Early accurate diagnosis of serious abdominal surgical disease during pregnancy is more difficult for the following reasons: (1) altered anatomic relationships, (2) impaired palpation and detection of nonuterine masses, (3) depressed symptoms, (4) symptoms that mimic the normal discomforts of pregnancy, and (5) difficulty in differentiating surgical and obstetric disorders. In general, elective surgery should be avoided during pregnancy, but operation should be performed promptly for definite or probable acute disorders. The approach to surgical problems in pregnant or puerperal patients should be the same as in nonpregnant patients, with prompt surgical intervention when indicated. The risk of inducing labor with diagnostic laparoscopy or laparotomy is low, provided unnecessary manipulation of the uterus and adnexa is avoided. Spontaneous abortion is most likely to occur if surgery is performed before 14 weeks' gestation or when peritonitis is present.
- Symptoms include abdominal pain, usually localized to right lower or mid quadrant, with nausea, vomiting, and/or anorexia.
- Patients may have an elevated white blood cell count with a left shift.
- Ultrasound or CT scan demonstrates enlargement or inflammation of the appendix.
Acute appendicitis is the most common extrauterine complication of pregnancy for which surgery is performed. Suspected appendicitis accounts for nearly two-thirds of all nonobstetric exploratory celiotomies performed during pregnancy; most cases occur in the second and third trimesters.
Appendicitis occurs in 0.1–1.4 per 1000 pregnancies. Although the incidence of disease is not increased during gestation, rupture of the appendix occurs 2–3 times more often during pregnancy secondary to delays in diagnosis and operation. Maternal and perinatal morbidity and mortality rates are greatly increased when appendicitis is complicated by peritonitis.
The diagnosis of appendicitis in pregnancy is challenging. Signs and symptoms often are atypical and not dramatic. Right lower quadrant or middle quadrant pain almost always is present when acute appendicitis occurs in pregnancy but may be ascribed to so-called round ligament pain or urinary tract infection. In nonpregnant women, the appendix is located in the right lower quadrant (65%), in the pelvis (30%), or retrocecally (5%). Traditionally it was taught that pregnancy displaces the appendix upwardly. However, some retrospective studies suggest that there is only minimal appendiceal migration throughout pregnancy.
The most consistent clinical symptom encountered in pregnant women with appendicitis is vague pain on the right side of the abdomen, although atypical pain patterns abound. Muscle guarding and rebound tenderness are much less demonstrable as gestation progresses. If pain changes from localized tenderness to a more diffuse nature, appendiceal perforation should be suspected. Rectal and vaginal tenderness are present in 80% of patients, particularly in early pregnancy. Nausea, vomiting, and anorexia usually are present, as in the nonpregnant patient. During early appendicitis, the temperature and pulse rate are relatively normal. High fever is not characteristic of the disease, and 25% of pregnant women with appendicitis are afebrile.
The relative leukocytosis of pregnancy (normal 6000–16,000/μL) clouds interpretation of infection. Although not all patients with appendicitis have white blood cell counts above 16,000/μL, at least 75% show a left shift in the differential. Urinalysis may reveal significant pyuria (20%) as well as microscopic hematuria. This is particularly true in the latter half of pregnancy, when the appendix migrates closer to the retroperitoneal ureter.
In the nonpregnant patient, CT of the abdomen with and without contrast has become an important tool aiding in the diagnosis of appendicitis. To avoid the risk of radiation to the fetus, US has a distinct role as the first-line imaging modality in pregnancy (Fig. 25–1). Graded compression ultrasonography has been found to have a high positive predictive value but average sensitivity in diagnosing appendicitis. MRI is helpful in further aiding the diagnosis in patients for whom sonographic findings are nondiagnostic. If US is nondiagnostic and MRI is not available, CT may be appropriate. A noncompressible appendix on ultrasound is abnormal, whereas MRI or CT may demonstrate an enlarged, fluid-filled appendix with or without a fecalith. An appendix measuring > 6 mm should be considered abnormal.
Acute appendicitis diagnosed by graded compression ultrasonography. A: Longitudinal image of the right lower quadrant demonstrates the appendix as a blind-ending, thick-walled tubular structure. B: Transverse images with and without compression demonstrate this structure remains at least 6 mm thick with compression.
(Images used, with permission, from Dr. Maitraya Patel, Olive View-UCLA Medical Center, Sylmar, CA.)
