Patient

Acta Medica 2016; 5: 37–46
acta medica
R EVIEW
Surgery of the Pregnant Patient
Derya KARAKOÇ1, [MD]
1 Hacettepe University Faculty of Medicine,
Department of General Surgery, Associate
Proffessor
* Corresponding Author: Derya KARAKOÇ,
MD, Hacettepe University Medical School
Department of General Surgery,
Sihhiye, Ankara, 06100, Turkey
e-mail: [email protected]
A BST R AC T
Nonobstetric surgery during pregnancy is not rare. Physiologic changes due to
pregnancy, the insufficiency and potential side effects of imaging methods and
the vulnerability of the fetus and the mother are some of the topics that necessitate additional care during preoperative decision making, operation and postoperative care of these patients. While trying to highlight some of the maternal
and fetal concerns during pregnancy for general surgeons, this review also tries
to summarize some of the common surgical problems that obstetricians can face
during pregnancy.
Key words: Surgery, pregnancy
Received 16 November 2015; accepted 15 January 2016;
published online 25 February 2016
T
he incidence of nonobstetric surgery during
pregnancy is 1–2% [1]. Pregnancy causes profound anatomical and physiological changes to
the mother which can lead to difficulty in diagnosis, surgical decision making, preoperative, operative and postoperative care. Besides these changes, concern for the well being of the fetus complicate the process most. The surgeon taking care of a
pregnant patient must be aware of the changes pregnancy brings, must adhere to general surgical principles and some of the surgical disorders complicating pregnancy.
Physiologic Changes Of The Pregnancy
Fluid Homeostasis and Blood Volume
To provide the required perfusion of the placenta and the fetus, blood volume expands under the
influence of renin angiotensin system and antidiuretic hormone during pregnancy [2,3]. This process starts as early as the 6th week of pregnancy and
progresses until the 34th week4. By the end of gestation body water increases by approximately 3–4 L;
of this, 2–3 L comprise of placental-fetal circulation
and the remainder is due to expansion of the maternal blood volume. When the effect of increased plasma volume is evaluated; it can be interpreted that
© 2016 Acta Medica. All rights reserved.
there would be a decrease in plasma oncotic pressure which can lead to interstitial edema and as a result the mother would tolerate blood loss with little
change in vital signs. On the other hand, placenta
lacks the ability to autoregulate flow, this is the reason fetal distress may be the earliest sign of maternal fluid loss.
Cardiovascular System
Preload increases due to the increase in blood volume, but the vasodilatory effect of progesterone
causes a decrease in afterload. Cardiac output increases. Stroke volume increases by 20–30% and
heart rate increases 15–20 beats/minute compared
to baseline. All chambers of the heart dilate and this
predisposes heart to arrhythmia. Mitral regurgitation and atrial fibrillation may develop throughout
pregnancy. During late pregnancy, a holosystolic
murmur over medial aspects of bilateral breast may
be heard which is called as mammary soufflé and
preexisting murmur may get louder. A louder S1 is
expected but sustained S3 or S4 gallop requires further evaluation. Although leg edema is a common
finding, it should be remembered that sudden onset
leg edema may be a sign of thromboembolic disease
or preeclampsia [4,5,6].
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A Surgical and Obstetrical Issue
Respiratory System
both by pituitary and placental secretion which lead
The maternal respiratory system has to deal with to increase in cortisol level. Thus the diagnosis of
the excessive CO2 produced by the fetus and has to Cushing Syndrome and adrenal insufficiency may
provide the additional O2 demand. In addition, be- be difficult during pregnancy [9]. Gonadotrophincause of the enlarged uterus and increased intraab- releasing hormone and corticotrophin-releasing
dominal pressure the diaphragm gets elevated. To hormone are both expressed by the placenta and
compensate for the increased need in this difficult their levels rise during pregnancy. Human chorionposition the chest circumference increases [7]. The ic gonadotropin which structurally is similar to TSH,
tidal volume increases 30–50% and the respirato- may cause differences in thyroid functions. As there
ry rate increases slightly, as a result minute venti- is need for increased glucose and aminoacids for the
lation increases and respiratory alkalosis may arise. fetus, there is great change in the carbohydrate and
Peak flow and forced expiratory volume at 1 second fat metabolism. Lipolysis increases to provide fatty
(FEV1) do not change, but functional residual capac- acid and glycerol which is the preferential substrate
ity decreases especially at the supine position. Due for maternal gluconeogenesis [10]. Both insulin and
to the exertion dyspnea, the diagnosis of respiratory insulin resistance also increase during pregnancy.
