SURGERY IN THE PREGNANT PATIENT
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References
- Sabiston Textbook of Surgery, 20th ED
- British Journal of Anesthesia
- ACOG Guidelines
SURGERY IN PREGNANT PATIENT
- Pregnant patient present unique clinical challenge
- 1-2% of pregnant women require surgical procedures
- Non-obstetric surgery necessary in up to 1% of
pregnancies
- Most indications are common for the patient’s age group
and unrelated to pregnancy
o Acute appendicitis (1:2000)
o Symptomatic cholelithiasis (6:1000)
o Maternal trauma
o Surgery for maternal malignancy
- In the largest single series concerning surgery and
anesthesia during pregnancy
o 42% - first trimester
o 35% - 2nd trimester
o 23% - 3rd trimester
- Changes in maternal anatomy and physiology and safety
of fetus are among the issues which the surgeon must be
cognizant
- The presentation of surgical diseases in the pregnant
patient may be atypical or may mimic signs and
symptoms associated with normal pregnancy
- A standard evaluation may be unreliable because of
pregnancy associated changes in diagnostic tests or
laboratory test results
- Many physicians may be more conservative in regard to
diagnostic evaluation and treatment
- Any of these factors may result in delay in diagnosis and
treatment ! adverse effects on maternal and fetal
outcome
CHANGES IN PREGNANCY
ANATOMIC CHANGES
- Breast changes
- The diaphragm can be elevated in pregnancy up to 4cm
- The lower chest wall can widen up to 7cm
o “barrel chested” appearance during pregnancy
- Reduced lung capacity
- Bowels are displaced upward and to the periphery d/t
enlarging gravid uterus
- Inguinal swelling secondary to varicosities of the round
ligament
o Often mistaken for inguinal or femoral hernia
o Careful PE and U/S needed
- Changes in uterine size
- Changes in position and orientation of abdominal viscera
from enlarging uterus ! modify the perception or
manifestation of an intra-abdominal process
o Be mindful of the area of maximal area of tenderness
(d/t displacement of viscera)
PHYSIOLOGIC CHANGES
- Many changes to the maternal body through mechanical
and hormonal alterations
- Progesterone and Estrogen
o 2 of the principal hormones of pregnancy
o Mediate many of the maternal physiologic changes in
pregnancy
- ↑ progesterone, and ↓ serum motilin = smooth muscle
relaxation
o Producing multiple effects on several organ systems
Esophagus
- The lower esophageal sphincter (LES) tone is ↓
- When combined with ↑ intra-abdominal pressure ! ↑ in
incidence of GERD
Stomach – diminished gastric tone and motility
Small bowel – Motility is ↓ thus ↑ small bowel transit time
Colon – Pregnancy-related changes usually manifest as
constipation ! ↓ motility and obstruction
↑ in portal venous pressure
- ↑ in pressure in collateral venous circulation
- Dilation of veins of gastroesophageal junction
- Most common result of ↑ pressure ! dilation of the
hemorrhoidal veins
o Complaint of hemorrhoids
Gallbladder
- Function is altered
- As well as chemical composition of bile
- During the second and third trimesters, the volume of
gallbladder may be twice that found in non-pregnant state
- Gallbladder emptying is markedly slower
- ↑ cholesterol saturation
o Sludge and stone formation
o Up to 4% of pregnant patient have gallstones on
routine obstetric U/S
- 1 in every 1000 pregnant patients develop symptoms
Some changes resemble liver disease
- Spider angiomas and palmar erythema
- From elevated estrogen levels
Cardiovascular
- ↑ CO (by up to 40% or 1.5L/min)
- ↑ baseline HR (10-15bpm above normal)
- ↑ plasma volume ! mild dilutional anemia
At 36th to 40th week of AOG
- Cardiac output falls back to almost normal
During 3rd trimester, CO is dramatically ↓ when mother is lying
supine
- ↑ portal venous pressure
- Caused by compromised venous return from lower
extremity
- caused by compression of IVC by gravid uterus
- 30o lateral decubitus position ! relieve compression
Respiratory
- ↓ respiratory function and oxygen reserve as a result of:
o ↑ O2 consumption
o ↓ residual volume and functional residual capacity
o ↑ RR, tidal volume and minute ventilation
o ↑ airway edema
o ↑ Chest wall compliance
Hematologic Changes
- Blood vol – ↑ 30-50% volume
- WBC (mm3) – ↑ 5,000 – 14,000
- Hemoglobin (g/dL) - ↓ 100-140
- Hematocrit (%) – 32-42
- Plasma volume (mL) - ↑ 30-50%
Physiologic Changes in Pregnancy
(Sabiston) – Read and Study this
SAFETY CONCERNS IN SURGERY
RADIOLOGIC CONCERNS
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- Primary organogenesis occurs during this time and the
Category Description Examples
teratogenic effects of radiation, particularly to the
developing CNS, are at the highest A Adequate and well- Vitamin B6
- Greatest concern with radiation exposure is the risk to the controlled studies have Levothyroxine
fetus from exposure failed to demonstrate a risk Folic acid
- Accepted maximum dose of ionizing radiation during to the fetus in the 1st Magnesium
entire pregnancy is 5 rads (0.05 Gy; 5 cGy; 50 mGy) trimester of pregnancy Sulfate
- The fetus is at the highest risk from radiation exposure ! (and there is no evidence Liothyronine
from pre-implantation period to approximately 15 weeks’ in later tri)
gestation (organogenesis)
- Perinatal radiation exposure has been associated w/ B Animal reproduction Metformin
childhood leukemia and childhood malignancies studies have failed to Hydrochlorthiazid
- Higher than 10 cGy (100 mGy) ! Congenital demonstrate a risk to the e
malformation fetus and there are no Cyclobenzaprine
- Avoid unnecessary fetal exposure to ionizing radiation, adequate and well- Amoxicillin
esp. during the 1st and early 2nd trimesters controlled studies in Pantoprazole
FETAL RADIATION EXPOSURE WITH RADIOGRAPHIC pregnant women Insulin
IMAGING Acetaminophen
Aspartane
Famotidine
Ibuprofen

