Surgery in pregnancy

Veronika Pavukova20881625

SSC060 - Medway Integrates Surgical Training Programme

Surgery in pregnancy

Abdominal surgery

Laparoscopy

Pre-operative care

Introduction

• 8,000 urgent non-OB surgeries annually
• impacts up to 2% of pregnancies

-> high complication rate due to delayed diagnosis/treatment for fear of unnecessary tests/procedures during pregnancy Lack of guidance from NICE within the UK -> recommendations provided by the American College of Ob/Gyn

Introduction

Venous thromboembolism risk

Tests and screening of mother

NSAIDs, opiods, dosage

Discuss pain management

Pre-operative care

Obstetrician readily available

Discuss blood transfusion

Monitor foetus

Informed consent

In case of spontaneous preterm labour

HIV risk

Stress on foetus may worsen existing conditions or induce preterm labour

Discuss risks to both mother and foetus

OVERALL DEEMED LOW RISK

2.6% LBW baby

Surgical related risks to baby

3.3% preterm labour

0.25% emergency caesarean

4% maternal death

10% miscarriage

Medication and pain management

Corticosteroids

Administered for foetal benefit due to potential for preterm delivery (applicable with foetuses at viable gestational age)

Opioids

Risk of neonatal withdrawl in late pregnancy (3rd trimester)

NSAIDs

Never administered after 32 weeks of gestation-> risk of prolonged bleeding effects

(The radiographer 2012)

• dangerous foetal dose = 10-20 rads
• PanScan = <5 rads
• CT of the abdomen= 0.3 rads

Protection and precautions:

• lead shielding
• positioning patient at max distance from radiation source

Radiology and pregnancy

Protection or result of complications?

(BUPA)

• Generally safe in all 3 trimesters

-> becomes technically complicated in 3rd trimester)-> anatomical changes

• 3x increased risk in open surgery (Nation Inpatient Sample)

Methods:

• Hasson technique

-> open trochar placement

• Verress needle

-> needle inserted into alternate point

Laparoscopy

(ejog)

(Research gate)

(MRSIRG)

• Longer and more complex procedure
• Difficult in obese patients
• Difficult to maintain pneumoperitoneum

Disadvantages

• Prevention of bowel injury
• Prevention of gas embolism
• Prevention of vascular injuries
• Allows correct anatomical repair of the incision

Advantages

1. Incision directly into abdominal wall
2. Cut through peritoneum made
3. Entry into abdomen
4. Insertion of instruments

Methods

Hasson technique

(RSNA Journals)

(JNS)

• Injuries to major vessles

-> abdominal aorta, inferior vena cava, common iliac arteries

Disadvantages

• Quick and easy procedure

• Minimises intraoperative gas leakage

Advantages

1. Needle used to pierce abdominal wall tissue
2. Peritoneal cavity inflated
3. Trocar easily inserted

Methods

Verres needle

• Expanded uterus

-> changed anatomy, so physical examination difficult

• Pregnancy or pathology symptoms?

Obstacles

• Highest rates of surgically-induced labour
• General reluctance for abdominal surgery in pregnancy
• Complicated diagnosis

1:1600 pregnancies

1:800 - 1:1500 pregnancies

Cholecystitis

Appendicitis

Abdominal surgery in pregnancy

(MDedge)

Preganancy is not a disease, and pregant women should not be turned away from surgical procedures just because of concerns about the risks. Most surgeries tend to be low risk and are best for the patient to get done as soon as possible.

Conclusion

• NIHR Evidence. (n.d.). General surgery is mostly safe during pregnancy. [online] Available at: https://evidence.nihr.ac.uk/alert/general-surgery-is-mostly-safe-during-pregnancy/ [Accessed 1 Mar. 2022].

• Babb, M., Koren, G. and Einarson, A. (2010). Treating pain during pregnancy. Canadian Family Physician, [online] 56(1), pp.25–27. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2809170/.

• Risks associated with surgery during pregnancy. (n.d.). [online] Available at: https://alderhey.nhs.uk/application/files/7515/7425/6077/Risks_Associated_With_Surgery_During_Pregnancy_PIAG_0011.pdf [Accessed 1 Mar. 2022].

• Aptilon Duque, G. and Mohney, S. (2020). Appendicitis in Pregnancy. [online] PubMed. Available at: https://www.ncbi.nlm.nih.gov/books/NBK551642/.

• Skubic, J.J. and Salim, A. (2017). Emergency general surgery in pregnancy. Trauma Surgery & Acute Care Open, 2(1), p.e000125.

• Bullewww.acog.org. (n.d.). Nonobstetric Surgery During Pregnancy. [online] Available at: https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2019/04/nonobstetric-surgery-during-pregnancy [Accessed 1 Mar. 2022].ted list

References

QUESTIONS?