Surgery in pregnancy
Veronika Pavukova20881625
SSC060 - Medway Integrates Surgical Training Programme
Introduction
Pre-operative care
Laparoscopy
Abdominal surgery
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
Pre-operative care
Informed consent
Discuss risks to both mother and foetus
Discuss blood transfusion
HIV risk
Discuss pain management
NSAIDs, opiods, dosage
Tests and screening of mother
Venous thromboembolism risk
Monitor foetus
Stress on foetus may worsen existing conditions or induce preterm labour
Obstetrician readily available
In case of spontaneous preterm labour
Surgical related risks to baby
0.25% emergency caesarean
2.6% LBW baby
10% miscarriage
OVERALL DEEMED LOW RISK
4% maternal death
3.3% preterm labour
Medication and pain management
NSAIDs
Corticosteroids
Opioids
Never administered after 32 weeks of gestation-> risk of prolonged bleeding effects
Administered for foetal benefit due to potential for preterm delivery (applicable with foetuses at viable gestational age)
Risk of neonatal withdrawl in late pregnancy (3rd trimester)
Radiology and pregnancy
Protection or result of complications?
- 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
(The radiographer 2012)
Laparoscopy
- Generally safe in all 3 trimesters
-> becomes technically complicated in 3rd trimester)-> anatomical changes
- 3x increased risk in open surgery (Nation Inpatient Sample)
Methods:
-> open trochar placement
-> needle inserted into alternate point
(BUPA)
(ejog)
Hasson technique
Methods
- Incision directly into abdominal wall
- Cut through peritoneum made
- Entry into abdomen
- Insertion of instruments
Advantages
Disadvantages
- Prevention of bowel injury
- Prevention of gas embolism
- Prevention of vascular injuries
- Allows correct anatomical repair of the incision
- Longer and more complex procedure
- Difficult in obese patients
- Difficult to maintain pneumoperitoneum
(MRSIRG)
(Research gate)
Verres needle
Methods
- Needle used to pierce abdominal wall tissue
- Peritoneal cavity inflated
- Trocar easily inserted
Disadvantages
Advantages
- Minimises intraoperative gas leakage
- Injuries to major vessles
-> abdominal aorta, inferior vena cava, common iliac arteries
(JNS)
(RSNA Journals)
Abdominal surgery in pregnancy
Appendicitis
Obstacles
- Highest rates of surgically-induced labour
- General reluctance for abdominal surgery in pregnancy
- Complicated diagnosis
1:800 - 1:1500 pregnancies
Cholecystitis
1:1600 pregnancies
-> changed anatomy, so physical examination difficult
- Pregnancy or pathology symptoms?
Conclusion
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.
(MDedge)
References
- 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
QUESTIONS?
Surgery in pregnancy
Veronika Pavukova
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Transcript
Surgery in pregnancy
Veronika Pavukova20881625
SSC060 - Medway Integrates Surgical Training Programme
Introduction
Pre-operative care
Laparoscopy
Abdominal surgery
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/GynPre-operative care
Informed consent
Discuss risks to both mother and foetus
Discuss blood transfusion
HIV risk
Discuss pain management
NSAIDs, opiods, dosage
Tests and screening of mother
Venous thromboembolism risk
Monitor foetus
Stress on foetus may worsen existing conditions or induce preterm labour
Obstetrician readily available
In case of spontaneous preterm labour
Surgical related risks to baby
0.25% emergency caesarean
2.6% LBW baby
10% miscarriage
OVERALL DEEMED LOW RISK
4% maternal death
3.3% preterm labour
Medication and pain management
NSAIDs
Corticosteroids
Opioids
Never administered after 32 weeks of gestation-> risk of prolonged bleeding effects
Administered for foetal benefit due to potential for preterm delivery (applicable with foetuses at viable gestational age)
Risk of neonatal withdrawl in late pregnancy (3rd trimester)
Radiology and pregnancy
Protection or result of complications?
- dangerous foetal dose = 10-20 rads
- PanScan = <5 rads
- CT of the abdomen= 0.3 rads
Protection and precautions:(The radiographer 2012)
Laparoscopy
- 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(BUPA)
(ejog)
Hasson technique
Methods
Advantages
Disadvantages
(MRSIRG)
(Research gate)
Verres needle
Methods
Disadvantages
Advantages
- Injuries to major vessles
-> abdominal aorta, inferior vena cava, common iliac arteries(JNS)
(RSNA Journals)
Abdominal surgery in pregnancy
Appendicitis
Obstacles
1:800 - 1:1500 pregnancies
Cholecystitis
1:1600 pregnancies
- Expanded uterus
-> changed anatomy, so physical examination difficultConclusion
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.
(MDedge)
References
QUESTIONS?