In the 19th century, surgeons provided the foundations of operative obstetrics and gynecology. Today, these fields have specialized and are distinct, however there is crossover with diagnoses in a shared patient population. This point is dedicated to serving as a general overview for managing pregnant patients from a general surgery perspective.
Interventions
- Around 800 nonobstetrical, urgent surgical procedures are performed every year on pregnant patients in the United States
- These procedures are completed to treat
- Appendicitis
- Biliary disease
- Ovarian torsion
- Breast disease
- Bowel obstruction
- Trauma
- Appendectomy and cholecystectomy make up 50% of the surgeries performed during pregnancy
Timing
- Past
- Avoided due to
- Surgery and anesthesia teratogenesis
- Preterm birth
- Spontaneous abortions
- Preferred timing was during 2nd trimester as it was though to carry the lowest risk
- Avoided due to
- Present day
- A pregnant patient should not be denied a necessary surgery or have the surgery delayed, regardless of trimester.
- Recommendations from ACOG and the ASA as listed below:
- Medically necessary urgent/emergent nonobstetric surgery shouldn’t be denied or delayed regardless of trimester to avoid the well-established increased morbidity and mortality for both mother and fetus associated with delays in care
- Currently used anesthetics have been shown to have no teratogenic effects in humans when used in standard concentrations at any gestational age
- Elective surgery should be postponed until after delivery
- Given potential for preterm delivery, corticosteroid administration should be considered with fetuses at viable premature gestational ages in conjunction with an obstetrician, and patients should be monitored in the perioperative period for signs or symptoms of preterm labor
- If the fetus is considered previable, it is generally sufficient to assess the fetal heart rate by Doppler before and after the procedure
- If the fetus is considered viable (≥24 weeks), simultaneous fetal heart rate and contraction monitoring should be performed before, during, and after the procedure to assess fetal well-being and absence of contractions
- Surgery should be done at an institution with neonatal and pediatric services
- An obstetric care provider with cesarean delivery privileges should be readily available
Imaging
- While it is recommended to avoid unnecessary radiation in pregnant patients, if imaging is necessary (e.g., CT, radiograph), then it should be ordered.
- Imaging hierarchy
- Ultrasound
- MRI
- CT, radiograph
- Fetal radiation risk is a cumulative risk. Single studies show that fetuses rarely reach the 50 mGy threshold that would warrant concern.
- ACOG Committee Opinion: Guidelines for Diagnostic Imaging During Pregnancy and Lactation
Physiologic and Anatomy Changes
- Cardiovascular
- Heart is displaced superolaterally
- Blood volume increases and acts as protective buffer against blood loss during delivery
- Respiratory
- Progesterone increases sensitivity to CO2 and induces airway dilation
- Uterus pushes diaphragm upward → dyspnea in third trimester
- Gastrointestinal: progesterone reduces lower esophageal sphincter tone → results in heartburn, nausea, vomiting
- Renal: kidneys enter state of hyperfiltration due to increased plasma volume
Surgery Guidelines
- ACOG Committee Opinion: Nonobstetric Surgery During Pregnancy
- Guidelines for the Use of Laparoscopy during Pregnancy (SAGES)
- Non-obstetric Acute Abdomen in Pregnancy: A Review of Literature