Pyelonephritis is the most common misdiagnosis in patients with acute appendicitis in pregnancy. The differential diagnosis of appendicitis includes gastrointestinal disorders such as gastroenteritis, small bowel obstruction, diverticulitis, pancreatitis, mesenteric adenitis, diverticulitis, and neoplasm; also possible are gynecologic and obstetric disorders such as ruptured corpus luteum cyst, adnexal torsion, ectopic pregnancy, placental abruption, early labor, round ligament syndrome, chorioamnionitis, degenerating myoma, or salpingitis.
Postoperative preterm labor has been reported to occur in 25% of second-trimester and as high as 50% of third-trimester patients. Most preterm deliveries occur within the first postoperative week. Perinatal loss may occur in association with preterm labor and delivery or with generalized peritonitis and sepsis, occurring in 0–1.5% of uncomplicated appendicitis cases. Twenty-five percent of pregnant women with appendicitis will progress to perforation; this risk is greatest when surgery is delayed more than 24 hours. With appendiceal rupture, fetal loss rates are reportedly as high as 30%, and maternal mortality rates as high as 4% are reported. This is of particular concern because appendiceal rupture occurs most frequently in the third trimester.
Immediate surgical intervention is indicated once the diagnosis of appendicitis is made. In the setting of active labor, the surgery should be performed immediately postpartum. Delaying treatment increases the risk of perforation, which in turn increases the risk of fetal loss. Under appropriate conditions, laparoscopic appendectomy may be as safe as open appendectomy. A systematic review of 637 cases of laparoscopic appendectomy showed a significantly higher rate of fetal loss (6% vs. 3.1%), though equal or lesser rates of preterm delivery compared with open appendectomy. Large series report a negative surgical exploration rate between 13% and as high as 55%, likely due to the many processes that may mimic appendicitis in pregnancy. When the appendix appears normal at laparotomy, careful exploration for other nonobstetric and obstetric conditions is important.
Treatment of nonperforated acute appendicitis complicating pregnancy is appendectomy. A single dose of preoperative prophylactic antibiotics should be routinely given. In the setting of perforation, peritonitis, or abscess formation, broad-spectrum intravenous antibiotics should be continued until culture and sensitivities can narrow antibiotic choice. If drainage is necessary for generalized peritonitis, drains should be placed transabdominally and not transvaginally. During the first trimester, a transverse incision at McBurney's point or over the area of maximal tenderness is generally considered appropriate. If the diagnosis is not certain, a vertical midline incision can be made. Laparoscopy is an alternate surgical approach used with increasing frequency, especially in the first half of pregnancy. In the late second or third trimester, a muscle-splitting incision centered over the point of maximal tenderness usually provides optimal appendiceal exposure. As a rule, appendiceal disease is managed and the pregnancy is left alone. A Smead-Jones combined mass and fascial closure with secondary wound closure 72 hours later may be advisable when the appendix is gangrenous or perforated or in the presence of peritonitis or abscess formation.
Induced abortion is rarely indicated. Depending on the gestational age and expert neonatal care available, abdominal delivery occasionally is performed when peritonitis, sepsis, or a large appendiceal or cul-de-sac abscess occurs. Data are limited, so making definitive recommendations regarding the use of prophylactic tocolytics is difficult. It appears unnecessary in uncomplicated appendicitis but may be appropriate with advanced disease. Caution is indicated because of reports that tocolytics are associated with an increased risk of pulmonary edema in women with sepsis. Labor that follows shortly after surgery in the late third trimester should be allowed to progress because it is not associated with a significant risk of wound dehiscence. At times, the large uterus may help wall off an infection, which after delivery may become disrupted, leading to an acute abdomen within hours postpartum.
Better fluid and nutritional support, use of antibiotics, safer anesthesia, prompt surgical intervention, and improved surgical technique have been important elements in the significant reduction of maternal mortality from appendicitis during pregnancy. Similarly, the fetal mortality rate has significantly improved over the past 50 years. Perinatal loss is low and maternal mortality negligible in cases of uncomplicated appendicitis, but increase significantly in the setting of peritonitis or appendiceal rupture. Thus it is imperative to avoid surgical delay. A higher negative laparotomy or laparoscopy rate may be an acceptable trade-off for a lower fetal mortality rate.
