SURGERY IN THE PREGNANT PATIENT

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Trauma and Surgery in the Pregnant Patient
PRINCIPLES OF SURGERY NICHOLAS LEYLAND,BASc,MD,MHC
M,FRCSC CHIEF OF OBSTETRICS AND GYNAECOLOGY,
MEDICAL DIRECTOR OF THE MOTHER AND CHILD
PROGRAM ST.JOSEPHS HEALTH CENTRE, ASSOCIATE
PROFESSOR OF OB/GYN, 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 .LEYLANDS 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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Penetrating Trauma

• 1. There were visceral injuries when the entrance
  wound was in either the upper abdomen or
  back.2. When the entry wound site was anterior
  and below the uterine fundus, there were no
  visceral injuries.3. Half the women had
  perinatal deaths due to either maternal shock,
  uteroplacental injury, or direct fetal injury.

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MANAGEMENT OF TRAUMA

• An important aspect of management is
  repositioning of the large uterus away from the
  great vessels to diminish its effect on decreased
  cardiac output.
• Almost 20 percent of women who had contractions
  more frequently than every 10 minutes in the
  first 4 hours had an associated placental
  abruption.
• For the woman who is D-negative, administration
  of anti-D immunoglobulin should be considered.

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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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CARDIOPULMONARY RESUSCITATION

• There are special considerations for
  cardiopulmonary resuscitation (CPR) conducted in
  the second half of pregnancy.
• uterine displacement is paramount to accompany
  other resuscitative efforts

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Cardiovascular Disease

• KEY POINTS
•   ?    Hemodynamic changes in pregnancy may
  adversely affect maternal cardiac
  performance.  ?    Intercurrent events during
  pregnancy are usually the cause of
  decompensation.   ?    Labor, delivery, and
  postpartum are times of hemodynamic
  instability.  ?    Invasive hemodynamic
  monitoring should be used to address specific
  clinical questions.  ?    Many maternal heart
  conditions can be medically managed during
  pregnancy. A few are associated with a very high
  risk of maternal mortality.  ?    Many patients
  with congenital heart disease can successfully
  complete a pregnancy.  ?    Preconceptual
  counseling is based on achieving a balance
  between medical information and the patient's
  value system.

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THERAPEUTIC PARALYSIS
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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!