1. Surgical illness during pregnancy requires careful consideration of risks to both the mother and fetus. 2. The second trimester is generally safest for elective surgery due to lower risks of teratogenesis, miscarriage, and preterm delivery. 3. Emergency surgery may be required at any time in pregnancy to stabilize the mother, with close monitoring of the fetus thereafter.

1. Surgical illness during pregnancy
By;
Dr Syeda Sumaiya(2019-2022)
Pg scholar dept of OBG
NIUM, Bengaluru-91.
Under the guidance of;
Prof Wajeeha Begum
HOD dept
of OBG NIUM,
Bengaluru-91.

2. Principles of general surgery during pregnancy:
• „
Try to avoid major elective surgery, specially abdominal, till delivery.
• Second trimester is the safest time for surgery as the risks of
teratogenesis, miscarriage and preterm delivery are lowest.
• Diagnosis of acute abdomen is difficult in pregnant state.
• „Emergency surgery has to be done at any time during pregnancy.
• Laparoscopic surgery can be performed safely during pregnancy.

3. • Use of non-ionizing imaging procedures, e.g. USG, MRI is
preferred to minimize fetal irradiation.
• Imaging of abdominal organs is difficult in pregnancy due to the
presence of gravid uterus.
• Management of pregnant woman with trauma should always be to
stabilize the mother first, with evaluation of the fetus thereafter.
• Operation should be done preferably by a senior surgeon with an
expert anesthetist. An obstetrician should remain as a standby. „
Minimal handling of the uterus should be done.

4. • „Postoperatively, the patient is to be given pain relief for 48 hours.
Use of tocolytics may be helpful
• Close observation is mandatory for evidences of miscarriage or
preterm labor.
• „In majority of cases, taken all the precautions, the risk of adverse
perinatal outcome is low. However, risk of surgery must be balanced
against the complications of the underlying pathology that need
surgery.

5. ACUTE APPENDICITIS
• Acute appendicitis is the most common acute surgical condition of the
abdomen, it might be obstructive or nonobstructive variety
• Symptoms include:
• Pain abdomen, initial typical pain is diffuse and dull and is situated in
the umbilical or lower epigastric region. Gradually the pain is localised
in the right lower quadrant at or near McBurney’s point.
• Anorexia and nausea
murphy’s triad
Pain Vomiting temperature

6. In pregnancy;
• Incidence is about 1 in 1,000 pregnancies. It is the commonest
nongynecological cause of acute abdomen requiring surgery.
Diagnosis is difficult in pregnancy due to
(a) Nausea and vomiting common in normal pregnancy are also the
common symptoms of appendicitis
(b) Leukocytosis is common in normal pregnancy

7. (c) Appendix moves upwards and outwards as the uterus enlarges. So
pain and tenderness may not be located in the right iliac fossa (Mc
Burney’s point)
(d) Diagnosis is often confused with disturbed ectopic pregnancy,
pyelonephritis, twisted ovarian cyst, abruptio placenta and red
degeneration of a fibroid, preterm labor.
Effect of appendicitis on pregnancy;
may lead to miscarriage, preterm delivery, increased perinatal
mortality and maternal mortality.

8. Effect of pregnancy on appendicitis is adverse because of
(a) late diagnosis
(b) failure of localization due to displacement of the position and as
such
(c) peritonitis is more common, specially, in last trimester.

9. • The risks of maternal and fetal mortality from appendicitis in
pregnancy is high specially when associated with perforations.
Ultrasonography is commonly done.
• Appendiceal mural thickening, peri appendiceal fluid and a non
compressible tubal structure (6 mm or more) are suggestive.
• MRI may be used when ultrasound is inconclusive.

10. TRAUMA IN PREGNANCY
• Trauma in pregnancy may be due to blunt trauma, motor vehicle
accident, fall or following domestic violence.
• Placental abruption is the common complication following minor as
well as major abdominal trauma.
• Common types of penetrating trauma in pregnant women are due to
road traffic accidents, gunshot or stab wounds.
• Maternal death rates in penetrating trauma is two-thirds lower than
in the non-gravid women. It is due to protective effects of the uterus
to other abdominal organs. Fetal death is high (70%).

11. ACUTE PANCREATITIS:
Acute pancreatitis means acute inflammation superimposed on a
normal gland .
Symptoms include;
• Pain abdomen frequently located in the midepigastrium often radiates
to the back or flanks.
• Repeated vomiting with nausea.

