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

Severe choledocholithiasis and cholecystitis are not uncommon during pregnancy. When they do occur, it is usually in late pregnancy or in the puerperium. About 90% of patients with cholecystitis have gallstones; 90% of stones will be visualized by ultrasonography. Symptomatic relief may be all that is required.

Conventional gallbladder surgery in pregnant women should be attempted only in complicated cases (eg, obstruction), because it may increase the perinatal mortality rate to about 15%. Cholecystostomy and lithotomy may be all that is feasible during advanced pregnancy, cholecystectomy being deferred until after delivery. On the other hand, withholding surgery may result in necrosis and perforation of the gallbladder and peritonitis. Cholangitis due to impacted common duct stone requires surgical removal of gallstones and establishment of biliary drainage. Endoscopic retrograde cholangiopancreatography and endoscopic retrograde sphincterotomy can be performed safely in pregnant women if precautions are taken to minimize exposure to radiation. In the early to mid second trimester, laparoscopic cholecystectomy can be performed with minimal maternal morbidity and no fetal mortality.

Idiopathic cholestasis of pregnancy is due to a hereditary metabolic (hepatic) deficiency aggravated by the high estrogen levels of pregnancy. It causes intrahepatic biliary obstruction of varying degrees. The rise in bile acids is sufficient in the third trimester to cause severe, intractable, generalized itching and sometimes clinical jaundice. There may be mild elevations in blood bilirubin and alkaline phosphatase levels. The fetus is also threatened by this condition. An increased incidence of preterm delivery has been reported as well as unexplained intrauterine fetal demise. For this reason, antenatal surveillance of the fetus is mandatory in patients with this diagnosis. Resins such as cholestyramine (4 g three times a day) absorb bile acids in the large bowel and relieve pruritus but are difficult to take and may cause constipation. Their use requires vitamin K supplementation. Limited but very encouraging experience has been reported with ursodeoxycholic acid, 16 mg/kg/d orally for 3 weeks, or dexamethasone, 12 mg/d orally for 7 days. The disorder is relieved once the infant has been delivered, but it recurs in subsequent pregnancies and sometimes with the use of oral contraceptives.

Ovarian Tumors

The most common adnexal mass in early pregnancy is the corpus luteum, which may become cystic and enlarge to 6 cm in diameter. Any persistent mass over 6 cm should be evaluated by ultrasound examination; unilocular cysts are likely to be corpus luteum cysts, whereas septated or semisolid tumors are likely to be neoplasms. The incidence of malignancy in ovarian masses over 6 cm in diameter is 2.5%. Ovarian tumors may undergo torsion and cause abdominal pain and nausea and vomiting and must be differentiated from appendicitis, other bowel disease, and ectopic pregnancy. Patients with suspected ovarian cancer should be referred to a tertiary perinatal center to determine whether the pregnancy can progress to fetal viability or whether treatment should be instituted without delay.