Oto A, Ernst RD, Shah R, et al. Right-lower-quadrant pain and suspected appendicitis in pregnant women: Evaluation with MR imaging–initial experience. Radiology
Pates JA, Avendanio TC
, Zaretsky MV, McIntire DD, Twickler DM. The appendix in pregnancy: Confirming historical observations with a contemporary modality. Obstet Gynecol
Walsh CA, Tang T, Walsh SR. Laparoscopic versus open appendectomy in pregnancy: A systematic review. Int J Surg
Cholecystitis & Cholelithiasis
- Patients usually present with abdominal pain in the right upper quadrant or epigastric region.
- Serum laboratories may demonstrate an elevation in the white blood cell count and/or elevated liver enzymes.
- Ultrasound of the right upper quadrant of the abdomen is usually diagnostic in these cases.
Gallbladder disease is one of the most common medical conditions and the second most common surgical disorder during pregnancy. Gallstones are responsible for 90% of cholecystitis in Western countries; parasitic infections are a less common cause. Acute cholecystitis occurs in 1 in 1600 to 1 in 10,000 pregnancies. Well-described risk factors for cholelithiasis are age, female sex, fertility, obesity, and family history. It has been estimated that at least 3.5% of pregnant women harbor gallstones. Multiparas are at increased risk of gallbladder disease. Both progesterone and estrogen increase bile lithogenicity; progesterone decreases gallbladder contractility. These changes are seen by the end of the first trimester of pregnancy.
Signs and symptoms are similar to those seen in the nonpregnant state and include anorexia, nausea, vomiting, dyspepsia, and intolerance of fatty foods. Biliary tract disease may cause right upper quadrant, epigastric, right scapular, shoulder, and even left upper quadrant or left lower quadrant pain that tends to be episodic. Biliary colic attacks often are of acute onset, seemingly are triggered by meals, and may last from a few minutes to several hours. Fever, right upper quadrant pain, and tenderness under the liver with deep inspiration (Murphy's sign) are often present in patients with acute cholecystitis. In severe cases the patient may have mild jaundice or appear septic.
An elevated white blood cell count with an increase in immature forms is seen with acute cholecystitis. Aspartate transaminase (AST) and alanine transaminase (ALT) levels are often increased. Modest increases in the alkaline phosphatase and bilirubin levels are anticipated very early in cholecystitis or common duct obstruction. However, a more characteristic pattern of relatively normal AST and ALT levels with elevated alkaline phosphatase and bilirubin levels is generally found after the first day of the attack. These changes are not diagnostic and do not signify common bile duct stone or obstruction alone, but when present they serve to support the diagnosis. Elevated lipase and amylase support the diagnosis of an associated pancreatitis.
US findings of gallbladder stones, a thickened gallbladder wall, fluid collection around the gallbladder, a dilated common bile duct, or even swelling in the pancreas are suggestive of cholelithiasis and cholecystitis. The diagnostic accuracy of US for detecting gallstones in pregnancy is 95%, making it the diagnostic test of choice.
The major diagnostic difficulty imposed by pregnancy is differentiating between cholecystitis and appendicitis. In addition to its association with gallstones, cholecystitis can be infectious secondary to Salmonella typhi or parasites. A number of other lesions of the biliary tract occur rarely during gestation, including choledochal cysts, which are seen as a spherical dilatation of the common bile duct with a very narrow or obstructed distal end. Associated pancreatitis may be present. Severe preeclampsia with associated right upper quadrant abdominal pain and abnormal liver function tests; hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome; acute fatty liver of pregnancy; and acute viral hepatitis are in the differential diagnosis. The presence of proteinuria, nondependent edema, hypertension, and sustained increases in AST and ALT levels compared with alkaline phosphatase level are clinical and laboratory features usually associated with preeclampsia. Peptic ulcer disease, myocardial infarction, and herpes zoster also have overlapping symptoms.
Secondary infection with enteric flora such as Escherichia coli, Klebsiella, or Streptococcus faecalis complicates one-fifth of cases. Pancreatitis may frequently accompany cholecystitis during pregnancy. Removal of the gallbladder and gallstones may be preferred over conservative medical therapy when pancreatitis is concurrent, as it is associated with fetal loss in 3–20% of pregnant patients. Other uncommon complications of cholecystitis during gestation are retained intraductal stones, gangrenous cholecystitis, galbladder perforation with biliary peritonitis, cholecystoenteric fistulas, and ascending cholangitis.