C Animal reproduction Tramadol

studies have shown an Gabapentin
adverse effect on the fetus Amlodipine
and there are no adequate Trazodone
and well-controlled studies Prednisone
in humans but potential Pseudophidrine
benefits may warrant use Fluconazole
of the drug in pregnant Ciprofloxacin
women

D Positive evidence of Lisinopril

MAGNETIC RESONANCE IMAGING (MRI)
human fetal risk based on Alprazolam
- Avoids exposure to ionizing radiation
adverse reaction but Losartan
- Poses an unknown risk to the fetus
o Theoretically, the gradient magnetic fields may potential benefits may Clonazepam
warrant use of drug in Lorazepam
produce electric currents and the high frequency
pregnant women despite Alcohol
currents induced by radiofrequency fields may cause
potential risks Lithium
local generation of heat
Phenytoin
- The National Radiological Protection Board has advised
Most forms of
against the use of MRI during 1st trimester of pregnancy
chemotherapy
- Animal studies have shown no teratogenic effect or ↑
incidence of fetal death or congenital malformations from X *Fetal abnormalities and/or Atorvastatin,
electromagnetic radiation, static magnetic field, there is positive evidence Simvastatin,
radiofrequency magnetic fields, or IV contrast agents of human fetal risk based Thalidomide,
used during MRI on adverse reaction data Warfarin,
*Risks outweigh potential Methotrexate,
ULTRASONOGRAPHY benefits Finasteride,
- Routinely used by obstetricians during pregnancy Isoretinoin
- Although tissue heating and cavitation are theoretical
effects of ultrasound exposure, such effects have never N Has not classified drug
been reported
- Deeper structures are difficult to visualize and may be
obscured by superficial structures that are more echo
dense
Disadvantage:
- It has limited field of view
- Highly operator-dependent
- Despite these limitations, certain disease processes, such
as palpable breast mass, gallbladder stones, or
suspected appendicitis, may be evaluated effectively and
safety

MEDICATION CONCERN
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- Leg elevation

SURGICAL PROCEDURES
Delaying semi-elective surgical procedures until after the first
trimester may reduce the risk for teratogenicity

