Safety and timing of nonobstetric abdominal surgery in pregnancy.

BACKGROUND/AIMS: Abdominal disorders occurring during pregnancy pose special difficulties in diagnosis and management to the obstetrician and surgeon. The advisability of nonobstetric abdominal surgery during pregnancy is uncertain. Our objective was to evaluate the safety and timing of abdominal surgery during pregnancy. METHODS: We retrospectively reviewed 77 consecutive gravid patients undergoing nonobstetric abdominal surgery from 1989 to 1996 at an urban academic medical center and a large affiliated community teaching hospital. Medical records were evaluated for clinical presentation, perioperative management, preterm labor, and maternal and fetal morbidity and mortality. RESULTS: The rate of nonobstetric abdominal surgery during pregnancy was 1 in every 527 births. Among the 77 patients, the indications for surgery were adnexal mass (42%), acute appendicitis (21%), gallstone disease (17%) and other (21%). There was no maternal or fetal loss or identifiable neonatal birth defect. Preterm labor occurred in 26% of the second-trimester patients and 82% of the third-trimester patients. Preterm labor was most common in patients with appendicitis and after adnexal surgery. Preterm delivery occurred in 16% of the patients, but appeared to be directly related to the abdominal surgery in only 5%. CONCLUSION: Surgery during the first or second trimester is not associated with significant preterm labor, fetal loss or risk of teratogenicity. Surgery during the third trimester is associated with preterm labor, but not fetal loss.     

Primary hyperparathyroidism during pregnancy.

Historically, primary hyperparathyroidism during pregnancy was associated with significant risk of maternal morbidity and fetal death. Maternal hypercalcemia results in fetal hypercalcemia, leading to suppression of fetal parathyroid gland function. Neonatal hypocalcemia with tetany is a common occurrence after birth when maternal calcium flow is interrupted. From 1930 to 1990, 109 cases of women with primary hyperparathyroidism associated with pregnancy have been reported, 39 of whom were treated surgically before delivery. Although fetal mortality rates for medically treated women have improved, fetal morbidity continues to remain higher than in women who undergo surgical treatment of parathyroid disease during pregnancy. Of 850 patients treated surgically for primary hyperparathyroidism since 1960, 12 were pregnant. Four of the patients were treated medically during pregnancy and underwent surgery after delivery; all four infants had neonatal hypocalcemia and tetany. The remaining eight patients were treated surgically during pregnancy: six in the second trimester and two (one with associated pancreatitis and one with hypercalcemic crisis) during the first trimester. There was no fetal or maternal morbidity or death in the surgical group. Parathyroid adenomas were present in 10 of the patients, hyperplasia in one, and parathyroid carcinoma in one. The management of maternal primary hyperparathyroidism diagnosed during pregnancy should be based on the patient's symptoms and severity of disease. Hyperparathyroidism characterized by progressive symptoms should be treated surgically, preferably during the second trimester. Symptom-free patients and those with mild hypercalcemia diagnosed in the third trimester may be managed medically, postponing operation until after delivery.     

Management of biliary tract disease during pregnancy: a decision analysis

Background The appropriate management of biliary tract disease during pregnancy is uncertain. Although laparoscopic cholecystectomy can be performed safely during pregnancy, the timing and indications for this surgical intervention have not been firmly established. Methods We constructed a Markov decision analytic model that incorporates maternal well-being and fetal outcome into a choice between nonoperative management (NM) and laparoscopic cholecystectomy (LC) for pregnant women with biliary tract disease (BTD). Our model cycles through weeks of pregnancy for a cohort of 200 gravid women presenting with biliary tract disease in both the first and second trimesters. Weekly state probabilities and utilities for fetal outcome were derived from the literature, while weekly utilities for disease and operative states were estimated in consultation with obstetricians. We cycled the model from 6 to 42 weeks and from 19 to 42 weeks to simulate first and second trimester presentations. Outcomes are expressed in quality pregnancy weeks (QPWs). One QPW is the utility of a normal healthy week of pregnancy. Results A comprehensive search of the literature yielded a fetal death rate following LC for biliary tract disease of 2.2% and following NM of 7%. Relapse rates were found to be trimester dependent and estimated to be 55%, 55%, and 40% in the first, second, and third trimester, respectively. For a hypothetical cohort of 100 women presenting with biliary tract disease in their first trimester, LC generated 12,800 QPWs compared with 12,400 QPWs for NM, an average gain of 4 QPWs per woman. For the cohort of women entering the model in the second trimester, 11,600 QPWs were accrued by the LC group and 11,400 QPWs by the NM group, an average gain of 2 QPWs per woman. These findings were sensitive only to changes in fetal death rates under the two treatment arms. Conclusions Laparoscopic cholecystectomy is superior to nonoperative management for pregnant women presenting in the first or second trimester with biliary tract disease.     