The initial management of symptomatic cholelithiasis and cholecystitis in pregnancy is nonoperative with bowel rest, intravenous hydration, correction of electrolyte imbalances, and analgesics. If antibiotics are not routinely given, they should be administered if no improvement is seen in 12–24 hours or if systemic symptoms are noted. This therapy results in resolution of acute symptoms in most patients. Surgical intervention is indicated if symptoms fail to improve with medical management, for recurrent episodes of biliary colic, and for complications such as recurrent cholecystitis, choledocholithiasis, and gallstone pancreatitis. Because recurrence rates for symptomatic biliary disease during pregnancy may be as high as 60–92%, active surgical management, especially in the second trimester, has been advocated in recent years. Recent literature has demonstrated the safety of open and laparoscopic cholecystectomy during pregnancy. Endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy may be an alternative for selected patients with common bile duct stones. Operative therapy for uncomplicated cholecystitis performed during the second and third trimesters does not appear to be associated with an appreciable increase in morbidity and mortality rates or fetal loss.
The outcomes for mother and fetus after uncomplicated gallbladder surgery are excellent. Morbidity and mortality rates increase with maternal age and extent of disease.
Andriulli A, Loperfido S, Napolitano G, et al. Incidence rates of post-ERCP complications: A systematic survey of prospective studies. Am J Gastroenterol
Date RS, Kaushal M, Ramesh A. A review of the management of gallstone disease and its complications in pregnancy. Am J Surg
Jackson H, Granger S, Price R, et al. Diagnosis and laparoscopic treatment of surgical diseases during pregnancy: An evidence-based review. Surg Endosc
- Patients usually present with epigastric pain that may radiate to the back.
- Serum amylase and lipase levels are elevated, findings diagnostic of pancreatitis.
- Ultrasound may demonstrate an enlarged pancreas and fluid within the peritoneal cavity.
The incidence of acute pancreatitis in pregnancy reportedly ranges from 1 in 1000 to 1 in 5000 deliveries. Pancreatitis occurs most frequently in the third trimester and puerperium. The mortality rate associated with acute pancreatitis may be higher during pregnancy because of delayed diagnosis. The ultimate cause of pancreatitis is the presence of activated digestive enzymes within the pancreas. Many cases of pancreatitis are idiopathic. As in the nonpregnant state, cholelithiasis is the most commonly identified cause, followed by alcoholism, lipidemia, viral and drug-induced pancreatitis, familial pancreatitis, structural abnormalities of the pancreas or duodenum, severe abdominal trauma, vascular disease, and preeclampsia-associated pancreatitis.
Gravidas with pancreatitis usually present with severe, steady epigastric pain that often radiates to the back in general approximation of the retroperitoneal location of the pancreas. Often exacerbated by food intake, its onset may be gradual or acute and is frequently accompanied by nausea and vomiting. During gestation, patients may present primarily with vomiting with little or no abdominal pain. Although physical examination is rarely diagnostic, several findings of note may be present, including a low-grade fever, tachycardia, and orthostatic hypotension. The latter finding may be present with hemorrhagic pancreatitis in addition to Cullen's sign (periumbilical ecchymosis) and Turner's sign (flank ecchymosis). Epigastric tenderness and ileus also may be present.
The cornerstone of diagnosis is the determination of serum amylase and lipase levels. Interpretation of serum amylase levels in pregnancy is difficult at times because of the physiologic, up to 2-fold rise in serum amylase level during pregnancy. A laboratory serum amylase level that is more than 2 times above the upper limit of normal suggests pancreatitis. However, an elevated serum amylase level is not specific for pancreatitis because cholecystitis, bowel obstruction, hepatic trauma, or a perforated duodenal ulcer can cause similar serum amylase level elevations. Serum amylase levels usually return to normal within a few days of an attack of uncomplicated acute pancreatitis. Serum lipase level is a pancreas-specific enzyme and lipase elevation can guide the differential diagnosis toward pancreatitis. In severe pancreatitis, hypocalcemia develops as calcium is complexed by fatty acids liberated by lipase.
Sonographic examination may demonstrate an enlarged pancreas with a blunted contour, peritoneal or peripancreatic fluid, and abscess or pseudocyst formation. Ultrasonography allows for the diagnosis of cholelithiasis, which may be etiologic for pancreatitis. The mere presence of gallstones, however, does not demonstrate etiologic relevance. US is also helpful for evaluating other differential diagnostic considerations.
Especially pertinent in the differential diagnosis of pancreatitis in pregnancy are hyperemesis gravidarum, preeclampsia, ruptured ectopic pregnancy (often with elevated serum amylase levels), perforated peptic ulcer, intestinal obstruction or ischemia, acute cholecystitis, ruptured spleen, liver abscess, and perinephric abscess.
