GASTROINTESTINAL SURGERY DURING PREGNANCY - 09/09/11
Résumé |
Gastrointestinal surgical problems occur in approximately 0.5% to 1% of all pregnancies.72 Accurate diagnosis and timely surgical management of these conditions can be a difficult challenge because signs and symptoms of these diseases can mimic findings in a normal pregnancy, particularly in the first trimester. It is important not to let the pregnant condition delay diagnosis because of reluctance to evaluate appropriate symptoms and signs.
The anatomic and physiologic changes during normal pregnancy can alter the usual presentation of many surgical conditions and can affect the reliability of laboratory studies frequently used to help establish a diagnosis. These changes may result in a delay in seeking surgical consultation, which may have an impact on the initiation of evaluation and treatment. Invariably, these delays adversely affect maternal and fetal outcomes.
Anatomic changes that can affect the presentation of gastrointestinal surgical diseases are most commonly due to displacement of intraperitoneal organs by the gravid uterus. These changes can alter the location of pain and tenderness, particularly for conditions such as appendicitis. In addition, uterine pressure on the inferior vena cava during the third trimester may exacerbate the effects of hypotension in the pregnant woman because of blood loss or dehydration.
Pregnancy commonly results in physiologic changes, such as an expanded intravascular volume, anemia, decreased heart rate, leukocytosis, and mild elevations in serum alkaline phosphatase and hepatic transaminase levels.1, 18, 20, 39 These changes affect the maternal response to hypovolemia or dehydration, which can increase the risk of fetal distress because of the suppression of classic clinical findings associated with an acute decrease in intravascular volume. Pregnancy-associated changes in serum tests can mimic abnormalities that are commonly associated with complications of surgical diseases such as cholecystitis.
Simple maneuvers such as placing the mother in the left lateral decubitus position during hypotensive episodes or during fluid resuscitation can help avoid obstruction of venous return by a large uterus and minimize decreases in uterine blood flow.39 Gynecologic problems are common causes of abdominal pain and tenderness during pregnancy, and thus an obstetrician should be involved in the evaluation of any pregnant patient with abdominal pain. Gynecologic causes of abdominal pain are considered in greater detail in the article on abdominal pain during pregnancy elsewhere in this issue.
There is often reluctance to obtain radiologic studies during pregnancy because of the risk of fetal irradiation. This risk is greatest during the first trimester during fetal organogenesis; after the first trimester, low levels of radiation exposure pose minimal risk to in utero development.9 This fact is particularly important to keep in mind when an x-ray study is needed to confirm a suspected diagnosis that may result in surgery.
Fetal monitoring should be done in conjunction with an obstetrician whenever an acute surgical condition is suspected and fetal heart tones are detectable. Evaluation of the effect of acute disease and its treatment on the fetus can help determine the need for tocolytics. There has been a trend to avoid the routine prophylactic use of tocolytics because of scant evidence of improved fetal or maternal outcomes from prophylactic administration.33
Some complications of acute surgical diseases are increased in pregnancy. A prime example is deep venous thrombophlebitis. Hence, all patients who undergo operation during pregnancy should have prophylaxis against deep venous thrombophlebitis by the use of either low-dose subcutaneous heparin or compression stockings, unless contraindicated.
The popularity of laparoscopic operations in pregnant patients has resulted in less morbidity from treatment and greater patient acceptance of operation in appropriate circumstances. Laparoscopy is relatively contraindicated during the third trimester.22 The ability to perform laparoscopy is minimally affected during the first half of pregnancy, provided that the technique is altered. Pregnancy requires that the initial (periumbilical) trocar site insertion be done under direct vision rather than puncture being done blindly with a Veress needle. Trocar placement may need to be modified from the usual sites because of anatomic alterations from uterine growth. It is helpful to tilt the patient slightly to the left while she is in the supine position on the operating room table to offset the gravid uterus from the inferior vena cava. A low intra-abdominal insufflation pressure should generally be used (≤12 mm Hg) because increased intra-abdominal pressure may reduce placental perfusion. Likewise, maternal monitoring of end-tidal carbon dioxide pressure and oxygen saturation is mandatory during operation, and arterial blood gas values are needed to correlate these readings with serum arterial oxygen and carbon dioxide levels. Fetal monitoring is necessary to detect fetal distress, which can often be reversed by early intervention.
The health of the mother should generally be the first priority in the treatment of surgical diseases during pregnancy. Evaluation by an obstetrician with specialty training in maternal-fetal medicine and with experience in high-risk pregnancies can aid significantly in the evaluation and outcome of these patients.
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| Address reprint requests to Mark A. Malangoni, MD, Department of Surgery, Case Western Reserve University, School of Medicine, 2500 MetroHealth Drive, Cleveland, OH 44109-1998 |
Vol 27 - N° 1
P. 73-88 - mars 1998 Retour au numéro
Article précédent
- THE SAFETY AND EFFICACY OF GASTROINTESTINAL ENDOSCOPY DURING PREGNANCY
- Mitchell S. Cappell
- NUTRITIONAL ASSESSMENT AND SUPPORT DURING PREGNANCY
- Elie Hamaoui, Michal Hamaoui
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