Surgical diseases in pregnancy (acute appendictitis (Diagnosis ( …
Surgical diseases in pregnancy
Acute abdomen in pregnancy
Acute appendicitis (the most often!)
Cholelithiasis and cholecystitis
Pregnancy often makes the diagnosis of appendictitis more difficult for the following reasons:
Anorexia, nausea, and vomiting that accompany normal pregnancy are also common symptoms of appendictitis.
As the uterus enlarges, the appendix usually moves upward and outward to the side, so that pain and tenderness may not be prominent in the right lower quadrant
Some degree of leukocytosis is physiological during normal pregnancy
Appendictitis may be confused with preterm labor, pyelonephritis, renal colic, placental abruption, necrosis of a uterine leiomyoma
Pregnant women, especially those in late gestation, frequently do not have symptoms considered „typical” for appendictitis
persistent abdominal pain and tenderness
if appendictitis is suspected, prompt surgical exploration is the right treatment, even if diagnostic errors sometimes lead to removal of normal appendix. It is less harmful than to postpone intervention until generalized peritonitis develops
Diagnostic laparoscopy in the first half of pregnancy is the first-choice treatment, if laparotomy is chosen most practitioners prefer an incision over the McBurney point
Before exploration, intravenous antimicrobial therapy is begun, usually with a second-generation of cephalosporin or third-generation penicillin.
Uterine contractions are common, but tocolysis is not necessary
If appendictitis is undiagnosed before delivery often after the large uterus rapidly empties, walled-off infection is disrupted causing an acute surgical abdomen
influence on pregnancy
ncreases the likeliehood of abortion or preterm labor, especially when it is accopanied with peritonitis
Cholelithiasis and cholecystitis
Gallbladder disease during pregnancy – there is no doubt that pregnancy is lithogenic and increases the risk of cholelithiasis
After the first trimester both gallbladder volume during fasting and residual volume after contracting in response to a meal are doubled
Incomplete emptying may result in retention of cholesterol crystals, and prerequisite for cholesterol gallstones
Biliary sludge, which can be a forerunner to gallstones, develops in 30% women during pregnancy
Symptomatic cholecystitis is intially managed in a manner similar to that for nonpregnant women.
Nowadays there is a trend to favor surgical therapy. After conservative treatment there is a high reccurance rate during the same pregnancy. Moreover, if cholecystitis reccurs later in gestation, preterm labor is more likely and cholecystectomy more difficult technically.
Laparoscopic surgery is as acceptable as laparotomy
ERCP – Endoscopic retrograde cholangiopancreatography
Biliary duct gallstones during pregnancy ERCP is performed when common duct obstruction is suspected
It has become common to perform endoscopic sphincterotomy and gallstone extraction followed by laparoscopic cholecystectomy in a few days, especially in patients with associated biliary pancreatitis.
Asymptomatic gallstones in pregnancy
Cholecystectomy is not indicated for silent stones
more frequent in the right kidney
Risk factors: Caucasian race, II and III trimester, prior renal stone, family history
More often in pregnancy because of hormonal changes, urinary tract dilatation and obstruction leading to urinary rentention
US scan is the first line screening test in pregnancy
MRI in II i III trimester
Mild to moderate hydronephrosis is physiologic in pregnancy and kidney pelvis is usually wider in the right kidney
Emergency intervention is indicated in ineffecitive expectant management, obstructed infected upper urinary tract, impending renal deterioration, incurable pain or vomiting, anuria or high grade obstruction of solitary or transplanted kidney
Insertion of the renal stents – safe procedure in pregnancy, in extremal cases – transdermal nephrostomy