Although all of the usual complications of pancreatitis can occur in parturients, there is no special predisposition to complications during pregnancy. Acute complications include hemorrhagic pancreatitis with severe hypotension and hypocalcemia, acute respiratory distress syndrome, pleural effusions, pancreatic ascites, abscess formation, and liponecrosis.
Treatment of acute pancreatitis is aimed at correcting any underlying predisposing factors and treating the pancreatic inflammation. In pregnancy, acute pancreatitis is managed as it is in the nonpregnant state, except that nutritional supplementation is considered at an earlier point in treatment to protect the fetus, either via nasojejunal tube feeding of an elemental formula or total parenteral nutrition. Treatment is primarily medical and supportive, including bowel rest with or without nasogastric suction, intravenous fluid and electrolyte replacement, and parenteral analgesics. Antibiotics are reserved for cases with evidence of an acute infection. In patients with gallstone pancreatitis, consideration is given to early cholecystectomy or ERCP after the acute inflammation subsides. In pancreatitis not caused by gallstones, surgical exploration is reserved for patients with pancreatic abscess, ruptured pseudocyst, severe hemorrhagic pancreatitis, or pancreatitis secondary to a lesion that is amenable to surgery. Pregnancy does not influence the course of pancreatitis.
Maternal mortality rates as high as 37% were reported before the era of modern medical and surgical management. Respiratory failure, shock, need for massive fluid replacement, and severe hypocalcemia are predictive of disease severity. Most recent single-institution series reflect a reduced maternal mortality rate of less than 1%; perinatal death ranges from 3–20%, depending on severity of disease. Preterm labor appears to occur in a high proportion of patients with acute pancreatitis in later gestation.
Eddy JJ, Gideonsen MD, Song JY, Grobman WA, O'Halloran P. Pancreatitis in pregnancy. Obstet Gynecol
Luminita CS, Steidl ET, Rivera-Alsina ME. Acute hyperlipidemic pancreatitis in pregnancy. Am J Obstet Gynecol
- Patients typically present with epigastric discomfort.
- Endoscopy is diagnostic of peptic ulcer disease.
Pregnancy appears to be somewhat protective against the development of gastrointestinal ulcers, as gastric secretion and motility are reduced and mucus secretion is increased. Close to 90% of women with known peptic ulcer disease experience significant improvement during pregnancy, but more than half will have recurrence of symptoms within 3 months postpartum. Thus peptic ulcer disease occurring as a complication of pregnancy or diagnosed during gestation is encountered infrequently, although the exact incidence is unknown. Infection with Helicobacter pylori is associated with the development of peptic ulcer disease.
Signs and symptoms of peptic ulcer disease in pregnancy can be mistakenly dismissed as being a normal part of the gravid state. Dyspepsia is the major symptom of ulcers during gestation, although reflux symptoms and nausea are also common. Epigastric discomfort that is temporally unrelated to meals is often reported. Abdominal pain might suggest a perforated ulcer, especially in the presence of peritoneal signs and systemic shock. Endoscopy is the diagnostic method of choice for these patients if empiric clinical therapy, including lifestyle and diet modifications, antacids, antisecretory agents, and treatment for H pylori when positive, fail to improve symptoms.
Gastroesophageal reflux disease and functional or nonulcer dyspepsia are common occurrences in pregnancy and may result in symptoms very similar to those of peptic ulcer disease. Biliary colic, chronic pancreatitis, Mallory-Weiss tears, and irritable bowel syndrome must also be considered. In recent years the diagnosis of persistent hyperemesis gravidarum has been linked to H pylori infection. Women with jaundice, persistent symptoms of dysphagia or odynophagia, weight loss, occult gastrointestinal bleeding, a family history of gastrointestinal cancers or unexplained anemia postpartum should be assessed for malignancy. A history of prior gastric surgery should prompt an evaluation for surgical complications. Ulcer perforation should be suspected in the setting of sudden, severe, diffuse abdominal pain followed by tachycardia and peritoneal signs.
Fewer than 100 parturients with complications of peptic ulcer disease, such as perforation, bleeding, and obstruction, have been reported. Most of these cases have occurred in the third trimester of pregnancy. Gastric perforation during pregnancy has an exceedingly high mortality rate, partly because of the difficulty in establishing the proper diagnosis. Other causes of upper gastrointestinal bleeding in pregnancy are reflux esophagitis and Mallory-Weiss tears. Surgical intervention is indicated for significant bleeding ulcerations. In patients requiring surgery for complicated peptic ulcers late in the third trimester, concurrent caesarean delivery may be indicated to enhance operative exposure of the upper abdomen and to prevent potential fetal death or damage from maternal hypotension and hypoxemia.
