www.downstatesurgery.org Irina Kovatch, MD SUNY Downstate Morbidity and Mortality

Irina Kovatch, MD
SUNY Downstate
Morbidity and Mortality
March 15, 2012
Case Presentation
 36yo F at 37 wks of gestation c/o 4d hx of right
sided abd pain, N/V, anorexia
Seen in ED 3 days prior with similar complains and
sent home on zofran/pepcid for gastroenteritis
PMH: G1P0, gestational DM
PSH: none
Meds: humulin qhs, zofran, pepcid
Case Presentation
 no distress
 abd gravid, right sided tenderness, no rebound, no
Labs: WBC - 18.9, T.B. - 1.9
 6mm tubular structure in RLQ - may represent appendix
 GB sludge, no evidence of acute cholecystitis, CBD 2mm
Air and fluid
density noted
inferior to the
Hospital Course
Admitted to L&D
OB evaluation
OR 2/8/12
 epidural anesthesia
 ex-lap, washout of contained perforated appendicitis,
placement of 2 JP drains
 preop and postop fetal monitoring – wnl
Hospital Course
 WBC 21
 fetal distress (category III fetal heart tracing)
Emergency c-section under GETA
 placental abruption
 hemorrhagic amniotic fluid
 EBL - 2L
Intraop surgical re-evaluation
 abd washout and repositioning of the drains
Hospital Course
POD 1-4
 Ileus
 WBC decreased to 15
 JP – purulent output
CT Abd/Pelvis
in RLQ
7.1x5.4 cm
Hospital Course
POD 6
 IR drainage of abscess (60cc, 12 Fr pigtail)
 Diet
 POD 7-12
 JPs – minimal output
 IR drain – 50cc/day of purulent fluid
Repeat CT Abd/Pelvis
POD 22 - Drain Study
no abscess,
8-25 cc/day
Admitted to NICU in critical condition
APGAR: 5 (1min), 8 (5min)
Weight - 3505 gm
Labs: WBC - 25.7, Creat - 1.7, pH - 7.0, BE: -11.9
 CPAP x 2 days
 IV Abx
 NPO x 3 days
 IV D10 (FS 30-60)
Poor Moro reflex
Brain ischemia and petechial hemorrhage on MRI
Cortical thumbs bilaterally
Left shoulder distocia and left Erb’s Palsy
Large PDA with L -> R shunt and right atrial
Posterior thorax hemangioma
Pregnant women and
non-obstetric surgery
Elective nonobstetric surgery is avoided because of
additional risks to the mother and the fetus
Surgical procedures are necessary in ~0.75%
Advances in diagnostic modalities have improved
the clinician's ability to diagnose surgical conditions
Reduced need for exploratory surgery
Reduced risks associated with delayed diagnosis
of disorders requiring surgical intervention
Diagnostic modalities: CT, MRI, US and Doppler
for Nonobstetric Conditions
Requiring Surgery During Pregnancy
Physiological Changes
Related to Pregnancy
Cardiovascular and hemodynamic
Endocrine and metabolic
Respiratory tract
Gastrointestinal tract
Cardiovascular and
Expansion of the plasma volume and an increase in
RBC mass
 begin at week 4 of pregnancy and peak at 28-34 weeks
Plasma volume expansion exceeds the increase in
red cell volume, leading to "physiologic anemia“
Major hemodynamic changes include
 increase in cardiac output
 reductions in SVR and systemic BP
Changes in coagulation factors produce a
hypercoagulable state
Major hematologic changes include
Physiologic anemia
Mild thrombocytopenia
Increased procoagulant factors, and diminished
WBC begins to increase in the 2nd month of
pregnancy and plateaus in the 2nd or 3rd trimester
(9000 - 15,000 cells/microL)
Endocrine and Metabolic
Endocrine adaptations
 begin just after conception
 evolve through delivery
 revert back to the nonpregnant state over several
 virtually all endocrine glands are affected
Placental hormones have major affect on glucose
and lipid metabolism to ensure that the fetus has
an ample supply of fuel and nutrients at all times
Respiratory Tract
Hormonal changes associated with pregnancy and
the mechanical effect of the gravid uterus elevate the
diaphragm and increase the thoracic diameter
Pregnancy is a state of relative hyperventilation
centrally mediated through progesterone
respiratory rate does not change, but tidal volume
increases resulting in a 50% increase in MV
PaO2 increases and PaCO2 decreases during
Gastrointestinal Tract
Higher incidence of GERD and gastric aspiration
 increased intra-abdominal pressure
 relaxation of the lower esophageal sphincter
Gallbladder volume and the lithogenicity of bile are
Serum alk phos levels are significantly increased,