Severe fetal bradycardia in a pregnant surgical patient despite normal oxygénation and blood pressure

PURPOSE: To report and discuss a case of fetal bradycardia in a parturient under anesthesia for cholecystectomy despite normal maternal oxygenation and arterial blood pressure. CLINICAL FEATURES: A 27-yr-old woman (gravida 2 para 1), with a fetus of 34 weeks gestation, received general anesthesia for cholecystectomy. After anesthesia induction and tracheal intubation, anesthesia was maintained with oxygen, sevoflurane and iv remifentanil infusion. While preparing for surgery, the fetal heart rate decreased within about half a minute to 70 beats x min(-1) and remained at that level. The maternal blood pressure, heart rate and oxygen saturation were normal. An emergency Cesarean delivery was performed. The infant had Apgar scores of 1 at one minute, 5 at five minutes, 7 at ten minutes and required resuscitation after birth. CONCLUSION: Ideally, women having non-obstetric surgery during the third trimester of pregnancy will have intraoperative fetal heart rate monitoring.     

Suspicion of acute appendicitis in the third trimester of pregnancy: pros and cons of a laparoscopic procedure

The presentation of acute appendicitis during pregnancy may cause diagnostic and therapeutic difficulty. Delay in diagnosis may lead to increased maternal and fetal risk. Therefore, an aggressive surgical approach is mandatory, even though this may result in an increased number of appendectomies for normal appendices. Diagnostic laparoscopy, followed by laparoscopic appendectomy in case of inflammation, seems a logical strategy. We present the case of a 36-week pregnant woman who presented with suspicion of acute appendicitis. The pro and cons of a laparoscopic approach in the third trimester of pregnancy are discussed as is its safety by reviewing the literature.     

The acute abdomen in the pregnant patient

Background: The acute abdomen in the pregnant patient poses a difficult diagnostic and therapeutic challenge to the surgeon. Appendicitis, cholecystitis, and bowel obstruction account for the majority of the abdominal pain syndromes which require surgical intervention. Laparoscopy is being used increasingly in the diagnosis and operative management of these disorders. Methods: We examine our experience over the last 3 years with 47 women who developed significant abdominal pain during pregnancy. Thirty-four patients had symptomatic gallstone disease, nine had appendicitis, two had incarcerated inguinal hernias, and two had pelvic masses. Twenty-two patients with biliary colic and two patients with acute cholecystitis were managed conservatively during pregnancy. Twenty-three of these underwent laparoscopic cholecystectomy in the postpartum period. A total of 23 women required surgical intervention during pregnancy and 15 underwent a variety of laparoscopic procedures. Ten patients underwent laparoscopic cholecystectomy, and five had laparoscopic appendectomy. The remaining five patients had open appendectomy. Among the 15 laparoscopic procedures, four were performed in the first trimester, seven were performed in the second trimester, and four were performed in the third trimester. Results: Laparoscopy didn't result in increased maternal morbidity. There were no congenital malformations, fetal losses, or premature deliveries in the pregnant patients who underwent laparoscopy. Conclusions: Laparoscopy can be a useful means of diagnosis and in addition a therapeutic tool in selected pregnant patients with abdominal pain. Close maternal and fetal monitoring is essential during and after the procedure. Laparoscopic cholecystectomy is safe and can be performed without additional risk to the fetus for those who require surgical intervention during pregnancy.     

妊娠期急性胰腺炎的诊断和治疗：附48例报告

目的 探讨妊娠期急性胰腺炎的临床特点和诊断与处理原则.方法 回顾性分析8年收治的妊娠期急性胰腺炎48例的临床资料.38例行非手术治疗(治愈36例);10例手术治疗,手术以清除坏死组织和终止妊娠为主.结果 全组以单纯性胰腺炎居多,占64.58%(31/48).孕妇死亡5例(10.42%).胎儿死亡3例(6.25%),均为重症胰腺炎患者.孕妇合并重症胰腺炎的病死率为29.41%.结论 妊娠期急性胰腺炎属于发病率不高,但病死率较高的严重疾患,是妊娠合并外科急腹症死亡的首位因素.该病治疗以非手术治疗为主,病情严重者应及时手术治疗,并不因妊娠而改变手术指征.治疗中同时需顾及孕妇和胎儿的安全.     

Complete small bowel obstruction secondary to transomental herniation in pregnancy

During pregnancy, abdominal pain can be caused by both obstetric and non-obstetric causes. Non-obstetric causes of severe abdominal pain during pregnancy must always be considered. Complete bowel obstruction caused by an internal hernia is rare in obstetric surgical patients. Delays in diagnosis can occur due to non-specific signs and symptoms which can be present in normal pregnancy, and a reluctance to operate on the pregnant patient. Prompt diagnosis and early surgical intervention is the cornerstone for a good outcome. Surgical intervention during pregnancy is associated with increased risk of foetal loss. The use of intra-operative cardiotocography for foetal monitoring in non-obstetric surgery remains controversial.     

Anesthesia for non-obstetric surgery in the pregnant patient

Surgery during pregnancy is relatively common. The present review of the literature will focus on relevant issues such as maternal safety during non-obstetric surgery in pregnancy, teratogenicity of anesthetic drugs, the avoidance of fetal asphyxia, the prevention of preterm labor, the safety of laparoscopy, the need to monitor the fetal heart rate and will finally give a practical approach to manage these patients.