Dyspepsia during pregnancy first should be treated with dietary and lifestyle changes, supplemented with antacids or sucralfate. When symptoms persist, H2-receptor antagonists or, in severe cases, proton pump inhibitors can be used. Administration of triple-drug therapy for H pylori during pregnancy is controversial; because complications from peptic ulcer disease during pregnancy are low and there are theoretical concerns of teratogenicity from treatment, it is often deferred until postpartum. Empiric treatment of H pylori without testing is not recommended.
Chen YH, Lin HC, Lou HY. Increased risk of low birthweight, infants small for gestational age, and preterm delivery for women with peptic ulcer. Am J Obstet Gynecol
Engemise S, Oshowo A, Kyei-Mensah A. Perforated duodenal ulcer in the puerperium. Arch Gynecol Obstet
Talley N, Vakil N. Guidelines for the management of dyspepsia. Practice Parameters Committee of the American College of Gastroenterology. Am J Gastroenterol
Acute Intestinal Obstruction
- Patients typically present with the classic triad of abdominal pain, vomiting, and obstipation.
- The diagnosis is confirmed with abdominal x-ray series.
Intestinal obstruction is an infrequently encountered complication of pregnancy that is estimated to occur in approximately 1–3 of every 10,000 pregnancies. However, it is the third most common nonobstetric reason for laparotomy during pregnancy (following appendicitis and biliary tract disease). It occurs most commonly in the third trimester. The most common causes of mechanical obstruction are adhesions (60%) and volvulus (25%), followed by intussusception, hernia, and neoplasm. Volvulus is much more prevalent during pregnancy; the risk is greatest when uterine size rapidly changes (eg, second trimester and immediately postpartum).
The same classic triad of abdominal pain, vomiting, and obstipation is observed in pregnant and nonpregnant women with intestinal obstruction. Pain may be diffuse, constant, or periodic, occurring every 4–5 minutes with small-bowel obstruction or every 10–15 minutes with large-bowel obstruction. Bowel sounds are of little value in making an early diagnosis of obstruction, and tenderness to palpation typically is absent with early obstruction. Vomiting occurs early with small-bowel obstruction. Guarding and rebound tenderness are observed in association with strangulation or perforation. Late in the course of disease, fever, oliguria, and shock occur as manifestations of massive fluid loss into the bowel, acidosis, and infection. The classic findings of bowel ischemia include fever, tachycardia, localized abdominal pain, marked leukocytosis, and metabolic acidosis. Unfortunately, most laboratory abnormalities arise once bowel ischemia has progressed to bowel necrosis.
The diagnosis usually is confirmed by radiologic studies, which should be obtained when intestinal obstruction is suspected. A single abdominal series (upright and supine abdominal film) is nondiagnostic in up to 50% of early cases, but serial films usually reveal progressive changes that confirm the diagnosis. Volvulus should be suspected when a single, grossly dilated loop of bowel is seen. A volvulus primarily occurs at the cecum but may also be seen at the sigmoid colon. Occasionally, more extensive radiologic imaging is indicated, given the high risk of fetal death with delayed treatment.
The diagnosis of hyperemesis gravidarum in the second and third trimesters should be viewed with caution and made only after gastrointestinal causes of the symptoms including pancreatitis have been excluded. Mesenteric ischemia, adynamic ileus of the colon, and acute colonic pseudo-obstruction (Ogilvie's syndrome) are included in the differential diagnosis but are rarely seen during pregnancy.
Intestinal obstruction in pregnancy is associated with a maternal mortality rate of 6%, often secondary to infection and irreversible shock. Early diagnosis and treatment are essential for an improved outcome. Perinatal mortality is approximately 20% and usually results from maternal hypotension and resultant fetal hypoxia and acidosis.
