Surgical Complications During Pregnancy

Introduction

Elective major surgery should be avoided during pregnancy. Normal uncomplicated pregnancy does not alter operative risk except as it may interfere with the diagnosis of abdominal disorders and increase the technical problems of intra-abdominal surgery. Abortion is not a serious hazard after operation unless peritoneal sepsis or other significant complications occur. During the first trimester, congenital anomalies may be induced in the developing fetus by hypoxia. Thus, the second trimester is usually the optimal time for operative procedures.

Appendicitis

Appendicitis occurs in about one of 1500 pregnancies. Diagnosis may be difficult, since the appendix is carried high and to the right, away from McBurney's point, as the uterus enlarges, and localization of pain does not always occur. Nausea, vomiting, fever, and leukocytosis occur regularly. Any right-sided abdominal pain associated with these symptoms should arouse suspicion. In at least 20% of obstetric patients, the diagnosis of appendicitis is not made until rupture occurs and peritonitis has become established. Such a delay may lead to premature labor or abortion. With early diagnosis and appendectomy, the prognosis is good for mother and baby.

Mourad J et al: Appendicitis in pregnancy: new information that contradicts long-held clinical beliefs. Am J Obstet Gynecol 2000;182:1027.

Sharp HT: The acute abdomen during pregnancy. Clin Obstet Gynecol 2002;45:405.

Carcinoma of the Breast

Cancer of the breast is diagnosed approximately once in 3500 pregnancies. Pregnancy may accelerate the growth of cancer of the breast, and delay in diagnosis affects the outcome of treatment. Inflammatory carcinoma is an extremely virulent type of breast cancer that occurs most commonly during lactation. Prepregnancy mammography should be encouraged for women over age 35 who are anticipating a pregnancy.

Breast enlargement during pregnancy obscures parenchymal masses, and breast tissue hyperplasia decreases the accuracy of mammography. Any discrete mass should be evaluated by aspiration to verify its cystic structure, with fine-needle biopsy if it is solid. A definitive diagnosis may require excisional biopsy under local anesthesia. If breast biopsy confirms the diagnosis of cancer, surgery should be done regardless of the stage of the pregnancy. If spread to the regional glands has occurred, irradiation or chemotherapy should be considered. Under these circumstances, the alternatives are termination of an early pregnancy or delay of therapy for fetal maturation.

Choledocholithiasis, Cholecystitis, & Idiopathic Cholestasis of Pregnancy