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PREGNANCY AND COMMONSURGICAL DISEASES
BY
DR. SEFEEN SAIF ATTYASOHAG TEACHING HOSPITAL
TOPICSIntroductionAcute appendicitisCholecystitis and cholelithiasisIntestinal obstructionHerniasThyrotoxicosisCancer breast
INTRODUCTIONThe incidence of surgical illness is the same in
pregnant women as in nonpregnant women of the same age group
Pregnancy may alter or mask the signs and symptoms of the disease
The fetus must be considered in planning a surgical prcedure
Pregnancy may modify the timing of a semiselective operation or the surgical approach of an emergency abdominal procedure
Purely elective surgery should be deferred until the postpartum period
Any major operation represents a risk not only to the mother but to the fetus as well
During the first trimester ,congenital anomalies may be induced in the developing fetus by hypoxia ,therefore if surgery does become necessary the greatest precaution must be taken to prevent hypoxia and hypotension
The second trimester is usually the optimum time for operative procedures
Diagnostic radiologic examinations of the lower abdomen and pelvis should be avoided during pregnancy ,if possible ,especially during the first 6 weeks of gestation ,when the fetus is particularly susceptible to irradiation
Radioactive isotopes pose a particular hazard to the fetus when they are used in the pregnant patient
Radioactive iodine for thyroid scanning ,selenomethionine for imaging of the pancreas bone scanning with radioactive strontium or calcium are contraindicated during pregnancy because these agents cross the placenta and are taken up by the fetal tissues
Sonography has proven to be useful diagnostic method in many circumstances and avoids the pitfalls of x-ray exposure , at present it is considered safe for use during pregnancy
ACUTE APPENDICITIS Acute appendicitis occurs about once in every 2000
pregnancies The signs and symptoms are the same as in nonpregnant
women ,but they may be considerably modified Because Nausea and vomiting Lower abdominal discomfort Moderate leucocytosis Elevated sedimentation rateAre seen frequently in the first and second trimester therefore errors in diagnosis are more frequently made
The enlarging uterus often carries the appendix higher in the abdomen ,so that McBurney’s point can no longer be used as a point of reference ,and maximal tenderness is proportionately higher
The presence of the gravid uterus may effectively block off the omentum and loops of small intestine and thus hinder the walling off process particularly in the third trimester .therefore ,rupture of the appendix is more often associated with widespread dissemination of infection ,generalized peritonitis and higher death rate
Because of the flaccidity of the anterior abdominal wall in the last trimester ,there may be little rigidity assocciated with inflammation of the appendix and rebound tenderness may be hard to define ,so that one cannot rely upon these physical findings
Treatment of acute appendicitis during pregnancy is by immediate operation
Because of the extreme seriousness of perforation when it occurs ,it is better to remove a normal appendix when the diagnosis is in doubt than to wait for typical signs or symptoms and risk of consequences
Regional anaesthesia is preferred ,and the transverse or oblique muscle –splitting incision should be placed somewhat higher than in the non pregnant woman
In fact ,late in the third trimester the appendix may be in the right upper quadrant of the abdomen and a right paramedian incision is more appropriate
Premature labour is not common following an uncomplicated appendectomy
Appendicular abscess
In appendicular abscess following perforation ,the gravid uterus forms the medial wall of the abscess
This intense inflammatory process initiates uterine contractions ,with premature labour ,with evacuation there is a sudden reduction in the size of the uterus and the abscess ruptures into the general peritoneal cavity
CHOLECYSTITIS AND CHOLELITHIASIS
pregnancy may contribute to the formation of gall stones by:
Encouraging bile stasis Increasing the concentration of cholesterol in
the bile Fostering changes in bile solubilityTherefore cholelithiasis is more common in
women who have borne children
Acute cholecystitis in pregnancy occurs less often than acute appendicitis ,the prevalence being about one in 3500-6500 pregnancies and is associated with gallstones in 50% of cases
The symptoms are the same as in nonpregnant patient with :
abrupt onset of colicky pain in the right upper quadrant of the abdomen
Low grade fever Nausea and vomiting
Acute chlecystitis may be difficult to distinguish from acute appendicitis ,with the high position of the appendix associated with the third trimester of pregnancy
ultrasound is helpful in making the diagnosis
Unlike appendicitis ,however ,acute cholecystitis in the first trimester of pregnancy is best managed conservatively with:
Hospitalization Parenteral fluids Nasogastric suction Antispasmodics Analgesics And broad –spectrum antibiotics
In 3 out of 4 patients treated ,there will be a definite improvement within 2 days ,and a definitive surgical procedure can be deferred until the second trimester or the postpartum period
Surgery should be done whenever there is doubt regarding the differentiation from acute appendicitis or if there is no response to conservative therapy as manifested by
Enlarging mass (empyema) jaundice(common bile duct obstruction) Evidence of rupture Or associated pancreatitis Gallstone-induced pancreatitis increases both fetal and
maternal death rate
INTESTINAL OBSTRUCTION
