Surgery and trauma

Question 1

Discuss appendicitis in pregnancy
-Incidence
-Presentation and investigations (2 and 3)
-Risk to fetus (3)

Answer 1

1. Incidence
   -1:1000 pregnancies
2. Presentation and investigations
   -Most occur in 2nd trimester
   -Presentation same as appendicitis in non-pregnant women except for localisation of pain. Can have focal tenderness anywhere along the R side
3. Investigations
   -WCC and CRP raised
   -USS Sensitivity 70-100%, Specificity 85-96%
   -CT/MRI if USS unclear
4. Risk to fetus
   -Simple appendicitis - 1%
   -Ruptured appendix 36%
   -PTB

Question 2

Discuss management of appendicitis in pregnancy
-Types of management (3)
-Types of surgery (3)
-Additional management (2)

Answer 2

1. Types of management
   -Surgery indicated
   -Antibiotics alone not sufficient
   -If chronic appendicitis can consider conservative management
2. Types of surgery
   -Simple appendix - laparoscopic
   -If perforation - laparotomy via LANZ incision
   -If severe maternal illness consider concurrent CS
3. Additional measures
   -VTE prophylaxis
   -Broad spectrum Abx

Question 3

Discuss non-obstetric surgery in pregnant patients
-Incidence (4)
-Timing of surgery (2)
-Route of surgery (2)

Answer 3

1. Incidence
   -1-2:1000 pregnancies
   -Appendix 0.1%
   -Biliary disease 0.1%
   -Ovarian cysts 1.2%
2. Timing of surgery
   -Elective surgery should be deferred until after pregnancy
   -In acute cases pregnancy should not deter surgery as can have worse outcomes for women and baby to not undergo surgery
3. Route of surgery
   -Laparoscopy before 34 weeks
   -No evidence for worse outcomes with laparoscopy cf laparotomy

Question 4

Discuss anaesthetic risks for non-obstetric surgery
-Maternal considerations (5)
-Fetal considerations (2)

Answer 4

1. Maternal considerations
   -GA carries 17 x greater risk for pregnant women cf regional
   -GA risk of failed intubation = 3%
   -Intubation difficulty increased secondary to mucosa oedema, engorged breasts
   -Increased risk of gastric aspiration
   -Increased risk of more rapid hypoxia
2. Fetal risks
   -No evidence any anaesthetic is teratogenic
   -No evidence exposure to GA effects developing fetal brain

Question 5

Discuss surgical risks associated with non-obstetric surgery in pregnancy
-Risks to mother (2)
-Risks to fetus (4)

Answer 5

1. Risks to mother
   -Reduced visual field secondary to gravid uterus can result in increased vessel and visceral injury
   -Maternal death 0.06%
2. Risks to fetus
   -Risk of miscarriage 10.5% in first trimester
   -Risk of miscarriage 1% in second trimester - no difference from background rate
   -No evidence surgery increases PTB or still birth
   -Uterine injury at time of surgery can lead to uterine rupture, fetal and placental laceration, PTD, infection

Question 6

Discuss operative considerations for non-obstetric surgery in pregnant women
-Pre-operative (3)
-Intra-operative (8)

Answer 6

1. Pre-operative
   -Fetal heart monitoring with doppler or CTG pre and post op
   -Consider steroids and MgSO4 if concern for fetal delivery pre-term
   -Position mother in left lateral, provide good oxygenation and avoid hypotension to avoid fetal hypoxia
2. Intra-operative
   -Uterine manipulation is contra-indicated
   -Primary port placement depends on size of gravid uterus
   -Consider sub-xiphisternum, supra-umbillicus, palmers point
   -Consider ipsilaternal port placement to avoid working across uterus
   -Consider Hassan entry
   -Insufflation pressures to 20-25mmHg for entry then to 12mmHg for remainder of operation
   -Consider 30 degree scope to see around uterus
   -Electrosurgery is safe
   -No indication for anti-D. Surgery is not a sensitising event unless trauma

Question 7

Discuss post-operative care for non-obstetric surgery in pregnant women. (3)

Answer 7

1. Antibiotics
2. VTE prophylaxis
3. Avoid Cox2 and NSAIDS

Question 8

Discuss trauma in obstetrics
-Incidence (3)
-Main causes (6)
-Trauma specific issues at each trimester

Answer 8

1. Incidence
   -8% of pregnancies affected
   -Leading non-obstetric cause for maternal morbidity and mortality
   -fetal mortality increases with gestational age
2. Causes
   -MVA
   -Violence and assault
   -Fails
   -Suicide
   -Toxic exposure
   -Drowning
3. Trimester specific trauma issues
   First trimester
   -Thick walled uterus and boney pelvis protect the fetus
   Second trimester
   -Amount of amniotic fluid relative to fetal size protective
   Third trimester
   -Most dangerous
   -Thin walled uterus and reduced relative amount of amniotic fluid
   -Pelvic injury can lead to significant haemorrhage given increased vascularity of pelvis
   -Shearing forces can lead to uterine abruption

Question 9

Discuss fetal risks associated with trauma (5)

Answer 9

1. Fetal loss
2. Fetal injury
3. PTL
4. Placental abruption
5. Uterine rupture - high mortality for both mother and fetus

Question 10

Discuss management of pregnant women following trauma
-General points (6)

Answer 10

1. Mother’s stability takes priority
2. Do not withhold drugs, investigations for fetal wellbeing in unstable mother
3. Perimortem CS if >20 weeks
4. Do Kliehauer and give anti D if Rh -ve
5. Assess fetal well being on secondary assessment with FHR monitoring - 4hrs if CTG or doppler
6. Resus as per usual but with left lateral tilt and consider perimortem CS. Maternal hyperaemia and hypoxia occur sooner than in non pregnant women