problems may be difficult during pregnancy. Besides
the changes of lower respiratory system, upper re- Hematologic System
spiratory system also undergoes numerous chang- The increase in plasma volume relative to red blood
es such as the edema of pharynx and larynx which cell mass results in a physiologic anemia of pregresults in difficulty in intubation and necessitates nancy and hematocrit value during pregnancy is apsmaller endotracheal tubes. In addition, the blood proximately 33%. A physiologic leukocytosis occurs
vessels in the nose undergo vasodilatation causing because of increased cortisol production and the
capillary engorgement which may lead to rhinitis, white blood cell count can be as high as 14000 cells/
nasal congestion and nose bleeding [6].
mm3. Although the increase in serum leukocyte
count does not affect immune function, it decreases
the value of this test as a screening tool for pathologGastrointestinal System
During pregnancy, serum transaminase and bilirubin ical conditions such as appendicitis [4]. Pregnancy
levels are decreased slightly whereas serum alkaline leads to a procoagulant state with the increase in the
phosphatase levels are increased because of placen- majority of the clotting factors, decrease in the qualtal production. Placenta also produces gastrin which ity of natural anticoagulants and a reduction in fiincreases gastric acidity [6]. The gravid uterus causes brinolytic activity. These changes are greatest at the
an increase in gastrointestinal transit time by its me- time of delivery [11].
chanical effect and elevated progesterone may contribute to this. Progesterone also reduces the eosoph- Renal System
ageal sphincter tone and as a result gastroesophageal Increased plasma volume, cardiac output and sysreflux, esophagitis, nausea, vomiting and constipation temic vasodilatation in pregnancy leads to renal vasare common during pregnancy [8]. While the hiatal cular dilatation which in turn causes an increase in
herniation risk increases, the complications of groin glomerular filtration rate and effective renal plasma
hernia decrease as the gravid uterus prevents the in- flow [12]. The renal collecting system dilates from
testine from coming into contact with the pelvis. The the first trimester as a result of a combination of
anatomical alterations with the displacement of gas- the effects of progesterone mediated smooth mustrointestinal organs may cause difficulty in the diag- cle relaxation and the compression of the ureters at
nosis of acute abdominal pathologies. The stretch of the pelvic brim, resulting in hydroureteronephrothe peritoneum which results in desensitization can sis. These lead to urine stasis, increasing the incidence of urinary tract infections, nephrolithiasis
lead to the loss of peritoneal irritation signs.
and pyelonephritis.
Endocrine System
Pregnancy causes a great change in endocrine sys- Breast
tem. One of the major changes occur in cortisol Serious changes occur in breasts throughout preglevel. Pregnancy increases corticotrophin releas- nancy in response to an increase in the circulating
ing hormone and adrenocorticotrophic hormone estrogen, progesterone and prolactin. Early in the
38
© 2016 Acta Medica. All rights reserved.
Acta Medica 2016; 5: 37–46
first trimester, estrogen and progesterone secreted
by the corpus luteum induce lobuloalveolar formation and proliferating glandular epithelium, causing progressive branching of the lactiferous ducts.
During the second trimester, placental estrogen induces proliferation and differentiation of the alveolar
epithelium into secretory epithelium. Estrogen, progesterone and prolactin cause the alveoli to branch,
resulting in the enlargement of the breast. Then prolactin stimulates milk production. These physiological changes of the breast cause a diffuse and marked
increase in parenchymal density and breast becomes
firm and nodular on palpation [4].
Laboratory Changes of Pregnacy
The physiologic changes of pregnancy may lead to
quite a lot of laboratory changes. Some of the laboratory changes of pregnancy are summarized in
Table 1.
