Centre for Minimally Invasive Surgery

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• Centre for Minimally Invasive Surgery
• In Gynaecology

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SURGERY IN THE PREGNANT PATIENT

• PRINCIPLES OF SURGERY
• NICHOLAS LEYLAND,BASc,MD,FRCSC.
• CHIEF OF OBSTETRICS AND GYNAECOLOGY,
• MEDICAL DIRECTOR OF THE MOTHER AND CHILD PROGRAM
• ST.JOSEPHS HEALTH CENTRE,
• UNIVERSITY OF TORONTO

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SURGERY IN THE PREGNANT PATIENT

• Learning objectives
• 1)TRAUMA IN PREGNANCY
• 2)THE ACUTE ABDOMEN IN PREGNANCY
• 3)NEUROVASCULAR EMERGENCIES
• 4)CASES
• 5) UPDATE LEYLAND

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THERAPEUTIC PARALYSIS
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TRAUMA IN PREGNANCYMATERNAL PHYSIOLOGYSurgical
Implications

• Cardiovascular Changes CO 50,Blood Vol 50
• Maternal rbc 30 Dilutional Anaemia
• WBC 12000, Labour 20,000
• GI Appendix (localization), Progesterone
  Decreased motility, alk phosphatase, no change
  in Transaminases
• Respiratory Changes e.g. Decreased pCO2
  

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TRAUMA IN PREGNANCYPrinciples

• ABCs.. FETUS?
• Maternal physiology
• Investigations .AXIOM IF AN INVESTIGATION IS
  INDICATED DO IT
• Fetal viability.24 weeks
• Fetal monitoring.OBS/PERINATOLOGY
• Transfer to regional center ONLY after maternal
  stabilization

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TRAUMA IN PREGNANCYHead Trauma

• Dead Mother Dead Fetus

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TRAUMA IN PREGNANCYBLUNT ABDOMINAL TRAUMA

• MVA, ASSAULT, FALLS
• MANGEMENT PRINCIPLES..
• OBS PRINCIPLES.

PLACENTAL CONSIDERATIONS FETAL MATERNAL
TRANSFUSION UTERINE RUPTURE PRETERM LABOUR FETAL
MONITORING!!!!!!!!!
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TRAUMA IN PREGNANCY

• RADIOLOGIC INVESTIGATIONS ADVERSE AFFECTS TO
  FETUS RARE lt 10cGy
• cSPINE, CXR, Angiography, CT, MRI
• Shielding of abdomen

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TRAUMA IN PREGNANCYPenetrating Abdominal Trauma

• Gunshot Woundsentry/ exit
• Xray localization
• Laparotomyuterine status/ fetal viability
• Knife Woundsfistulogam?
• Uterus 500 ml/min at term
• Postmortem Ceasarean

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G.I. DISEASE IN PREGNANCYAPPENDICITIS

• Abdominal pain, nausea,vomiting
• Anorexia
• Localization of the pain and tenderness
• Ultrasound?
• Laparoscopy?Negative Laparotomy Rate
• Fetal Mortality and Maternal Morbidity rates are
  directly correlated to the delay in diagnosis and
  treatment

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OB/GYNE CONDITIONS MIMICKING APPENDICITIS

• PRETERM LABOUR
• PLACENTAL ABRUPTION
• DEGENERATION OF FIBROIDS
• ADNEXAL EVENTS
• ROUND LIGAMENT PAIN
• ECTOPIC PREGNANCY
• CHORIOAMNIONITIS

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CHOLECYSTITIS IN PREGNANCY

• SIGNS AND SYMPTOMS
• DDx
• MI
• ACUTE FATTY LIVER OF PREGNANCY
• APPENDICITIS
• SEVERE PREECLAMPSIA/HELLP
• PUD
• PANCREATITIS

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CHOLECYSTITIS IN PREGNANCY

• DIAGNOSISU/S
• TREATMENTMEDICAL.1ST AND 3D TM
• SURGICAL.2ND TM
• FAILURE OF MEDICAL OR RECURRENT ATTACKS
• LAPAROSCOPY?

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G.I. DISEASE IN PREGNANCYBOWEL OBSTRUCTION

• Morbidity and Mortality related to the delay in
  diagnosis
• Previous Surgery and Adhesions--3d TM
• Volvulus, Hernia, Intussusception
• Signs and Symptoms
• Diagnosis Serial Assessments and Serial AXRs
• Management?

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PANCREATITIS IN PREGNACY

• PRESENTATION
• INVESTIGATIONS
• MANAGEMENT
• FETAL CONSIDERATIONS?

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NEUROVASCULAR EMERGENCIES IN PREGNANCY

• AVMs, ANEURYSMS
• SURGICAL MANAGEMENT TREATMENT AT THE TIME OF
  PRESENTATION(ANEURYSM)
• AVM LESS CLEAR
• SUPERIOR SAGITAL SINUS THROMBOSIS

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THERAPEUTIC PARALYSIS
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CASES
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CASE 1

• 29 YR OLD _at_ 34 WEEKS GESTATION
• N/V X 8 HOURS, ANOREXIA(NEW ONSET)
• PX AFEBRILE, TENDER MID- ABDOMEN RIGHT WITH
  REBOUND
• UTERUS NON TENDER BUT CAUSES TENDERNESS ON RIGHT
  WITH PALPATION FROM THE LEFT

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CASE 1

• INVESTIGATIONS?
• DDx?
• FETAL CONSIDERATIONS?
• MANAGEMENT

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CASE 2

• THE MOOSE STORY

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CASE 2

• THE MOOSE STORY
• NOW IN THE NEUROSURGICAL ICU
• CONSULTS OBS RE CT, ANGIOGRAPHY
• CONSIDERATION OF TERMINATION?

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CASE 2

• THE MOOSE STORY
• THE HAPPY ENDING.

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CASE 3

• 30 YR OLD WOMAN AT 24 WEEKS GESTATION MVA HIT
  FROM BEHIND
• HAD SEAT BELT ON, NO HEAD INJURY
• O/E VSS, BRUISED AND TENDER ABDOMEN
• FETAL HEART TONES HEARD
• WHAT ARE THE ISSUES HERE?

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CASE 3

• MATERNAL CONSIDERATIONS FIRST!
• FETUS SECONDARY
• MONITORING IF FETUS VIABLE
• FETAL MATERNAL TRANSFUSION KLEIHAUER
• SURGICAL DELIVERY IF FETAL DISTRESS AND MOTHER IS
  STABLE

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SURGERY IN THE PREGNANT PATIENT

• AVOID THERAPEUTIC PARALYSIS
• IF AN INVESTIGATION IS INDICATED FOR DIAGNOSIS
  ---DO IT!
• NEVER COMPROMIZE THE MATERNAL CARE FOR THE SAKE
  OF THE FETUS!
• THERE ARE VERY FEW DRUGS OR INVESTIGATIVE TESTS
  WHICH CAUSE SERIOUS FETAL DAMAGE

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SURGERY IN THE PREGNANT PATIENT

• Learning objectives
• 1)TRAUMA IN PREGNANCY
• 2)THE ACUTE ABDOMEN IN PREGNANCY
• 3)NEUROVASCULAR EMERGENCIES
• 4)CASES

THANKS!
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