amylase levels may be normal or slightly elevated
Abdominal bloating and constipation are probably
caused by hormonal changes that reduce small
bowel and colonic motility
Surgical Issues
Potential concerns of anesthesia and surgery include
 teratogenesis
 miscarriage
 hemorrhage resulting in hypotension and/or transfusion
 infection
 aspiration
 untoward reactions to anesthetic agents
 preterm labor/delivery
 risks and complications associated with specific surgical
Surgical Issues
Physician and patient need to weigh the risks of
surgery and anesthesia on the developing fetus
against the maternal and fetal risks of delaying
surgical intervention
There are no randomized trials evaluating
management of nonobstetrical surgery in
pregnant patients - all recommendations are
made based on data from observational studies,
expert opinion, and extrapolation from trials in
nonpregnant individuals
Surgical Issues
Whenever a pregnant woman undergoes
nonobstetrical surgery, consultations among her
obstetrical provider, surgeon, anesthesiologist,
and neonatologist are important
Personnel and the capacity to perform an
emergent cesarean delivery should be readily
available if fetus has attained a viable
gestational age
Pregnancy is a hypercoagulable state
It protects against excessive blood loss at delivery,
but also increases the risk of a thromboembolic
event in the postsurgical period
SCDs should be used in all pregnant women
undergoing surgery
The need for pharmacologic thromboprophylaxis
should be determined on a case-by-case basis
 scope and length of the procedure
 additional risk factors for venous thrombosis
Antibiotic Prophylaxis
The need for antibiotic prophylaxis depends on the
specific procedure
Antibiotics with a good safety profile in pregnant
women include
 Cephalosporins
 Penicillins
 Erythromycin, azithromycin and clindamycin
Aminoglycosides are relatively safe, but carry a
risk of fetal (and maternal) ototoxicity and
Antibiotic Prophylaxis
Doxycycline is avoided during pregnancy because
other tetracyclines have been associated with
transient suppression of bone growth and with
staining of developing teeth
Trimethoprim and nitrofurantoin are avoided in the
1st trimester because of a potential for increased
incidence of congenital malformations
Fluoroquinolones are avoided during pregnancy
and lactation because they are toxic to developing
cartilage in experimental animal studies
Timing of Nonobstetric
Surgical Intervention
A literature review of studies reported 10.5% of
patients in the 1st trimester miscarried (compared to
8-16% baseline), but there were few details about
these patients and no control group
Some studies have reported higher rates of
miscarriage in 1st trimester abdominal surgery, but
it is not clear whether these higher rates were due to
the surgery itself, the underlying maternal condition
prompting the surgery, or other factors
Non-urgent surgery should be delayed, if possible,
until the early to mid 2nd trimester to avoid use of
potentially harmful drugs during organogenesis
In the early 2nd trimester the uterus is still small
enough to not obliterate the operative field, and the
rate of spontaneous preterm labor is much lower
when compared to the 3rd trimester (1 and 9%,
Prophylactic Glucocorticoids
If gestational age is 24-34 weeks, giving a course
glucocorticoids prior to surgery may reduce perinatal
morbidity/mortality if preterm birth occurs
Decision depends on the estimate of whether the
patient is at increased risk of preterm birth
Despite the potential benefits to the fetus, antenatal
corticosteroids are best avoided in the setting of
systemic infection because they impair the ability of
the maternal immune system to contain the infection
Prophylactic Tocolytics
There is no proven benefit to routine
administration of prophylactic perioperative
tocolytic therapy
Tocolytics are indicated for treatment of preterm
labor until resolution of the underlying, selflimited condition that may have caused the
Minimizing uterine manipulation may reduce
the risk of development of uterine contractions
and preterm labor
Surgical Approach
Laparoscopic surgery offers the same advantages