Imaging of the Pregnant Patient
Karakoc
an all-or-nothing threshold at 10 rads of exposure
during the first 8 weeks of gestation. However, exposures higher than 10 rads do not occur in routine
medical care. When potential effect of radiation exposure and estimated threshold dose of radiation are
weighed against the gestational age of the fetus, it is
seen that all-(death of embryo) or-none effect can occur by 5–10 rad exposure at 0–2 weeks; congenital
multisystem anomalies and growth retardation can
occur by 20–25 rad exposure at 3–8 weeks; severe
mental retardation, IQ deficit and microcephaly can
occur by 6–31 rad exposure at 8–15 weeks and severe mental retardation can occur by 25–28 rad exposure at 16–25 weeks of gestation [13,14]. When the
approximate fetal radiation exposure by commonly used radiographic studies are evaluated, it is seen
that a single chest X-Ray causes 0.00007 rads, computed tomography of the head causes less than 0.013
and computer tomography of the chest during first
trimester causes 0.002 rads of exposure. These doses
are comparable to exposure doses during transcontinental flight [5].
One of the most important challenges when diagnosing the pregnant patient is the use of imaging
methods, because of the fear of potential effects of Ultrasonography
the methods on the fetus. First, it should be kept in Is the primary investigation in the diagnostic evalmind that any delay in making the diagnosis or any uation of the pregnant patient. Both transabdomiimproper diagnosis may be damaging on both the nal and endovaginal techniques can be used to evalfetus and the mother far beyond the possible side ef- uate the uterus, ovaries and other pelvic structures.
fects of the imaging tools. Thus, it should be kept in The disadvantages of ultrasound are its operator demind that diagnostic tools should be used with cau- pendency and factors such as bowel gas, the gravtion and taking their usefulness, radiation exposure, id uterus and obesity, which may limit the quality of
use of contrast material, their need for proper diag- the examination. There are no documented adverse
nosis and management of the patient in to account effects of ultrasonography on fetus. An upper limat all times.
it of 720 mW/cm2 for spatial-peak temporal average
Ionizing radiation may cause physical and chem- intensity is proposed for obstetric ultrasound. The
ical processes leading to either cellular death result- Doppler technique is not recommended in the first
ing in morphological changes or changes in nucle- trimester because of the potential harmful effect of
ar DNA leading to carcinogenesis, chromosomal ab- the heating of tissues [15–17].
errations and genetic mutations [13]. This means
that the potential effects of radiation on the fetus Computer Tomography (CT)
are fetal loss, malformation and cancer in later life CT is the investigation of choice when there is a
[13]. Fetal loss is most probable when exposure oc- life-threatening situation and rapid diagnosis is recurs during the first 2 weeks of gestation, but expo- quired, especially at the third trimester of pregnancy.
sure during this time is uncontrolled and not no- CT is the primary tool in cases of hypovolemic blunt
ticed as women are not yet aware of their pregnan- trauma or severe sepsis when a variety of sites of incy in this period. During the organogenesis period jury or infection need to be evaluated. When CT is
which occurs between 2–15 weeks, maternal expo- used in pregnant patients, automatic exposure consure should be minimized, because the fetus is most trol is to be used to reduce the radiation exposure.
susceptible to teratogenic effects during this period. Protocols should optimize settings to reduce the
The upper limit of fetal radiation exposure is thought dose as much as possible without losing image qualito be 5 rads. The risk of fetal loss appears to have ty. Shielding can be used, which in turn may provide
© 2016 Acta Medica. All rights reserved.
39
A Surgical and Obstetrical Issue
psychological benefit to the patient and the physician. In any situation a careful risk-benefit analysis
is required before the decision of performing CT in
pregnancy [15,18]. When CT is performed, the pregnant woman should be counseled regarding the possible increased occurrence of childhood cancers after fetal irradiation [19]. Iodinated contrast crosses
the placenta and enters the fetus at doses commonly used for diagnostic studies. In vivo animal studies
have not demonstrated mutagenic or teratogenic effects. No fetal thyroid dysfunction has been demonstrated following its use, although it has effect on
maternal thyroid tissue.
in pregnancy because of the risk of exposing the fetus to high magnetic fields and to gadolinium based
MRI contrast. In late pregnancy it is difficult for the
patient to assume the prone position for enough
time to acquire the images. MRI can be used for
evaluation of the diagnosed patient [20].
