Surgical Emergencies in Pregnancy Presentation

Surgical Emergencies in Pregnancy, based on March 2024, British Journal of Surgery Guidelines

1. Guidelines on General Surgical Emergencies in Pregnancy Kirengo T. MBChB, MBA, MSc, MRCS(Ed) ST3 Surgery, Glan Clwyd Hospital

2. BJS, Volume 111, Issue 3, March 2024

3. Introduction Objective : Comprehensive guidelines for general surgeons on managing emergency surgical conditions in pregnant patients S afety & optimal outcomes for mother and fetus Context : 2% of pregnancies may require emergency non-obstetric surgical intervention 1 in 500 pregnant women develop acute abd A ppendicitis is the most common. Challenges : P hysiological changes during pregnancy increase the complexity of diagnosing and managing surgical disease C oncerns over medication and imaging risks Guideline Scope : Covers emergency surgical care of pregnant patients E xcludes pre-existing conditions, cancer, major trauma management and a naesthetic considerations.

4. Introduction Methodology : AGREE II methodology, D ividing subjects into surgical sub-specialties C omprehensive literature reviews C onsensus meetings to formulate evidence-based recommendations Key Considerations : Adjustments are necessary in surgical interventions to accommodate the gravid uterus Early diagnosis and management are critical to minimize risks to both mother and fetus Multi-disciplinary collaboration is essential, including obstetricians, radiologists, and other specialists. Guidelines Include : Specific considerations for imaging Management strategies for common surgical emergencies Special considerations for less common but critical conditions such as hernias

5. Methodology Guideline Development Process: Adhered to AGREE II framework for evidence-based guideline formulation. Guideline Group Formation: Comprised members from the Association of Surgeons of Great Britain and Ireland and experts across various related specialties. Literature Review and Evidence Gathering: Conducted in English language publications via PubMed and the Cochrane Database. Included meta-analyses, systematic reviews, case series, and expert opinions. PICO Model Application: Specific questions formulated using the Population, Intervention, Comparison, Outcome (PICO) model. Virtual Meetings and Consensus: Multiple virtual meetings held to agree on PICO questions, review literature, and develop recommendations. Utilized an online voting platform, requiring over 80% consensus for recommendations. Evidence Grading: Recommendations graded based on the Oxford Centre for Evidence-Based Medicine Levels of Evidence.

6. General Considerations Early Identification and Monitoring : Use Modified Early Warning Scores (MEWS) for early detection of clinical deterioration in pregnant patients (+ 6wks postnatal) due to physiological changes during pregnancy. Early Delivery Considerations : Assess the necessity of early delivery based on the gestation period, maternal well-being, and risks associated with preterm delivery. In Utero Transfers : For expected preterm deliveries, especially before 28 weeks, consider transferring the mother to a facility with advanced neonatal intensive care. Steroids and Magnesium Sulphate : Administer antenatal corticosteroids between 24 and 34 + 6 weeks' gestation to reduce neonatal mortality and respiratory distress syndrome. Magnesium sulphate should be considered for neuroprotection in deliveries before 34 weeks.

7. Physiological Changes in pregnancy

8. Imaging in Pregnancy Prioritize non-ionizing radiation imaging modalities due to potential risks to the fetus Consider USS as the first line of investigation Consider MRI (without gadolinium) when ultrasound is inconclusive Reserve CT scans for cases where other modalities are inconclusive or unavailable, despite the risks of ionizing radiation (teratogenicity and carcinogenesis). Engage in a multidisciplinary discussion including surgeons, radiologists, and obstetricians for imaging decisions. Safety Considerations: Always weigh the potential risks of imaging against the benefits to both mother and fetus Discuss imaging options and associated risks with the patient, ensuring informed consent Consider fetal shielding during radiographic examinations to minimize radiation exposure Monitor and follow up on any potential adverse effects from imaging procedures

9. Appendicitis in Pregnancy Incidence: 1:1,000 pregnancies Diagnosis can be challenging due to physiological and anatomical changes during pregnancy, including displacement of the appendix by the gravid uterus. Scoring systems , developed for non-pregnant populations, have similar accuracy in pregnant patients. Imaging is crucial for confirmation. Ultrasound or MRI (without contrast) should be the first-line modalities, with *CT reserved for inconclusive cases. Treatment : Operative intervention is recommended over non-operative management (NOM) to prevent fetal loss or preterm delivery. Immediate surgery is suggested O utcomes between operative and successful NOM are similar, However, unsuccessful NOM followed by delayed surgery is associated with worse outcomes. Consultation with obstetric, neonatal, and anaesthetic specialists is essential to ensure comprehensive care.