12. • It is difficult to diagnose during pregnancy because of the
physiological increase of amylase value during the second and last
trimester.
• Serum amylase is elevated to 1000 IU/L or more, serum calcium is
usually low.
• Ultrasound is of diagnostic value.
• Preterm labor is more common.
• Once the diagnosis is made, the treatment should be conservative
rather than surgical. Medical management includes IV fluids, gastric
acid suppression, analgesia and nasogastric suction.

13. SYMPTOMATIC CHOLELITHIASIS:
• Incidence is about 1 in 2,000 pregnancies.
• It is the second most common nongynecological condition that needs
surgery during pregnancy.
• Initial management is conservative.
• Elective endocystectomy is done in the second trimester or
puerperium.

14. • Deterioration of clinical condition despite medical therapy or
recurrent biliary colic needs cholecystectomy regardless of trimester.
• Laparoscopic cholecystectomy can be done in the second trimester of
pregnancy safely.

15. PEPTIC ULCER:
• It is rare during pregnancy to appear for the first time.
• The course of the disease is unpredictable.
• Perforation and hemorrhage are uncommon during pregnancy.
• Infection with Helicobacter pylori plays an important part in the
pathogenesis.
• TREATMENT: Directed to inhibit acid production (H2 blocker),
acid neutralization (antacids) and eradication of H. pylori infection
(antibiotic).

16. LAPAROSCOPY IN PREGNANCY
• Laparoscopic surgery can be performed safely during pregnancy.
• Second trimester is the best time.
• Fetal risks and preterm labor are less as the uterine manipulation and
the use of narcotics are less.

17. Guidelines of laparoscopic surgery during pregnancy (SAGES,
2008)
1. Obstetric consultation is essential for preoperative and
postoperative management.
2. Diagnostic laparoscopy is safe and effective when done in a well
selected case. Laparoscopy can be done safely during any trimester
of pregnancy.
3. Gastric emptying time is prolonged in pregnancy. Risk of
aspiration during anesthesia could be reduced using antacid, and H2
blocker beforehand.

18. 4. Patient should be in the left lateral decubitus with minimum reverse
Trendelenburg
5. Open technique (Hasson) for entering the abdominal cavity to be
used. Veress needle may be avoided.
6. Antithrombotic prophylaxis are: use of pneumatic compression
devices (intraoperative as well as postoperative) and early
postoperative ambulation.

19. 7. CO2 pneumoperitoneum is maintained at 12–15 mm Hg, keeping
intraperitoneal pressure minimum.
8. Maternal end tidal CO2 should be maintained at 25–30 mm Hg
(capnography) to minimize maternal and fetal acidosis.
9. Fetal monitoring is to be continued and pneumoperitoneum is to
be released if fetal distress arises.
10. Operative time should be minimum as possible.

20. ACUTE PAIN IN ABDOMEN DURING
PREGNANCY
• Some amount of abdominal pain is common during pregnancy.
• One should be very careful to distinguish the pathological variety
from the physiological one.
• A meticulous history coupled with systematic and thorough
examinations (general, abdominal and vaginal) are mandatory to
arrive at a diagnosis on the real state of affairs.
• Many a times a delay in the diagnosis of a nongestational cause
terminates fatally.

21. • Consultation with a surgeon or a physician should be done whenever
felt necessary.
• Laboratory tests, ultrasonography and X-ray are helpful diagnostic
parameters.
• However, their limitations and restrictions in pregnancy should be
borne in mind.
• The physician should be conscious of the entity of disturbed tubal
pregnancy in early months and rupture of the uterus, in the later
months while dealing with acute abdomen in pregnancy.

22. early late medical surgical gynaecological
• Abortion
• Disturbed ectopic
• Hydatidiform
mole
• Acute
polyhydramnios
• Abruptio
placentae
Preterm
labour pains
• Rupture
uterus
• Polyhydramni
os
• Acute
fulminating
preeclampsia
• Eclampsia
• HELLP
syndrome
• Torsion of the
uterus
• Pyelitis
• Pyelonephritis
• Pneumonia
• Cystitis
• Hepatitis
• Acute fatty
liver
• Peptic ulcer
• Acute
appendicitis
• Intestinal or
gastric
perforation
• Intestinal
obstruction
• Volvulus
• Rectus sheath
hematoma
• Cholecystitis
• Choledocholithi
asis
• Biliary colic
• Renal or
ureteric calculi
• Malignant
disease
• torsion of
ovarian cyst
• Red
degeneration of
fibroid
• Retention of
urine due to
retroverted
gravid uterus
impacted
fibroid or
ovarian tumor
obstetrical nonobstetrical