Preoperative Evaluation and Preperation
Risks of surgery during pregnancy are increased for
not only the fetus but the mother as well. Physiologic
changes in the pregnant patient increase pulmonory
complications because establishing an airway is difficult due to airway edema and the increased risk of
aspiration. Due to stasis and increase in coagulation
factors there is tendency for thromboembolism, and
the risk of urinary tract infections increase because
of urinary tract dilatation, stasis and urinary catheterization. Risks to the fetus determine the timing
of surgery during pregnancy. There are the risks of
hydrocephaly and abortus during the first trimester
and risks of preterm labor and technical difficulty
during the last trimester [21,22]. As a result, surgery
is preferred to be performed during the second trimester when possible during pregnancy.
Magnetic Resonance Imaging (MRI)
MRI is accepted to be safe during pregnancy providing an overall topographic display and lacking ionizing radiation. MRI is best avoided unless the potential benefits outweigh the theoretical risks. This
statement refers to machines in clinical use at 1.5T
or less. The safety of 3T MRI has not been proven
yet. Because of the known association between gadolinium contrast agents and nephrogenic systemic fibrosis, concerns have been raised regarding the
use of gadolinium in pregnancy. Gadolinium based
contrast agents cross the placenta and are excret- Position of the patient
ed by the fetal kidneys in to the amniotic fluid and Aortacaval compression caused by the uterus, decan be swallowed back by the fetus. Despite the lack creases venous return which in turn decreases carof any evidence of adverse effects after MRI studies diac output and impairs uteroplacental perfusion.
in human fetus, gadolinium based contrast agents That is why the patient should be kept in left lateral
are classified as category C. MRI use is getting more decubitus position when possible.
common especially for the diagnosis of abdominal
Drug Use During Pregnancy
pain during pregnancy [18].
One of the main concerns for the surgery of a pregnant patient is the use of anesthetic, antibiotic and
Imaging of The Breast
Ultrasound is the first method to diagnose breast le- analgesic drugs and the verdict on which are to be
sions during pregnancy. Ultrasound examines the used before/during/after surgery. Besides the immorphology of the lesion and it can be used to tar- mediate drugs used for surgery; cardiac, respiratoget the lesion to prepare it for biopsy. Ultrasound is ry, hematologic and dermatologic medications may
also valuable to monitor the response to chemother- also be needed. Pharmacokinetics of drugs change
apy during pregnancy. The use of mammography during pregnancy due to increased renal clearance,
during pregnancy is limited because of the greater volume of distribution and changes in protein binddensity of the breast tissue and the prominence of ing. Drugs during pregnancy are rated in to 5 cateductal pattern, caused by the increase of fluid in the gories by United States Food and Drug administraparenchyma and ducts during pregnancy which de- tion. Category A is for drugs for which controlled
crease the sensitivity of the method. Concerns about studies demonstrate no risk, category B for drugs
radiation may cause hesitation in the use of mam- which present no evidence of risks in humans, catmography. A standard two-view mammogram ex- egory C for drugs for which risks cannot be ruled
poses the fetus to only 0.004 Gy of radiation, which out, category D for drugs with potential evidence
is not very irritant to the fetus especially in the third of risks and category X for drugs contraindicated in
trimester. MRI of the breast is not preferred early pregnancy [23]. It should be kept in mind that the
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© 2016 Acta Medica. All rights reserved.
