What are the key considerations for surgical conditions during pregnancy?

Key Considerations for Surgical Conditions During Pregnancy

The correct answer is (b) intestinal obstruction is most commonly caused by adhesions during pregnancy.

Surgical Emergencies in Pregnancy - General Principles

• Approximately 0.2% to 1.0% of all pregnant women require non-obstetrical general surgery during pregnancy 1
• The condition of the mother should always take priority because proper treatment of surgical diseases in the mother will usually benefit the fetus as well 1
• When surgery cannot be postponed until after birth, it should ideally be performed during the 4th to 6th months of pregnancy (second trimester) rather than the first trimester 2

Analysis of Answer Options

(a) Acute appendicitis is more common than in the nonpregnant state

• FALSE - While acute appendicitis is one of the most common surgical emergencies during pregnancy, its incidence is not higher than in non-pregnant women 3
• Diagnosis can be more challenging due to anatomical changes during pregnancy, but the overall incidence is not increased 1

(b) Intestinal obstruction is most commonly caused by adhesions

• TRUE - Adhesions from previous surgeries remain the most common cause of intestinal obstruction during pregnancy, similar to the non-pregnant state 3, 1
• Other causes of obstruction during pregnancy include volvulus, intussusception, and hernia, but adhesions remain the predominant etiology 1

(c) Laparoscopic cholecystectomy is contraindicated

• FALSE - Laparoscopic procedures can be safely performed during pregnancy with appropriate modifications 4
• Current guidelines recommend laparoscopic procedures when possible, with specific parameters: operative time limited to 90-120 minutes, low intra-abdominal pressure (10-13 mmHg), open introduction technique, and an experienced surgeon 4
• Careful monitoring of maternal condition is mandatory during laparoscopic procedures to ensure maternal and fetal well-being 4

(d) Leukocytosis is often indicative of a surgical abdominal pathology

• FALSE - Leukocytosis is a normal physiological finding during pregnancy and cannot be reliably used as an indicator of surgical abdominal pathology 1
• Physiologic leukocytosis of pregnancy can mask the inflammatory response to surgical conditions, making diagnosis more challenging 1

Surgical Management During Pregnancy

Timing of Surgery

• Emergency surgeries should never be delayed if the mother's condition is at risk, regardless of gestational age 2
• Elective surgeries should ideally be postponed until after delivery 2
• If surgery is necessary, the second trimester (4th-6th month) is generally considered the safest period 2

Anesthetic Considerations

• Pregnant women after 20 weeks should be positioned with left uterine displacement to prevent aortocaval compression 4
• Adequate maternal oxygenation and optimal uteroplacental perfusion should be maintained throughout the procedure 4
• Strategies to avoid hypoxemia, hypotension, acidosis, and hyperventilation are critical elements of anesthetic management 4

Fetal Monitoring

• For previable fetuses, heart tones should be auscultated before and after surgery 4
• For viable fetuses, electronic fetal heart rate and contraction monitoring can be performed during the procedure 4

Special Considerations for Common Surgical Emergencies

Appendicitis

• Diagnosis may be challenging due to anatomical displacement of the appendix as pregnancy progresses 3
• Early intervention is crucial to prevent perforation and subsequent complications 1

Cholecystitis

• Laparoscopic cholecystectomy can be safely performed with appropriate modifications 4
• Conservative management may be considered in select cases 3

Intestinal Obstruction

• Early diagnosis and management are essential to prevent complications 1
• Adhesions from previous surgeries are the most common cause 3, 1

Postoperative Care

• Multimodal analgesia including regional techniques, local anesthetic infiltration, and judicious opioid use is safe in pregnancy 4
• Adequate pain relief is essential to prevent reactive preterm contractions 4
• Paracetamol is the analgesic of choice for mild to moderate pain during any stage of pregnancy 4

Pitfalls and Caveats

• Physiologic changes of pregnancy can mask or mimic signs of acute abdominal conditions 1
• Diagnostic imaging should not be withheld when clinically indicated, though radiation exposure should be minimized 5
• Pregnancy-associated gastroesophageal reflux increases the risk of aspiration during surgery 4
• Maternal hypotension can cause reduced placental blood flow and fetal hypoxia 4