intestinal obstruction occurs infrequently during pregnancy ,but it should be considered in the differential diagnosis of any pregnant patient with an abdominal scar who develops abdominal pain and vomiting
Adhesive bands are the most common cause of intestinal obstruction
The most frequent causes of postoperative adhesions are appendectomies and gynecological operations
Other causes of intestinal obstruction during pregnancy are volvolus ,intussusception and large bowel cancer
The symptoms and signs of intestinal obstruction are the same as those in the nonpregnant woman,although the clinical picture may be obscured by the nausea and vomiting of early pregnancy ,round ligament pain, and abdominal distention already produced by pregnancy
When operation is indicated ,it should be performed without delay ,and pregnancy should be a second consideration
Near term ,a cesarean section may be required to obtain necessary exposure
HERNIAS
Hiatal hernias are common during pregnancy 15-20 % of pregnant women develop this condition as a result of pressure against the stomach by the enlarging uterus
The principal symptom is reflux esophagitis with severe heartburn ,aggravated by recumbency or the ingestion of a large meal and relieved by an upright position or antacids
Hematemesis may result from ulceration of the esophageal mucosa
Treatment is by: Elevation of the upper half of the body while
reclining Frequent small bland meals AntacidsMost hiatal hernias disappear following the
pregnancy surgical correction is required only for those
cases that persist and remain symptomatic
Umbilical, groin ,and ventral hernias are usually unaffected by pregnancy and can be repaired electively after delivery
Surgery during pregnancy is indicated only in the rare event of an incarcerated or strangulated hernia
THYROTOXICOSIS
Radioactive iodine is absolutely cotraindicated because of the risk to the foetus
The danger of surgery is miscarriageAntithyroid drugs cause goitre and
hypothyroidism to the baby
• Thyroidectomy for thyrotoxicosis during pregnancy should be reserved as a second line of treatment in specific situations such as:
a) persistent high ATD doses required to control maternal thyrotoxicosis ; b) patients who present serious side effects to ATD ,
c) non compliant patients; and finally d) rare cases with upper respiratory compressive symptoms due to goiter
size .
• Thyrotoxic pregnant women should be prepared for surgery by using beta-blocking agents and a 10-14 days course of super-saturated potassium iodide solution (50-100 mg/d) in order to reduce vascularity of the thyroid gland.
• Surgery in pregnancy is safest if it can be undertaken in the second trimester when organogenesis is complete, and thus the fetus is at minimal risk for teratogenic effects of medications, and the uterus is relatively resistant to contraction-stimulating events of drugs
CANCER BREASTCancer breast occurs infrequently during
pregnancy complicating one in 3000 pregnancies
The breast changes that occur during pregnancy make detection of early breast carcinoma much more difficult
In general breast cancers are detected earlier in women who perform breast self examination regularly
The disease is more malignant during pregnancy perhaps as a consequence of hormonal changes and suppression of the immune mechanism
As there is considerable procrastination in diagnosis ,most cases are advanced by the time the diagnosis is made
Needle aspiration will serve to distinguish cysts and galactoceles from solid tumors
Mammography is not very helpful during pregnancy ,because of the increased radiographic density of the breast
Biopsy and appropriate surgical treatment should be undertaken as soon as the cancer is suspected
If the cancer is confined to the breast ,the prognosis is good , if the axillary nodes are involved ,the outlook is poor
The overall cure rate for breast cancer developing during pregnancy or lactation is significantly lower than that of nonpregnant women of comparable age because of delay in diagnosis resulting in more advanced disease
Therapeutic abortion is not indicated in the patient with localized disease of a favorable microscopic type
Interuption of early pregnancy as part of estrogen ablation may be of some palliative benefit to the woman with advanced disease , but if the pregnancy has progressed beyond the 20th week the life of the fetus should take precedence
Pregnancies subsequent to treatment of breast carcinoma are best deferred for 3-5 years ,after the period of greatest risk of recurrence is past
JAUNDICE IN PREGNANCY
Jaundice in pregnancy may result from any liver disease that also affects nonpregnant women or from conditions unique to pregnancy .
The unique conditions include; 1-a generally modest and self-limited elevation in aminotransferase and
bilirubin levels during the first trimester, often in patients with hyperemesis gravidarum ;
2-intrahepatic cholestasis of pregnancy, which occurs during the second and third trimesters and resolves spontaneously after delivery ;
3 -acute fatty liver or 4 -HELLP syndrome (h emolysis, e levated l iver enzymes, and l ow p
latelets) in association with preeclampsia in the third trimester . Acute fatty liver may resemble fulminant hepatic failure, with early delivery being a prerequisite to maternal recovery; a defect in the oxidation of fatty acids is found in some infants born after these pregnancies
UTI IN PREGNANCY
-About 2% of women have acute symptomatic UTI in pregnancy
-Acute infection is associated with low biryh weight , prematurity and maternal anaemia
-Screening for infection in early pregnancy is justified because one -third of women with infection develop ascending UTI
-A seven day course of antibiotics is recommended and a 14 day course in presence of renal infection