Acta Medica 2016; 5: 37–46
Karakoc
Table 1. Laboratory Changes of Pregnancy
Hematologic Parameters
Hemoglobin
Decreases; 10-12 gr/dl
White Blood Cells
Increase; 14000/μl
Trombocytes
Normal
Erythrocyte sedimentation rate
Increases; can not be used during
pregnancy
Fibrinogen
Increases
D-Dimer
Increased rate of false positivity
Renal Functions
Blood Urea Nitrogen
≤ 14 mg/dl
Electrolytes
Normal
Albumin
3.0 gr/dl
Total protein
6.0 gr/dl
Bicarbonate
Decreases
Creatinine
≤ 0.8 mg/dl
Creatinine clearance
Increases
Liver Functions
Transaminases
Normal
Bilirubin
Normal
Alkaline Phosphatase
Increases
Blood Gases
pH
Slight alkalosis; 7.44
pCO2
28-32 mmHg
Thyroid Functions
TSH
Normal; May be decreased
sT4
Normal; May be increased
sT3
Normal
evaluation of the necessity of a drug is more important than its category and accidental exposure does
not warrant termination of pregnancy; because any
process which distresses the mother can effect the
fetus more than the medications [5].
with small diameter tubes and cricoid pressure may
be needed during intubation.
Analgesia
Acetaminophen is accepted to be safe during pregnancy and benzodiazepines should not be used
during organogenesis, labor and lactation. Opioids
are category C on short term and category D on
long-term use and nonsteroid anti-inflammatory
drugs are appropriate only for acute and short-term
use. They shouldn’t be used after 34 weeks of gestation because they have the risk to induce pulmonary
hypertension in the newborn.
Antibiotics
Are considered to be safe during pregnancy although
lately there are concerns about the risk of antibiotics
to induce childhood cancer [25]. Penicillin, erythromycin and cephalosporins are considered to be safe
during pregnancy whereas gentamycin should be
used sparingly as it may cause toxicity. Quinolones,
claritromycine and tetracyclines should never
be used.
Prophylaxis for Deep Vein Thrombosis
Establishment of effective intravascular volume, early mobilization, use of compression socks and pneumatic compression are preferred applications for the
prevention of deep venous thrombosis. For selected
high risk patients heparin or low molecular weight
heparin can also be used [26].
Fetal Monitorization
Monitoring fetal heart rate may be needed after 24
weeks of gestation. Fetal heart rate monitoring detects alterations in fetal perfusion and was designed
for labor and delivery. It may indicate maternal
stress such as hypoxia and hypotension and correcting maternal stress can correct fetal heart rate readings [5].
Surgical Technique
Anesthesia
Technically
speaking, abdominal surgery is of great
Most anesthetic agents are in the category C. A consensus statement published in 1998 in The New concern during pregnancy because of the gravid
England Journal of Medicine did not list any anes- uterus. Although classically laparotomy is the conthetic agent as definitive causes of fetal anomalies. ventional route of approach, laparoscopy is gaining
Inhalation and local anesthetics, muscle relaxants, high acceptance and use. Appendectomy, cholecysnarcotic analgesics and benzodiazepines are known tectomy, adnexial surgery are among the most freto be safe in pregnancy [24]. Tidal volume should be quently applied laparoscopic surgeries during pregincreased 30–40%, the patient should be intubated nancy [27,28]. Gasless method has also started to
be used [29]. Benefits associated with laparoscopy
© 2016 Acta Medica. All rights reserved.
41
A Surgical and Obstetrical Issue
include decreased postoperative pain, lower estimated blood loss, less analgesic use, earlier return to
normal function and shorter hospital stay. It is also
less stressful for maternal physiology and therefore
potentially better for the fetus. Risks of laparoscopic
surgery include theoretical risk of trauma to the fetus, risk of maternal absorption of CO2 and technical
difficulty [5]. During laparoscopy the table should
be tilted to right or left and trandelenburg position
can be preferred. Initial abdominal access can be accomplished with open, Veress needle or optical trocar technique. CO2 insufflation of 10–15 mmHg can
be used safely and intraoperative CO2 monitoring by
capnography should be used during the laparoscopy
of the pregnant patient [30].
