Only surgical emergency operations should be carried out in pregnancy eg Appendicitis and carcinoma of the breast.

Elective major surgery should be avoided during pregnancy.

Normal uncomplicated pregnancy may interfere with the diagnosis of abdominal surgical disorders.

What is the optimal time for operative intervention in pregnancy?

Surgical operations should ideally be done during the second trimester of pregnancy. This is because of the increased risk of developing congenital anomalies induced by fetal hypoxia.

What are the common surgical complications during pregnancy?

Appendicitis

Carcinoma (Cancer) of the breast

Gall bladder disease (Choledocholithiasis, cholecystitis and idiopathic cholestasis of pregnancy).

Ovarian tumours


Appendicitis in pregnancy

The incidence of appendicitis in pregnancy is about 1 in 1500 pregnancies.

Diagnostic difficulty of appendicitis in pregnancy

Because the appendix is carried high and to the right during pregnancy (away from the McBurney’s point,localization of pain does not occur always.

The common symptoms of appendicitis such as nausea, vomiting and fever also occur regularly in appendicitis in pregnancy. Leucocytosis (increased white blood cell count) also occurs regularly in appendicitis in pregnancy.Right sided abdominal pain associated with these symptoms should raise the suspicition of appendicitis in pregnancy.

Because of the diagnostic difficulty of appendicitis in pregnancy, in up to 20% of women with appendicitis in pregnancy the diagnosis is not made until rupture occurs and peritonitis is established.

Complicated appendicitis with rupture and peritonitis can lead to premature labour or abortion.

Cancer of the Breast in Pregnancy:

Cancer of the breast in pregnancy is diagnosed in approximately 1 in 3500 pregnancies.

Due to the increased levels of oestrogens in pregnancy, it may accelerate the growth of cancer of the breast.Therefore early diagnosis of cancer of the breast is very crucial in the prognosis and eventual outcome of the disease.

Early diagnosis of cancer of the breast in pregnancy can be made if routine prepregnancy mammography is done for women over 35 years of age,who are planning to become pregnant.

Diagnostic difficulty of cancer of the breast:

Mammography is not reliable in pregnancy ,because of breast tissue enlargement and hyperplasia which can obscure parenchymal masses.

Aspiration and fine needle biopsy should be done in any suspected mass . Fine needle biopsy is more appropriate if the mass is solid.

Excision biopsy under local anaesthesia can also be done for definitive diagnosis of cancer.

Principles of management of cancer of the breast in pregnancy

If cancer of the breast is diagnosed during pregnancy , surgery should be done, regardless of the stage of the pregnancy.

In late cases of diagnosis(such as spread to the regional lymph nodes, termination of pregnancy with irradiation and chemotherapy should be considered. Alternatively if the pregnancy is approaching term, treatment can be delayed for a few weeks while monitoring fetal lung maturity. If fetal lung maturity is confirmed ,induction and delivery followed by chemotherapy and/or radiotherapy can be done.

The other two common surgical complications in pregnancy ie ovarian tumours and gallbladder disease will be covered in another post.

References:

Page 782 Chapter 18 Obstetrics CMDT 2006 -Current Medical Diagnosis and Treatment. Edited by Lawrence M. Tierney, Jr. ,Stephen J. McPhee, Maxine A. Papadakis 45th edition Lange Publications.Mc Graw Hill

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