Surgical procedures
- ↑ risk of spontaneous abortion
- IGR
- ↓ birthweight neonates
Elective surgical procedures are DELAYED until at least 6
weeks after delivery
- Does not produce harm to fetus
- 6 weeks – back to normal physiology of mother
A large survey was done, and showed the ff in women who
ANESTHESIA CONCERNS
require surgery during pregnancy
- Duncan study
- Studies lacked information on indications for nonobstetric
- 2565 pregnant Canadian women
surgical procedures when maternal physiology has
- Statistically significant increase in spontaneous abortion in
returned to NONPREGNANT STATE and when impact on
both the 1st and 2nd trimesters
fetus is no longer a concern
- 6.5 to 7.1%
Emergent procedures ! the life of mother takes priority
Primarily
- An experienced anesthesiologist will be able to modify the
- Safety of mother and fetus
- Risk for spontaneous abortion anesthesia
- Teratogenesis related to anesthetic agents is of major During the 2nd trimester, after organ system differentiation has
occurred, there is almost no risk for anesthetic-induce
concern
malformation or spontaneous abortion
For mother
- Hypotension Later in pregnancy, during the 3rd tri:
- Risk for preterm delivery at its highest
- Hypoxia
- When the pregnant patient requires surgical intervention,
- Airway problem
consultation with obstetrician and possibly perinatologist
The fetus:
- Exposure to teratogenic effects of anesthetic agents is essential
- Risk for preterm labor
- Risk from changes in maternal physiology as a CONCERNS OF PRETERM LABOR
- Rate of premature labor induced by non-obstetric
consequence of anesthesia
intervention is 3.5%
- Incidence of preterm labor associated with non-obstetric
surgery is related to:
Fetal CNS or CVS may be affected by:
o Gestational age – the later the higher
- Maternal hypotension or hypoxia
o Indication for surgery – severity of underlying disease
- Maternal hyperventilation
- Placental passage of anesthetic agents that affect fetal are the most predictive indicators
- Intra-peritoneal surgeries and disease processes with
CNS and cardiovascular system
intra-peritoneal inflammation – most common reasons for
Changes in uterine blood flow and maternal acid-base status
preterm labor
and may cause hypoxemia or asphyxia in fetus
ABDOMINAL PAIN AND THE ACUTE ABDOMEN IN
EFFECTS OF ANESTHESIA
PREGNANCY
Direct or Active effects
- The approach is very similar to that for non-pregnant
- Teratogenic or embryotoxic properties
patients with acute abdomen
Indirect effects or Passive
- Consider the physiologic changes associated with
- Mechanisms whereby an anesthetic agent or surgical
pregnancy when interpreting findings from history and
procedure may interfere with maternal or fetal physiology
- More common physical exam:
o May be part of normal changes in pregnancy
Notes:
o When pregnant patients present with abdominal pain,
- When treating maternal hypotension, vasopressors such
it may be difficult to distinguish a pathophysiologic
as dopamine and epinephrine, although increasing
cause from normal pregnancy-associated symptoms
maternal systemic pressure, have little or no effect on
- On PE, findings may be less prominent than those in non-
uterine circulation
- Phenylephrine and metaraminol are alpha agonists that pregnant
- Some very commonly used laboratory tests have altered
are effective maintaining maternal blood pressure and
reference ranges in pregnancy
preventing fetal acidosis
- Changes can make initial evaluation process somewhat
MANEUVERS THAT INCREASE UTERINE BLOOD FLOW
- Fluid bolus more difficult
o Appendicitis would be expected to produce an
- Trendelenburg position
- Use of compression stockings elevated WBC. Yet pregnancy alone can produce
WBC ranging from 6,000-16,000mm3 in the second
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and third trimesters and from 20,000-30,000/mm3 in
early labor
- Changes in the position and orientation of abdominal
viscera from enlarging fetus – may modify perception or
manifestation of intra-abdominal process
Peritoneal signs may be absent because of:
1. Lifting and stretching of anterior abdominal wall
2. Underlying inflammation has no direct contact with
parietal peritoneum
a. Precludes any muscular response or
guarding that would otherwise be expected
LAPAROSCOPIC SURGERY
- Patients who underwent laparoscopic procedures had:
o ↓ pain
o Shorter hospital stays
o Quicker return to normal activity
- Major concerns of laparoscopy in pregnancy:
o Injury to uterus
o ↓ uterine blood flow – from insufflation
o Fetal acidosis
o Preterm labor from increased intra-abdominal
pressure
- During 2nd trimester, the uterus is no longer contained
within the pelvis
- The open technique for abdominal access can reduce the
risk for injury
o Usually use Hasson trocar (?)
o Really make an incision layer by layer
BREAST CANCER
- Evaluation in suspected:
o A PE with particular attention to the breast and
regional lymph nodes
o Mammogram of breast with shielding
o U/S of the breast and regional lymph nodes can be
used to assess the extent of disease and also guide
biopsy
▪ Ultrasound has been reported to be abnormal in
up to 100% of breast cancers occurring during
pregnancy
▪ Physiologic changes of breast engorgement,