Possible Surgical Disorders of Pregnancy
Acute Appendicitis
Is the most common nonobstetric surgical problem
of the pregnant patient with an incidence of 1/1500
pregnancies [31]. Although it can be seen throughout the whole pregnancy, it is more common in the
second trimester [32]. Anatomic and physiologic
changes caused by pregnancy may cause a delay in
the diagnosis of acute appendicitis because symptoms of appendicitis like anorexia, nausea and vomiting are frequently seen during pregnancy and laboratory changes like leukocytosis are also common
during normal pregnancy. Cephaled and counterclockwise displacement of the appendix changes the
place of abdominal pain and the displacement of the
visceral organs from the abdominal wall caused by
the gravid uterus complicates the physical findings.
Differential diagnosis of acute appendicitis during
pregnancy is a long list which includes obstetric disorders such as ectopic pregnancy, ruptured corpus
luteum cyst, ablation of placenta, chorioamnitis and
preterm labor; gynecologic disorders such as pelvic
inflammatory disease, endometriosis, adnexial torsion and degeneration of the myoma; urologic disorders such as pyelonephritis and urolithiasis and gastrointestinal disorders such as gastroenteritis, acute
cholecystitis, pancreatitis, intestinal obstruction and
gastrointestinal cancer. There is no consensus on
the best diagnostic pathway for appendicitis in pregnancy [33]. Ultrasound is the technique of choice for
investigating suspected appendicitis. Visualisation
of a blind–ending and dilation to more than 6 mm
diameter, aperistaltic and non-compressible tubular
structure arising from the caecum is important for
the diagnosis [34]. The sensitivity and specificity are
42
86% and 81% respectively [35]. If the ultrasonography is negative or doubtful, magnetic resonance imaging can be used for selected cases, with a sensitivity and specificity of 100% and 93%. The treatment of choice for acute appendicitis during pregnancy is appendectomy. Due to the diagnostic difficulties, the negative exploration rate is greater than
the nonpregnant state [36]. Negative exploration
rate reaches to 20–35% for pregnants while it is 15%
for non-pregnant appendicitis patients. The highest
and lowest rates of negative appendectomy are encountered in the second and last trimesters respectively [37].
Complications increase with the delay of diagnosis. Perforation and abscess cause a dramatic increase in fetal mortality. Fetal loss is 3–5% for acute
appendicitis, but it reaches to 20–36% with complications. When the surgery is delayed 24 hours, perforation risk increases from 0% to 66%. Maternal
mortality increases from 0.1% to 4% with perforation. There is no risk between negative exploration and early appendectomy to induce preterm labor which is 10–15% within the first week of surgery and returns to normal population rate thereafter [38–40]. Although laparoscopic technique may
cause higher fetal loss; appendectomy can be performed either by open or laparoscopic technique
[28]. The choice depends on the experience of the
surgeon, health status of the patient and the stage
of the pregnancy. When open method is preferred,
the incision is performed over the area of maximal tenderness.
Gall Bladder Disease
Is the second most common non-obstetric emergency, after appendicitis, requiring surgery during pregnancy. Hormonal changes of pregnancy may lead
to formation of gallstones. Progesterone delays the
emptying of the gall bladder and increases its residual volume with its smooth muscle relaxing and
cholecystokinin inhibiting effects and estrogen hypersaturates bile cholesterol. Asymptomatic biliary stones are found in 4.5% of pregnancies and 10–
40% necessitates surgery when they become symptomatic. The risk of acute cholecystitis is 1–6/10000
pregnacy [41,42]. Ultrasonography is the most appropriate initial imaging study for the evaluation of
acute cholecystitis in pregnancy and magnetic resonance imaging is the second step of imaging. It has
a 98% sensitivity and 94% specificity for the detection of biliary disease and is more sensitive than
© 2016 Acta Medica. All rights reserved.
