THE PREGNANT PATIENT

Santa Rosa Hospital

Sheila Sustache de Leon MD
Santa
Rosa
Hospital
Enero
2012

Sheila M. Sustache de Leon MD

Feb/ 2012

 Full term delivery at 37 week

of gestation.
12% of live births are
premature.
65% of all perinatal morbidity
and mortality is associated
with premature delivery.

Non pregnant
Uterus weight
70g

Cavity volume
10ml

pregnant
Uterus weight
1100g

Cavity volume
5L

liver

umbilicus

Extends Abdominal cavity

 Exerts pressure on the anterior abdominal wall.

Displaces the intestine superiorly and laterally.
Change the relationship between the abdominal visceral
organs.

In upright position
The uterus is supported by the anterior abdominal
wall.
Usually undergoes a dextrorotation because of the
presence of the rectosigmoid on the left.

In supine position
Uterine weight falls on the spinal column.
Compression of the surrounding great vessels.
Especially the flaccid IVA

 Electrical change in the myometrium

Resting membrane potential of the uterine
myocyte ranges from -40 to -60 mV.
Early in gestation
-60mV
Irregular electrical activity (slow waves)

Near term
-40 mV

 Rhythmic alteration in the membrane

potential lead to an action potential at the top
of slow waves.

Entry Ca2+

Voltage sensitive
Ca2+ channel

Allow interaction
actin-myosin

Electromechanical
coupling

Uterine
contraction

 Second trimester
Irregular contraction can be palpated though the
abdominal wall (Braxton hicks contractions)

Irregular in intensity
Infrequent
Unpredictable
Non-rhythmic
More uncomfortable than painful)
They do not increase in intensity, or frequency

 Small increase uterine pressure up to 80 mmHg.

Increase gap junctions results in rapid and efficient
conduction of the action potential uterine smooth
muscle.
Resulting coordinated
Dilatation of cervix and delivery of the baby.

http://www.medhelp.org

Stimulates uterine
activity

Down regulates uterine

activity

Estrogen (opposing the action of

Progesterone (block Ca2+ flux

progesterone)

thought cell membrane)

Oxytocin ( secreted from posterior

pituitary. Stimulate Ca2+ across
myometrial plasma membrane and
distinct receptor myometrium and
other reproductive tissues.)

PGE, PGF (favor activation of

the uterine musculature, onset uterine
contraction. Raise local [Ca2+] by
increasing release from intracellular
store. )

IL-1, IL-6 (produced locally by

placental tissue and act in concert with
other stimulatory factor)

 Multifactorial
Surgical manipulation
Intraabdominal inflammatory process

 The delaying or inhibition of labor stopping of

contraction during premature labor.
Intervention is directed at decreasing the uterine
smooth muscle activity thought inhibition of the
muscle contraction.
Tocolytic treatment may result in the delay of delivery
by aprox. 48 hrs, which allows for the administration
of steroids to promote fetal lung maturation.
Decrease risk of respiratory distress syndrome and
multiorgan failure in the preterm neonate.

 Magnesium sulfate
First line tocolytic agent
High intracellular [Mg] inhibits Ca2+ entry
myometrial cells interfering with actin-myosin
coupling. Also increase the sensitivity of K+
channels favoring hyperpolarization and uterine
relaxation.
Range 4 and 9 mg/dL

 Prostaglandins
Prostaglandin synthetase inhibitors specially
AINES are use to stop premature labor.
Indomethacin

Recomendated in Nonobstetric surgery.

Preoperative dose 50mg-100 mg PO
Postoperative 50 mg PO q 6 hrs for 48hrs.
Intraabdominal surgery preterm pregnant
Two doses of betamethasone 12mg 24hrs or four doses of
dexamethasone 6 mg 12 hrs
Ideally beginning 48 hrs prior to surgery.

 adrenergic agonists
Stimulation of uterine 2 receptor leads to activation
of adenylate cyclase and an increse in intracellular
cyclic adenosine monophosphate (cAMP)
concentration.
Activation of cAMP dependent protin kinase A inhibits
myosin light chain phosphorylation and actin myosin
coupling.
Protein Kinase A activity is also associate with increase
Ca2+ effux, decrease Ca2+ influx, and increases K+
conductance.

