This document discusses several common surgical diseases that may occur during pregnancy, including their presentation, diagnosis, and treatment considerations. It covers acute appendicitis, cholecystitis, intestinal obstruction, hernias, thyrotoxicosis, breast cancer, jaundice, urinary tract infections, and provides details on: - How pregnancy can modify the signs and symptoms of these conditions, making diagnosis more difficult. - The preferred timing and surgical approaches for treating these diseases while minimizing risks to the mother and fetus. - The importance of prompt treatment for conditions like acute appendicitis to prevent complications. - Nonsurgical and medical management options available for some diseases during early pregnancy.

1. PREGNANCY AND COMMON
SURGICAL DISEASES
BY
DR. SEFEEN SAIF ATTYA
SOHAG TEACHING HOSPITAL

2. TOPICS
Introduction
Acute appendicitis
Cholecystitis and cholelithiasis
Intestinal obstruction
Hernias
Thyrotoxicosis
Cancer breast

3. INTRODUCTION
The incidence of surgical illness is the same in
pregnant women as in nonpregnant women of
the same age group
Pregnancy may alter or mask the signs and
symptoms of the disease
The fetus must be considered in planning a
surgical prcedure
Pregnancy may modify the timing of a
semiselective operation or the surgical approach
of an emergency abdominal procedure

4. Purely elective surgery should be deferred
until the postpartum period
Any major operation represents a risk not only
to the mother but to the fetus as well
During the first trimester ,congenital
anomalies may be induced in the developing
fetus by hypoxia ,therefore if surgery does
become necessary the greatest precaution
must be taken to prevent hypoxia and
hypotension
The second trimester is usually the optimum
time for operative procedures

5. Diagnostic radiologic examinations of the
lower abdomen and pelvis should be avoided
during pregnancy ,if possible ,especially during
the first 6 weeks of gestation ,when the fetus
is particularly susceptible to irradiation
Radioactive isotopes pose a particular hazard to
the fetus when they are used in the pregnant
patient

6. Radioactive iodine for thyroid scanning
,selenomethionine for imaging of the
pancreas bone scanning with radioactive
strontium or calcium are contraindicated
during pregnancy because these agents cross
the placenta and are taken up by the fetal
tissues
Sonography has proven to be useful diagnostic
method in many circumstances and avoids the
pitfalls of x-ray exposure , at present it is
considered safe for use during pregnancy

7. ACUTE APPENDICITIS
 Acute appendicitis occurs about once in every 2000
pregnancies
 The signs and symptoms are the same as in nonpregnant
women ,but they may be considerably modified
Because
 Nausea and vomiting
 Lower abdominal discomfort
 Moderate leucocytosis
 Elevated sedimentation rate
Are seen frequently in the first and second trimester
 therefore errors in diagnosis are more frequently made

8. The enlarging uterus often carries the appendix
higher in the abdomen ,so that McBurney’s point
can no longer be used as a point of reference
,and maximal tenderness is proportionately
higher
The presence of the gravid uterus may effectively
block off the omentum and loops of small
intestine and thus hinder the walling off process
particularly in the third trimester .therefore
,rupture of the appendix is more often associated
with widespread dissemination of infection
,generalized peritonitis and higher death rate

9. Because of the flaccidity of the anterior
abdominal wall in the last trimester ,there
may be little rigidity assocciated with
inflammation of the appendix and rebound
tenderness may be hard to define ,so that one
cannot rely upon these physical findings

10. Treatment of acute appendicitis during
pregnancy is by immediate operation
Because of the extreme seriousness of
perforation when it occurs ,it is better to
remove a normal appendix when the
diagnosis is in doubt than to wait for typical
signs or symptoms and risk of consequences

11. Regional anaesthesia is preferred ,and the
transverse or oblique muscle –splitting
incision should be placed somewhat higher
than in the non pregnant woman
In fact ,late in the third trimester the appendix
may be in the right upper quadrant of the
abdomen and a right paramedian incision is
more appropriate
Premature labour is not common following an
uncomplicated appendectomy

12. Appendicular abscess
In appendicular abscess following perforation
,the gravid uterus forms the medial wall of the
abscess
This intense inflammatory process initiates
uterine contractions ,with premature labour
,with evacuation there is a sudden reduction
in the size of the uterus and the abscess
ruptures into the general peritoneal cavity

13. CHOLECYSTITIS AND CHOLELITHIASIS
pregnancy may contribute to the formation of
gall stones by:
Encouraging bile stasis
Increasing the concentration of cholesterol in
the bile
Fostering changes in bile solubility
Therefore cholelithiasis is more common in
women who have borne children

14. Acute cholecystitis in pregnancy occurs less
often than acute appendicitis ,the prevalence
being about one in 3500-6500 pregnancies
and is associated with gallstones in 50% of
cases
The symptoms are the same as in
nonpregnant patient with :
 abrupt onset of colicky pain in the right upper
quadrant of the abdomen
Low grade fever
Nausea and vomiting

15. Acute chlecystitis may be difficult to
distinguish from acute appendicitis ,with the
high position of the appendix associated with
the third trimester of pregnancy
 ultrasound is helpful in making the diagnosis

16. Unlike appendicitis ,however ,acute
cholecystitis in the first trimester of pregnancy
is best managed conservatively with:
 Hospitalization
 Parenteral fluids
 Nasogastric suction
 Antispasmodics
 Analgesics
 And broad –spectrum antibiotics