Acta Medica 2016; 5: 37–46
Karakoc
ultrasound for the detection of choledocholithia- Uteroplacental perfusion is the key point of fetal
zis [43]. Symptomatic cholelithiazis necessitates in- survival that is why fluid resuscitation is the most
travenous hydration, diet regulation and analgesia. important point of the therapy. Surgery depends on
Antibiotics should be used in cases of acute chole- the etiology of the obstruction.
cystitis and cholangitis. The risk of abortus is 12%
for the first trimester and 5.6% for the second tri- Thyroid Disease
mester and the risk of preterm labor is 40% for the Routine screening for thyroid disease is not reclast trimester with cholecystectomy by laparotomy. ommended during pregnancy and thyroid imaging
For this reason cholecystectomy in the second tri- is performed for symptomatic patients and for the
mester is preferred when the diagnosis is made in follow up of the known patients. Hypothyroidism
the first trimester and after the birth when the di- is rare during pregnancy, because it causes spontaagnosis is made in the last trimester for uncompli- neous abortion in the first trimester. When it develcated, symptomatic biliary disease. For complicated ops later in the pregnancy, it causes severe complicacases surgery is needed regardless of the gestational tions as preeclampsia, placental abruption, preterm
age [44]. When possible, laparoscopy is the preferred delivery, perinatal morbidity, mortality and postform of surgery for cholelithiasis [45].
partum hemorrhage [4]. Hyperthyroidism is seen
2/1000 pregnancies [48]. The differential diagnosis
Intestinal Obstruction
include hydatiform mole, hyperemesis gravidorum
Complicates 1 in 1500–66431 of pregnancies and and multiple pregnancies; as hypothyroidism hyper55% of the cases are due to adhesions [46]. Lately, thyroidism may also cause premature delivery, plathis rate seems to increase because of the increas- cental abruption and preeclampsia [48,49]. The risk
ing rate of abdominal surgery in young females. of thyroid crisis should not be forgotten while evalVolvulus is the second leading cause of intestinal ob- uating hyperthyroid patient. Among the antithyroid
struction during pregnancy. Volvulus constitutes drugs methimazol cannot be used during the first
4% of intestinal obstructions for non-pregnants, but trimester because of its teratogenic effect and pro25% for pregnants. Three periods of pregnancy in- pylthiouracil needs caution because of its hepatocrease the risk of intestinal obstruction. These are toxic effect [48]. For selected cases with noncomplithe 6–20 week period in which the uterus becomes ance or complication of treatment, surgery may be
an intraabdominal organ, the 32–36 week peri- necessary during the second trimester of pregnancy.
od in which the fetal head gets engaged to the pel- Monitorization of fetal heart rate and fetal growth is
vis and the early postpartum period. The patients necessary during the treatment of hyperthyroidism.
present with nausea, vomiting and abdominal pain,
symptoms that might be easily overlooked because Adrenal disease
of their general commonplace nature in pregnancy; Hyperaldosteronism, Cushing’s syndrome and
but the occurrence of these symptoms after the first pheochromocytoma are rare conditions complitrimester should always raise a suspicion about gas- cating pregnancy [50]. The diagnosis of hyperaltrointestinal pathology. Maternal mortality associ- dosteronism during pregnancy is difficult because
ated with bowel obstruction is about 6% with a fetal of the upregulated renin-angiotensin-aldosterone
mortality rate of about 26% [46]. Diagnosis of bow- system and physiologic elevation of aldosterone; so
el obstruction can be made from history and phys- the suppressed renin level is important for the diical examination, including the use of ultrasonog- agnosis. The resulting hypertension and hypokaleraphy, plain radiographs and magnetic resonans mia can lead a major complication that is why the
imaging. Ultrasonography can demonstrate dilat- control of hypertension is the most important step
ed bowel loops with air fluid levels. Aperistalsism of the therapy. Spironolactone is contraindicated
might also be seen with high-grade obstruc- as it may cause ambiguous genitelia[51]. Surgery
tion. Ultrasonography diagnosis of bowel obstruc- may be needed for unilateral lesions with uncontion is limited by the inability to identify the ob- trolled hypertension [4]. Another rare reason of
struction transition point, so there may be a need hypertension of pregnancy may be pheochromocyfor cross sectional study. Magnetic resonant imag- toma. Increased levels of metanephrine and cateing can visualize the point of transition and the ar- cholamines in 24-hour urine are important for dieas of hemorrhage, abscess and inflammation [47]. agnosis. Uncontrolled pheochromocytoma may
© 2016 Acta Medica. All rights reserved.