 Calcium channel blockers

Inhibits entry of calcium though voltage
dependent Ca2+ channels.
Nifedipine
Abolish uterine activity and prevent delivery with minimal
toxicity or side effects.

 The maternal physiologic homeostasis adapts in

order to promote a physiologic environment the
benefits the development and growth of the
fetus.

 Progesterone levels increase

Is a smooth muscle relaxant that play a major role
in assuring relaxation of the uterine smooth
muscle to prevent premature delivery.
In addition vascular, gastrointestinal and
urogenital smooth muscle relaxes.

 Plasma volume increase by up 50% and RBC

volumen by 20 % to 30%.
This increase in intravascular (blood) volumen
leads to a 50% increase in cardiac output (CO).
Marked venous and arterial vasodilatation. The
vasodilatation is facilitated by a decrease in
vasoconstrictor sensitivity and an increase in the
production of nitric oxide and prostacyclin.

 Common clinical signs and symptoms associated

with this increase in CO and associated
vasodilatation include:

Decrease exercise tolerance

Mild peripheral edema
Spider angiomata
Complains of stuffy sinuse
Increase in lower extremity varicosities
hemorrhoids

 To increase O2 delivery to the fetus and

remove the increased supply of CO2 produced
by the fetus.
Hyperventilates
Maternal O2 metabolism increases by 20% - 30%
and functional reserve capacity decrease.

 When intubation is needed, there significantly

less time to establish an airway and assure
continued oxygenation.
Is common to have sensation of SOB,
specifically in the second and third trimester.

 The lower esophageal

sphincter tone gradually
decreases.
Nausea and vomiting of
pregnancy is a common
occurrence affecting
between 50% and 90%
of all women.

 The gallbladder empties more slowly during

pregnancy and undergoes a gradual increase
in residual volume, both during fasting and
after meals.
Motility and volumes return to normal as early as
2 weeks after pregnancy.

 Prolonged small bowel transit time and

decreased colonic emptying work to maximize
nutrient and water absorption.
Contribute to the constipation reported by 38% of
pregnant women.

 Abdominal pain
Round ligament pain is described as an aching,
dragging pain.
Typically unilateral
Provoked by physical activity or even turning while sleeping.
Common occurrence third trimester

Pain in the hypochondrium.

Can result from uterine pressure on the lower ribs.
Px describes a very localizated, sharp, nonradiating pain.
That more often is on R+ compare to the L+ upper cuadrant.

 Hemoglobin concentrations may drop to 10

mg/dl.
Hematocrit values may go as low as 30%.
Pregnancy may be associated with an increase
in the WBC count.
Up to levels of 13,000 cell/mL.
Intrapartum and immediate postpartum (<24 hrs)
counts may be as high as 25,000 WBC/mL

 Platelet count may slightly decrease as the

pregnancy progresses.
Up 8% of pregnancy
The most common cause is gestational
thrombocytopenia.
Typically asymptomatic
Recover to normal levels a few weeks following the
delivery.

 Renal blood flow and glomerular filtration rate

increase by over 50%.
Creatinine levels decrease appropriately, resulting
in normal levels of 0.5 to 0.6 mg/mL.
Serum alkaline phosphatase levels gradually
increase.
Because of production of an alkaline phosphatase
isozyme by the placenta.

Albumin levels may be lower.

Associated with the increase in plasma volumen and
osmotic pressure may be decreased.

 In almost all clinical presentations, the risks of

misdiagnosis by avoiding the proper imaging
tests are greater compared to the risks of
sequelae from ionizing radiation to the fetus.

 Ionizing radiation
Fetal effects of ionizing radiation depend on the dose
absorbed by the fetal tissue and the stage of fetal
development during exposure.
The roentgen is a common unit of exposure.
Produce 0.26 milicoulomb/kg of air or 2 billon ion pairs/ cm of
exposed air.

One gray (Gy) is strictly defined as the deposition of 1.0

joule of energy/kg of tissue.
One rad is 1% of 1 Gy.