The management of bowel obstruction in pregnancy is essentially no different from treatment of nonpregnant patients. The cornerstones of therapy are bowel decompression, intravenous hydration, correction of electrolyte imbalances, and timely surgery when indicated. The patient's condition must be rapidly stabilized. The amount of fluid loss often is underestimated and may be 1–6 L by the time obstruction is identified on a scout film. Aggressive hydration is needed to support both the mother and the fetus. A nasogastric tube should be placed. Colonoscopy has been used successfully in the reduction of volvulus averting laparotomy. Ogilvie's syndrome can be managed with bowel rest, rehydration, and a rectal tube for large bowel decompression. Surgery is mandatory if perforation or gangrenous bowel is suspected or when the patient's symptoms do not resolve with medical management. A vertical midline incision on the abdomen provides the best operative exposure and can be extended as needed. Surgical principles for intraoperative management apply similarly to pregnant and nonpregnant patients. Caesarean delivery is performed first if the large uterus prevents adequate exposure of the bowel in term pregnancies or if indicated obstetrically. The entire bowel should be examined carefully because there may be more than 1 area of obstruction or limited bowel viability.
Dietrich CS 3rd, Hill CC, Hueman M. Surgical diseases presenting in pregnancy. Surg Clin North Am
Parangi S, Levine D, Henry A, Isakovich N, Pories S. Surgical gastrointestinal disorders during pregnancy. Am J Surg
Inflammatory Bowel Disease
(See Chapter 29, Gastrointestinal Disorders in Pregnancy, for more details.)
- Crohn's disease is one subcategory, characterized by insidious onset; episodes of low-grade fever, diarrhea, and right lower quadrant pain; and perianal disease with abscess and fistulas formed. Radiographic evidence of ulceration, structuring, or fistulas of the small intestine or colon. May involve any segment of the gastrointestinal tract from the mouth to the anus.
- Ulcerative colitis is the other subcategory of inflammatory bowel disease, manifesting with bloody diarrhea, lower abdominal cramps, fecal urgency, anemia, and low serum albumin. It is diagnosed with sigmoidoscopy and only involves the colon.
Inflammatory bowel disease (IBD) (Crohn's disease and ulcerative colitis) often affects women in their childbearing years; however, initial presentation of IBD during pregnancy is rare. IBD presents with crampy abdominal pain and diarrhea stained with blood or mucus. More rarely the patient has weight loss and fevers.
Because some of the early IBD symptoms are found in normal pregnancies, diagnosis can be delayed, leading to poorer outcome. Initial evaluation should begin with ultrasound, which can also evaluate gallbladder, pancreas, and adnexa. Bowel wall thickening or abscess formations may be seen. Gold standard for diagnosis is endoscopy with biopsy, which can be safely performed during pregnancy.
Initial management includes dietary modifications or bulking agents. Other medications that have been safely used in pregnancy are sulfasalazine, prednisone, and occasionally antibiotics. Patients receiving sulfasalazine should be given folate supplementation because sulfasalazine inhibits its absorption. Patients taking corticosteroids should receive stress-dose steroids during delivery or in surgery. Safety data of immunosuppressant use such as cyclosporine and anti–tumor necrosis factor-α in pregnancy are limited, but these agents have been used for persistent flares. Surgery during pregnancy is indicated for intestinal obstruction, megacolon, perforation, hemorrhage, abscess formation, and failed medical management. Delivery route should be based on obstetric indications except for patients who have active perianal disease; those with an ileal pouch and anastomosis may consider caesarean section to prevent injury to the anal sphincter.
The impact of IBD on pregnancy outcomes is controversial, though in general maternal and fetal outcomes are improved if IBD is in remission before conception. Postpartum flare is more common in Crohn's disease than ulcerative colitis.
Ilnyckyj A. Surgical treatment of inflammatory bowel diseases and pregnancy. Best Pract Res Clin Gastroenterol
Reddy D, Murphy SJ, Kane SV, et al. Relapses of inflammatory bowel disease during pregnancy: In-hospital management and birth outcomes. Am J Gastroenterol
- Patients with hemorrhoids typically present with complaints of painless bleeding, prolapse, pain, pruritus, and/or fecal soilage.
- Hemorrhoids are visible on physical examination or anoscopy.
Pregnancy is the most common cause of symptomatic hemorrhoids. Approximately 9–35% of pregnant and postpartum women suffer from hemorrhoids. Higher incidences of constipation, increased blood volume, and venous congestion secondary to the enlarging uterus contribute to hemorrhoid formation.
Patients with hemorrhoids typically present with complaints of painless bleeding, prolapse, pain, pruritus, and/or fecal soilage. On physical examination, hemorrhoids are visualized as a protrusion into or out of the anal canal. Internal hemorrhoids may require anoscopy for visualization.