17. In 3 out of 4 patients treated ,there will be a definite
improvement within 2 days ,and a definitive surgical
procedure can be deferred until the second
trimester or the postpartum period
Surgery should be done whenever there is doubt
regarding the differentiation from acute appendicitis
or if there is no response to conservative therapy as
manifested by
 Enlarging mass (empyema)
 jaundice(common bile duct obstruction)
 Evidence of rupture
 Or associated pancreatitis
 Gallstone-induced pancreatitis increases both fetal
and maternal death rate

18. INTESTINAL OBSTRUCTION
intestinal obstruction occurs infrequently during
pregnancy ,but it should be considered in the
differential diagnosis of any pregnant patient with an
abdominal scar who develops abdominal pain and
vomiting
Adhesive bands are the most common cause of
intestinal obstruction
The most frequent causes of postoperative adhesions
are appendectomies and gynecological operations
Other causes of intestinal obstruction during
pregnancy are volvolus ,intussusception and large
bowel cancer

19. The symptoms and signs of intestinal
obstruction are the same as those in the
nonpregnant woman,although the clinical
picture may be obscured by the nausea and
vomiting of early pregnancy ,round ligament
pain, and abdominal distention already
produced by pregnancy
When operation is indicated ,it should be
performed without delay ,and pregnancy
should be a second consideration
Near term ,a cesarean section may be
required to obtain necessary exposure

20. HERNIAS
Hiatal hernias are common during pregnancy 15-
20 % of pregnant women develop this condition
as a result of pressure against the stomach by the
enlarging uterus
The principal symptom is reflux esophagitis with
severe heartburn ,aggravated by recumbency or
the ingestion of a large meal and relieved by an
upright position or antacids
Hematemesis may result from ulceration of the
esophageal mucosa

21. Treatment is by:
 Elevation of the upper half of the body while
reclining
 Frequent small bland meals
 Antacids
Most hiatal hernias disappear following the
pregnancy
surgical correction is required only for those
cases that persist and remain symptomatic

22. Umbilical, groin ,and ventral hernias are
usually unaffected by pregnancy and can be
repaired electively after delivery
Surgery during pregnancy is indicated only in
the rare event of an incarcerated or
strangulated hernia

23. THYROTOXICOSIS
Radioactive iodine is absolutely cotraindicated
because of the risk to the foetus
The danger of surgery is miscarriage
Antithyroid drugs cause goitre and
hypothyroidism to the baby

24. • Thyroidectomy for thyrotoxicosis during pregnancy should be reserved as
a second line of treatment in specific situations such as:
a) persistent high ATD doses required to control maternal thyrotoxicosis;
b) patients who present serious side effects to ATD,
c) non compliant patients; and finally
d) rare cases with upper respiratory compressive symptoms due to goiter
size.
• Thyrotoxic pregnant women should be prepared for surgery by using beta-
blocking agents and a 10-14 days course of super-saturated potassium
iodide solution (50-100 mg/d) in order to reduce vascularity of the thyroid
gland.
• Surgery in pregnancy is safest if it can be undertaken in the second
trimester when organogenesis is complete, and thus the fetus is at
minimal risk for teratogenic effects of medications, and the uterus is
relatively resistant to contraction-stimulating events of drugs

25. CANCER BREAST
Cancer breast occurs infrequently during
pregnancy complicating one in 3000
pregnancies
The breast changes that occur during
pregnancy make detection of early breast
carcinoma much more difficult
In general breast cancers are detected earlier
in women who perform breast self
examination regularly

26. The disease is more malignant during pregnancy
perhaps as a consequence of hormonal changes
and suppression of the immune mechanism
As there is considerable procrastination in
diagnosis ,most cases are advanced by the time
the diagnosis is made
Needle aspiration will serve to distinguish cysts
and galactoceles from solid tumors
Mammography is not very helpful during
pregnancy ,because of the increased radiographic
density of the breast

27. Biopsy and appropriate surgical treatment
should be undertaken as soon as the cancer is
suspected
If the cancer is confined to the breast ,the
prognosis is good , if the axillary nodes are
involved ,the outlook is poor
The overall cure rate for breast cancer
developing during pregnancy or lactation is
significantly lower than that of nonpregnant
women of comparable age because of delay in
diagnosis resulting in more advanced disease

28. Therapeutic abortion is not indicated in the
patient with localized disease of a favorable
microscopic type
Interuption of early pregnancy as part of estrogen
ablation may be of some palliative benefit to the
woman with advanced disease , but if the
pregnancy has progressed beyond the 20th week
the life of the fetus should take precedence
Pregnancies subsequent to treatment of breast
carcinoma are best deferred for 3-5 years ,after
the period of greatest risk of recurrence is past

29. JAUNDICE IN PREGNANCY
Jaundice in pregnancy may result from any liver disease that also affects
nonpregnant women or from conditions unique to pregnancy.
The unique conditions include ;
1-a generally modest and self-limited elevation in aminotransferase and
bilirubin levels during the first trimester, often in patients with
hyperemesis gravidarum;
2-intrahepatic cholestasis of pregnancy, which occurs during the second and
third trimesters and resolves spontaneously after delivery;
3- acute fatty liver or
4- HELLP syndrome (h emolysis, e levated l iver enzymes, and l ow p latelets)
in association with preeclampsia in the third trimester .
Acute fatty liver may resemble fulminant hepatic failure, with early delivery
being a prerequisite to maternal recovery; a defect in the oxidation of
fatty acids is found in some infants born after these pregnancies

30. UTI IN PREGNANCY
-About 2% of women have acute symptomatic UTI
in pregnancy
-Acute infection is associated with low biryh weight
, prematurity and maternal anaemia
-Screening for infection in early pregnancy is
justified because one -third of women with
infection develop ascending UTI
-A seven day course of antibiotics is recommended
and a 14 day course in presence of renal
infection