10. Gallstone Disease in Pregnancy Gallstone disease is common during pregnancy due to hormonal changes. Incidence depends on imaging frequency; symptomatic gallstones can lead to maternal and fetal morbidity. Cholecystitis in Pregnancy Second most common non-obstetric abdominal emergency. Higher rates of preoperative infection and inflammatory response than in non-pregnant populations. Recurrent episodes can lead to miscarriage. Management Recommendations Acute Cholecystitis: Laparoscopic cholecystectomy (LC) recommended as soon as possible, preferably within 7 days from symptom onset. LC in the third trimester may be challenging due to limited intra-abdominal space. Choledocholithiasis (CBD Stone): ERCP is appropriate and safe. Consideration for laparoscopic cholecystectomy postpartum. Gallstone Pancreatitis: LC should be performed during pregnancy, with a preference for surgery in the second trimester to minimize fetal risks. Considerations and Precautions LC can be performed safely in any trimester but may be more challenging in the third trimester due to the gravid uterus. Decisions on surgery type and timing should include multidisciplinary discussions involving surgeons, obstetricians, and anesthesiologists . Immediate surgery recommended for acute conditions to avoid complications associated with delayed treatment.

11. Bowel Complications: Adhesional Small Bowel Obstruction Obstruction is 3 rd Most common surgical emergency Adhesions is the commonest cause of SBO Incidence increases with gestational age, especially in the second trimester and post-delivery due to sudden anatomical changes. Presents significant risks to both mother and fetus , with fetal loss rates between 17-26% and maternal mortality rates up to 10-20% in the third trimester. Diagnosis can be challenging due to pregnancy-related changes masking classical symptoms. Early imaging confirmation is crucial for identifying candidates for emergency surgery. Management aligns with non-pregnant patients, including possible use of oral water-soluble contrast for therapeutic and prognostic purposes. Routine abdominal radiography should not be used after Gastrografin . The absence of flatus and/or bowel movement should guide the decision to operate. Laparoscopic surgery may reduce morbidity in selected cases, considering gestational age and available surgical expertise.

12. Bowel Complications: Cont … Meckel's Diverticulum in Pregnancy : Symptoms are heterogeneous, often diagnosed during surgery. Higher proportion of cases may have a perforated Meckel's diverticulum, potentially reflecting diagnostic delays in pregnancy. Sigmoid Volvulus in Pregnancy : Rare, more common in multiparous women and increases with advancing gestational age. Endoscopic decompression may be less effective than in non-pregnant populations, especially in the third trimester.

13. Bowel Complications: Cont… Diverticular Disease in Pregnancy : Increasingly common due to younger individuals developing diverticular disease and older individuals becoming pregnant. Most pregnant patients with diverticulitis successfully managed with intravenous antibiotics. Surgical intervention required in a minority of cases, often concurrent with emergency caesarean section. This Photo by Unknown Author is licensed under CC BY-SA-NC This Photo by Unknown Author is licensed under CC BY-SA-NC

14. Perianal Diseases in Pregnancy

15. Perianal Diseases in Pregnancy

16. Hernias in Pregnancy Hernias may become more symptomatic or apparent during pregnancy due to increased intra-abdominal pressure. Elective repair of asymptomatic hernias is typically deferred until after delivery Pregnant Patients with Hernias : Avoid heavy lifting and excessive strain to reduce the risk of hernia complications Regular follow-up with both the surgeon and obstetrician to monitor the hernia and pregnancy progression. Emergency surgery may be required for incarcerated or strangulated hernias O pen suture repair is the preferred method due to the complexity and risks associated with laparoscopic surgery during pregnancy Groin Hernias : Rare in pregnancy due to the displacement of abdominal contents by the expanding uterus. Misdiagnosis with round ligament varicocele should be avoided; imaging with ultrasonography is recommended for accurate diagnosis.

17. Upper Gastrointestinal Complications Progesterone- Delayed gastric emptying Gastrin- increased gastric acidity. Peptic Ulcer Disease : Incidence of peptic ulcers and complications is low during pregnancy, possibly due to physiological changes or lifestyle modifications. Complications are rare, with few case reports of perforation mainly in the third trimester or postpartum phase.

18. Upper Gastrointestinal Complications

19. Spontaneous Haemoperitoneum in Pregnancy (SHiP) : Acute intraperitoneal hemorrhage during pregnancy or up to 42 days postpartum, excluding trauma, uterine rupture, or ectopic pregnancy V ery rare but has the highest mortality rate for both the mother (3%) and the fetus (25%) It commonly presents in the third trimester and is associated with advanced maternal age and artificial reproductive technologies Pts typically present with abdominal pain and hypovolemic shock, often leading to misdiagnosis as placental abruption The diagnosis is usually made post-emergency cesarean section, with a median volume of hemoperitoneum reported being 1600 ml. Causes of SHiP : Rupture of a Splenic Artery Aneurysm (SAA) is the most common non-pelvic cause O ther causes: spontaneous splenic rupture, splenic vein rupture, hepatic rupture, and iliac artery aneurysm rupture Consider: Ct angio + emobilization vs open surgery

20. Should a pregnant patient referred to the general surgery team be cared for on a surgical ward or an obstetric ward?

21. Conclusion Urgent surgical intervention may be required depending on the condition Non-ionizing radiation imaging preferred Collaboration with obstetricians, neonatologists, and anaesthetists is crucial for optimizing maternal and fetal outcomes Conservative management is preferred where possible, with surgical interventions considered based on risk assessments and the specific condition More research needed

22. Questions?