The current management approach to hemorrhoid disease is conservative, with simple outpatient treatment preferred, particularly during pregnancy and the puerperium. Medical therapy with dietary changes, avoidance of excessive straining, fiber supplementation, stool softeners, and hemorrhoidal analgesics often is the only requirement for nonthrombosed hemorrhoids. Often 6 weeks or longer are needed to perceive improvement. If conservative treatments fail, rubber-band ligation, infrared coagulation, or sclerotherapy appear to be safe during pregnancy. Hemorrhoidectomy is the best means of definitive therapy for hemorrhoidal disease but is rarely necessary during pregnancy. It should be considered postpartum if the patient continues to fail to respond to conservative measures, if hemorrhoids are severely prolapsed and require manual reduction, or if associated pathology such as ulceration, severe bleeding, fissure, or fistula is present. Thrombosis or clots in the vein lead to severe symptoms. If thrombosed external hemorrhoids remain tender and persist despite conservative treatment, surgical excision under local anesthesia is preferred over clot extraction, as this results in a high rate of clot recurrence.
Longo SA, Moore RC, Canzoneri BJ, Robichaux A. Gastrointestinal conditions during pregnancy. Clin Colon Rectal Surg
Spontaneous Hepatic & Splenic Rupture
- Patients with spontaneous hepatic or splenic rupture typically present with severe abdominal pain and the rapid onset of shock.
Intra-abdominal hemorrhage during pregnancy has diverse causes, including trauma, preexisting splenic disease, and preeclampsia–eclampsia. Often, the exact cause cannot be determined preoperatively. Spontaneous hepatic rupture may be associated with severe preeclampsia–eclampsia. (See Chapter 26, Hypertension in Pregnancy, for more details on preeclampsia–eclampsia.)
Spontaneous hepatic or splenic rupture is usually manifested by severe abdominal pain and shock, with thrombocytopenia and low fibrinogen levels.
Exploratory celiotomy in conjunction with aggressive transfusion of blood products including packed red blood cells, fresh-frozen plasma, and platelets should be undertaken immediately, as this has been associated with improved survival rates.
Bleeding from a lacerated or ruptured spleen does not cease spontaneously and requires immediate surgical attention. Evidence of a hemoperitoneum on imaging studies or a hemorrhagic peritoneal lavage in association with a falling hematocrit level and abdominal pain establish the presence of a hemoperitoneum.
Ruptured Splenic Artery Aneurysm
- Women with ruptured splenic artery aneurysm typically present with epigastric, left upper quadrant, or left shoulder pain.
- The diagnosis is usually confirmed by abdominal radiography or ultrasound.
Autopsy data suggest that splenic artery aneurysm occurs in 0.1% of adults and appear to be more common in women. It is estimated that 6–10% of lesions will rupture, with portal hypertension and pregnancy being the main risk factors. Twenty-five to 40% of ruptures occur during gestation, especially in the last trimester, and are a major cause of intraperitoneal hemorrhage. Pregnant women who develop ruptured splenic artery aneurysm have a 75% mortality rate, with an even higher fetal mortality rate of up to 95%. Most patients with this condition are thought preoperatively to have placental abruption or uterine rupture.
Before rupture, the presenting symptoms may be completely absent or vague. The most common symptom is vague epigastric, left upper quadrant, or left shoulder pain. In approximately 25% of patients a 2-stage rupture is seen, with a smaller primary hemorrhage into the lesser sac, which may allow for temporary tamponade of the bleeding until complete rupture into the peritoneal cavity occurs, causing hemorrhagic shock. A bruit may be audible. A highly diagnostic finding on flat x-ray film of the abdomen is demonstration in the upper left quadrant of an oval calcification with a central lucent area. In stable clinical situations, angiography can provide positive confirmation and is the gold standard for diagnosis. In pregnancy, however, ultrasonography and pulsed-wave Doppler studies are preferred in order to minimize fetal radiation exposure.
A splenic artery aneurysm in a woman of childbearing age should be treated in a timely manner, even during pregnancy, because of the increased risk of rupture and associated mortality. The elective operative mortality rate reportedly ranges between 0.5% and 1.3%.
He MX, Zheng JM, Zhang S, et al. Rupture of splenic artery aneurysm in pregnancy: A review of the literature and report of two cases. Am J Forensic Med Pathol
Parangi S, Levine D, Henry A, Isakovich N, Pories S. Surgical gastrointestinal disorders during pregnancy. Am J Surg