as to the nonpregnant woman and can be
performed safely during pregnancy
The surgical approach should be based on the
skills of the surgeon and the availability of the
appropriate staff and equipment
During laparotomy, the type of incision depends
on the surgical procedure and gestational age
 a vertical midline incision is recommended as gestation
advances to facilitate exposure and to allow for
extension of the incision
Fetal Heart Rate Monitoring
Maternal hemodynamic stability does not guarantee
that placental perfusion and fetal oxygenation are
The fetal heart rate should be documented pre- and
post-operatively at all gestational ages
Continuous monitoring is recommended for all
viable fetuses (>23-24 weeks) throughout surgery
 by using an electronic fetal heart rate monitor
 by Doppler ultrasound
 for abdominal operations, transvaginal ultrasound may be
Fetal Heart Rate Monitoring
If adequate maternal oxygenation and uterine
perfusion are maintained, the fetus usually
tolerates surgery and anesthesia well
Qualified personnel should be available to
monitor and interpret the fetal heart rate
An obstetrician should be readily available in
case an emergency cesarean delivery is
The fetal heart rate should be monitored in the
recovery room, intermittently for pre-viable
fetuses, and continuously for the viable fetus
Cesarean delivery is performed for standard
obstetrical indications; the presence of a
recent abdominal incision does not preclude
pushing in the second stage of labor
Anesthesia Risks - GETA
Difficult and failed intubation – 8x
Desaturation – 3x
Hemodynamic instability
Increased risk of anesthesia-related maternal
Newborn effects - all anesthetic induction and
maintenance agents cross the placenta
 neonate may require intubation
Anesthesia Risks - Regional
Has a better safety profile for the mother than GETA
and is preferred for surgery during pregnancy
The major concern is maternal hypotension which
may reduce placental perfusion
However, most pregnant women undergoing
surgery for nonobstetric conditions will need either
laparoscopy or urgent explorative laparotomy
requiring GETA
GETA has a 17-fold higher complication rate than
regional anesthesia
Acute Appendicitis
Most common general surgical problem
encountered during pregnancy
Incidence: 0.06 - 0.1% or 1 in 1500 deliveries
Pregnant women appear to be less likely to
have appendicitis than age-matched
nonpregnant women
Clinical Manifestations
Similar to those in nonpregnant individuals
Slightly higher rate of appendicitis in the 2nd
More likely to rupture during pregnancy, possibly
due to delay in diagnosis and intervention
RLQ pain is the most common symptom
Although the location of the appendix migrates a
few centimeters cephalad with the enlarging uterus,
most commonly pain occurs close to McBurney's
point regardless of the stage of pregnancy
Differential Diagnosis
Includes the causes of abdominal pain in
nonpregnant individuals and pregnancy-related
causes of abdominal pain
Leukocytosis can be a normal finding
In appendicitis, nausea and vomiting, if they occur,
follow the onset of pain
Peritoneal findings may be less prominent because
gravid uterus keeps the anterior abdominal wall (and
omentum) away from the inflamed appendix
Imaging - US
Initial imaging modality of choice
Sensitivity – 86%, specificity 81%
Allows for visualization of the pelvic organs and can
be used to exclude other causes of RLQ pain
Noncompressible blind ended tubular structure in
the RLQ with a maximal diameter >6 mm
The gravid uterus can interfere with performance of
this technique, esp. in the 3rd trimester, leading to a
high negative laparotomy rate when ultrasound
results are inconclusive
Imaging - MRI
Can be useful in cases where ultrasound
examination is inconclusive
Sensitivity – 91%, specificity – 98%
Offers an alternative to CT and avoids exposure to
ionizing radiation
If there is going to be a prolonged wait before an
MRI can be performed, the increasing risk of
rupture over time should be considered
Imaging - CT
Modifications to the CT protocol can limit estimated
fetal radiation exposure to less than 3 mGy (vs.