43
A Surgical and Obstetrical Issue
lead major complications, fetal and maternal mortality especially during the labor so the control of
hypertension is important. Alfa and beta blockers are the drugs to be used but caution is needed as beta blockers can cause intrauterine growth
retardation and the long term effects of phenoxybenzamine on fetus are not known. Surgery may
be needed during the second trimester of pregnancy. Another disorder of the adrenal gland to complicate pregnancy is the Cushing’s syndrome. The
diagnosis is difficult because of the physiologic hypercortisolemia of pregnancy which is due to the
upregulated hypothalamic-pituitary-adrenal axis.
Supressed ACTH and elevated 24-hour urinary
cortisol are important for diagnosis. As with other adrenal lesions Cushing’s syndrome is also associated with severe complications. Medical therapy is not preferred during the pregnancy because of
their teratogenic effect [51].
physiologic changes in pregnancy. Many diagnostic
radiographic procedures do not cause harm to the
fetus when used with proper shielding. Ultrasound
evaluation to exclude preexisting malformations
prior to interventions is needed and serial growth
scans should be performed. When possible, surgery should be delayed until the second trimester.
Open or laparoscopic surgery may be safe in experienced hands. Surgical procedures performed after
24 weeks of gestation should include intraoperative
fetal monitoring. Systemic chemotherapy should not
be started during the first trimester if at all possible. Chemotherapy treatments should be followed
by fetal well-being checks. Most chemotherapeutic
agents are safe during the 2nd and 3rd trimester. The
dosage should be the same as for non-pregnant patients based on actual height and weight of the patient. Chemotherapy should not be administered after 35 weeks of gestational age or within 3 weeks of
anticipated delivery. Radiation therapy should preferably be given postpartum. Termination of pregnancy may be considered in case of need for immediate treatment. No difference in prognosis has been
shown after termination of pregnancy. Differences at
the survival rates between pregnant and non-pregnant cancer patients may exist. Delivery should be
based on obstetrical indications with efforts made
to deliver at term. If preterm delivery is indicated,
when possible, fetal maturity should be confirmed.
The placenta should be examined for metastatic disease. No evidence exists that subsequent pregnancies increase the risk for disease recurrence. Breastfeeding is contraindicated with chemotherapy and
hormonal therapy [53,54].
Cancer
Approximately 20–30% of female cancer occurs in
women younger than 45 years of age [52]. The incidence of malignancy in pregnancy has increased
from 1/2000 in 1964 to 1/1000 deliveries in 2000 reference needed. The rate of increase is attributed to
not only higher rates of cancer in general but also
to a delay in childbearing to the third and fourth
decades of life [53]. Breast cancer, cervical cancer,
Hodgkin’s lymphoma, melanoma, leukemia, ovarian, colorectal and thyroid cancers are among the
frequent cancers of pregnancy. For along time, gestational cancer was associated with the thought that
the use of surgery, chemotherapy and radiotherapy
was incompatible with normal fetal outcome. The
experience gained mostly by small studies or stud- Conclusion
ies with obvious limitations, in combination with re- Surgery is not a rare entity complicating pregnancent developments in clinical and radiation oncolo- cy. Although the most appropriate time is the second
gy have changed the practice in gestational cancer. trimester, surgery can be performed in also first and
There are some basic principles for the management last trimester when needed especially for emergent
of pregnant cancer patient. Multidisciplinary clin- conditions. Surgical mortality of the pregnant paical management is fundamental to optimize out- tient is equivalent to the non pregnant and best fetal
comes. Patients should be informed in detail about outcomes are obtained with best maternal outcomes.
the risks and benefits of treatment, their beliefs and To achieve the best maternal outcomes, it is importwishes should be acknowledged. The treatment of ant to understand the physiologic, anatomic, laborapregnant patients should take in to consideration the tory and pharmacokinetic changes of pregnancy.
44
© 2016 Acta Medica. All rights reserved.
Acta Medica 2016; 5: 37–46
Karakoc
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