rapid cellular proliferation, and increased
vascularity make a reliable physical examination
difficult
- Assessment of pregnancy should include a maternal fetal
medicine consultation
o Should include counseling regarding maintaining or
terminating pregnancy
- Documentation of fetal growth and development and fetal
age by means of ultrasonographic assessment is
appropriate
- Medical Radical Mastectomy – the most common surgical
procedure
- However, breast-conserving surgery is possible if
radiation therapy can be delayed to the postpartum
period
o Usually followed by radiotherapy
- When surgery is performed at 25 weeks of gestation or
later, obstetrical and perinatal specialists must be onsite
and immediately available in the event of precipitous
delivery of a viable fetus
- The indications of systemic chemotherapy are the same in
pregnant and non-pregnant
o Not given on 1st tri of pregnancy
▪ Fetal malformation risks in the 2nd and 3rd tri are
approx. 1.3% not different than that of fetuses not
exposed to chemotherapy during pregnancy
o Not given after week 35 of pregnancy or within 3
weeks of planned delivery ! hematologic
complications
TRAUMA IN PREGNANCY
- Leading non-obstetric cause of maternal mortality
o Occurs in 5%
- Most common mechanisms of injury are:
o From falls
o From motor vehicle accidents
- Pregnant women who sustained trauma had a higher
incidence of:
o Spontaneous abortion
o Preterm labor
o Fetomaternal hemorrhage
o Abruptio placentae
o Uterine rupture
- The initial evaluation and tx is identical to non-pregnant
- Rapid assessment of the maternal airway, breathing, and
circulation, as well as ensuring adequate airway (ABC)
o Avoids maternal and fetal hypoxia
- Critical point – resuscitation of fetus is through mother
- As with primary survey, the secondary survey proceeds in
a fashion similar to non-pregnant
- Special attention is given abdominal examination
Important:
- All pregnant women with longer than 20 weeks gestation
should be managed in a left lateral tilt position (15-30
degrees) to reduce impact of aortocaval compression
o Alternatively, the uterus may be manually displaced
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- ↑ blood volume associated with pregnancy has important - May also improve chances of maternal survival by
implications in the trauma patient removing aortocaval compression and increasing cardiac
- Signs of blood loss: tachycardia and hypotension ! output
delayed until patient loses almost 30% of her blood - No fetal survival has been documented when fetal heart
volume tones were absent before emergent delivery
o As a result, the fetus may be experiencing - Fetus should be viable
hypoperfusion long before mother manifests any - Delivery of the viable fetus may also improve chances of
signs maternal survival
o Early and rapid fluid resuscitation should be initiated - No fetal survival has been detected when fetal heart tones
even if mother is normotensive were absent before emergent delivery
On PE - But a 75% chance of fetal survival has been reported
- Special attention is given to abdominal examination when fetal heart tones were present and gestational age
- Uterus remains protected by pelvis until approximately 12 was at least 26 weeks
weeks’ AOG and is relatively well sheltered from the - Maternal and fetal survival rates as high as 72% and 45%
abdominal injury until then respectively
o As the uterus grows, it becomes more prominent and - Best chance for fetal survival with an intact infant is when
more vulnerable to injury cesarean delivery occurs within 5 minutes of maternal
- Measurement of fundal height provides a rapid death. Four minutes of resuscitation followed by a 1-
approximation of the gestational age. At 20 weeks’ minute cesarean delivery offers the best chance for
gestation, it is at the level of umbilicus and is survival
approximately 1cm per week of gestation
- Intrauterine hemorrhage or uterine rupture may result in
discrepancy in measurement
- A pelvic exam is performed by obstetrician if possible,
evaluate for:
o Vaginal bleeding
o Ruptured membranes
o Bulging perineum
- Vaginal bleeding may indicate
o Abruptio placentae
o Placenta previa
o Preterm labor

BLUNT TRAUMA
- Most common cause of fetal death is Abruptio placenta
- Deceleration of fetal heart rate – earliest sign of abruption

PENETRATING TRAUMA
- Maternal death in fewer than 5% of cases
o From gunshot wounds and knife wounds
- The incidence of visceral injury w/ penetrating trauma
during pregnancy is 16-38% in comparison to 80-90% in
non-pregnant patients
- Fetal injury occurs in up to 70% of cases, with a 40-70%
rate of fetal death d/t direct injury or preterm labor

DIAGNOSTIC
- Supraumbilical diagnostic peritoneal lavage
- Diagnostic Laparoscopy
- CT scan
- Local wound exploration, and observation
- Treatment options include surgical exploration

EMERGENCY CESAREAN DELIVERY

- Emergency CS may indicated in:
o Maternal arrest after 4 minutes of unsuccessful
resuscitation
o Fetal compromise with a stable mother if the fetus is
of viable gestational age
o Obvious impending maternal death
o When the gravid uterus interferes with trauma-related
surgical intervention

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