standard abdominal CT of 20 - 40 mGy) and do not
limit diagnostic performance
Doses known to potentially cause adverse fetal
 30 mGy for risk of carcinogenesis
 50 mGy for deterministic effects
CT should be used when clinical findings and
ultrasound are inconclusive and MRI is not available
Management Approach
Decision to proceed to surgery is based on diagnostic
imaging and clinical judgment
Delaying intervention >24 hours increases the risk of
perforation (14–43%)
Risk of fetal loss is higher
 if appendix had perforated (36 vs. 1.5%)
 if peritonitis/peritoneal abscess (fetal loss: 6 vs. 2%, early
delivery: 11 vs. 4%)
Higher negative laparotomy rate (20 – 35%) is
considered acceptable
Maternal morbidity following appendectomy is
comparable to nonpregnant women unless the
appendix has perforated
Pregnancy related complications are frequent
 surgery in the 1st trimester - spontaneous abortion 33%
 surgery in the 2nd trimester - premature delivery 14%
Cesarean delivery is rarely indicated at the time of
Scant information on long-term outcome in offspring
Perforated Appendix
Urgent laparotomy is necessary with
appendectomy and irrigation and drainage of the
peritoneal cavity
Nonpregnant patients presenting with contained
perforation may benefit from non-operative
 immediate surgery associated with increased morbidity
- e.g. postoperative abscess, enterocutaneous fistula
Very limited evidence to support this approach in
pregnant women
Surgical Approach
If diagnosis is certain - transverse incision over the
point of maximal tenderness
If diagnosis is less certain - lower midline vertical
 permits adequate exposure of the abdomen for
diagnosis and treatment of other surgical conditions
 can also be used for a cesarean delivery, if necessary
Several case reports and small case series on the use
of laparoscopic appendectomy in pregnancy
suggested that it can be performed successfully
during all trimesters and with few complications
Laparoscopic Approach
Long-term data on the safety and efficacy are limited
One systematic review noted a higher rate of fetal loss
Decision should take into consideration
 skill and experience of the surgeon
 clinical factors such as the size of the gravid uterus
Modification of the technique during pregnancy
 slight left lateral positioning during the second half of
 open entry techniques
 limiting intra-abdominal pressure to <12 mmHg
Gallstone Disease
Acute cholecystitis is the 2nd most common
nonobstetrical surgical emergency
Pregnancy increases the risk for gallstones by
decreasing gallbladder motility and increasing
cholesterol saturation of bile
Presentation of gallstone disease is similar to that
in the nongestational state
WBC and alk phos level are normally elevated
in pregnancy - reduces the diagnostic
usefulness of these tests
Significant elevations of the transaminases, alk
phos or D. bili raises suspicion for CBD ,
cholangitis, or the Mirizzi syndrome
US offers the most reliable method for making
the diagnosis of gallstones and acute or chronic
Supportive care for 1st episode of biliary colic
Cholecystectomy for patients with recurrent
biliary attacks
Surgery is safest and easier to perform in the 2nd
or early 3rd trimester, and is technically difficult
near term
Nonsurgical interventions (e.g. ursodeoxycholic
acid) are contraindicated in pregnant women
Acute cholecystitis should be treated with
cholecystectomy during the initial hospitalization
 decreases relapse rates and hospital readmissions
Definitive surgical therapy is required
 for any patient with signs of sepsis
 when gangrene or perforation is suspected
 if patient develops progressive fever or intractable pain
Laparoscopic Approach
Should be used to perform cholecystectomy when
feasible and available
 better surgical exposure
 earlier recovery and reduced postoperative pain
 fewer wound complications
Convert to open technique to avoid injury to
surrounding structures if laparoscopic procedure
cannot be safely and/or effectively completed
Complicated Biliary Disease
Patients with choledocholithiasis, cholangitis, or
biliary pancreatitis require
 intravenous fluids
 antibiotics
 analgesia
 bowel rest
 followed by prompt intervention with ERCP and/or
Bowel Obstruction
Third most common non-obstetrical complication
 most common cause - intraabdominal adhesions (previous
surgery or pelvic infection)
 intussusception and volvulus (5 and 25% respectively)
More likely to happen with advancing gestation
Diagnosis and treatment are similar to that in
nonpregnant individuals
Delay in treatment increases maternal and fetal
morbidity and mortality
Breast Cancer
Pregnancy-associated breast cancer is relatively
Incidence is increasing as more women delay
Predominantly poorly differentiated and
diagnosed at an advanced stage
Breast US and mammography should be used to
evaluate any suspicious breast masses
 Clinically suspicious breast mass requires biopsy for
definitive diagnosis
 regardless of whether or not a woman is pregnant
 despite negative mammographic or ultrasound
 Locally advanced stage disease [stage III or IV]
and/or suspicious symptoms should prompt a
complete radiographic staging evaluation
 Modifications of the standard staging work-up may be
required to protect the fetus
Consider anatomic and physiologic changes related
to pregnancy during evaluation/management
Initial evaluation should focus on establishing
maternal cardiopulmonary stability
Any treatment required to save the mother's life or
treat her critical status should be undertaken,
regardless of her pregnancy
Sometimes, emptying the uterus by performing a
cesarean delivery is required to save the mother's life
Once catastrophic trauma has been excluded, patient
should be evaluated for obstetric complications
Abruption leading to nonreassuring fetal heart rate
patterns and death can occur despite relatively mild
maternal trauma or discomfort
If fetal viability stage is reached, continuous fetal and
uterine monitoring is recommended for at least 4 hrs
Anti-D immune globulin is administered to
unsensitized Rh(D)-negative women who experience
abdominal trauma