 In is a misconception to assume that the radiation

absorbed by the mother is the same as the
absorbed by the fetus.
Dosing of radiation to the uterus and conceptus
can vary several fold based on abdominal wall
depth and the anteverted or retroverted position
of the uterus.
DNA damage may be repaired of may result in cell
death, rapid cell growth, abnormal cell growth or
genetic mutation.

Radiation dosing to the conceptus an

uterus from selected radiographic
examinations.
Examination
Routine Chest x- ray
Abdominal flat plate
Intravenous pyelogram
CT, chest (uterus shielded, not
exposed)
CT, abdomen (uterus shielded,
not exposed)
CT, pelvis

DOSE (mrad)
0.5-1.0
140
78
16-23
150-190
2,000

 Growth impairment of organs occurs of the

population of cells cannot be replaced or
damage occurs to a small population of
progenitor cells at a vital stage of
development.

 The outcome of radiation exposure depends on

the absorbed dose and the stage of development
during exposure.
Potential death early in gestation.
Teratogenesis during organogenesis (4 to 10 weeks of
gestation).
Growth retardation at later gestational stages.

 Lethal Effects
Multicellular embryo, before the blastocyst stage
is most sensitive to the lethal effects of radiation
but resistant to teratogenesis if it survives.
More than 50% of all human pregnancies abort.
Determining the lethal dose of radiation at this stage is
difficult.

Significant radiation exposure in the first 2 weeks

of human development.
3 and 4 weeks of results in loss of the pregnancy.

 Teratogenic effects
Occurs during early organogenesis.
Correspond to weeks 2 to 8 in human
development (4 to 10 of gestation).
A significantly higher rate after exposure to
radiation in pregnancy have been report:
Microcephaly, pigmentary changes in the retina,
hydrocephalus, and optic nerve atrophy.

Exposure less than 5 rads does not increase the

risk for birth defects.
5 to 10 rads = teratogenicity
Greater than 10 rads = serious risk to the fetus.

 Intrauterine Growth restriction

Result from radiation induced cellular depletion.
Example: children exposed in utero to the
Japanese atomic blasts.
1,500 m from center of the explosion
Exposed to over 25 rads
2 a 3 cm shorter, 3 kg lighter head circumference 1 cm smaller
than normal (17 y/o)

 Oncogenic potential
The correlation between childhood cancer and in
utero exposure to radiation has been reported.

Ultrasound
Ultrasonography use high frecuency, no ionizing,
acoustic radiation to create images.
Audible sound range = 20 to 20,000 vibration/seg
Ultrasonography use frecuencies of 1 millon to 10 millons
vibrations/seg

Not been shown to produce fetal damage or harmful

effect.

 Rapid compression and decompression of

tissue by sound wave. Cause tissue damage.
Conversion of mechanical energy to thermal
energy.
Especially at the bone soft tissue interface, could
lead to local hypertermia.
CAVITATION could cause microscopic bubbles already
present in tissue to grow size because of absorption of
surrounding diffused gases.

 MRI
Use no ionizing radiation and relies on the magnetic
properties of tissue to create images.
Four magnetic fields interact during an MRI
examination to create the image.
Intrinsic magnetic field (2)
Extrinsic magnetic field (2)

Present danger to the developing fetus.

Charged particles and molecules moving in a strong
magnetic field create an electroestatic potential difference
and anormal RBC can alter their shape and create a charge
when moving within an electric field.
Can induce visual light flashes because of magnetic effects
on the photoreceptors in the eye, and heat can be generated
during the application of radiofrequencies.

 Elective examination of pregnant women by MRI postponed

until after the first trimester and completion of organogenesis.
Is not absolutely contraindicated.

Medication in pregnancy
Medications contraindicated in pregnancy include but are not
limited:

Coumarin derivatives
Isotretinoin
Metrotrexate
Diethylstibestrol
Thalidomide
Angiotensin converting enzyme (ACE) inhibitors
ACE antagonist
Tetracycline
Quinolones

The risks to the fetus may be less compared to the risk to the
mother when not using the proper medication.

Fetal monitoring
Fetal heart rate (FHR) Indirect assessment of fetal
well being.
Can be monitored externally using Doppler
device that is placed on the maternal abdomen.
Uterine activity is monitored by using a
tocodynometer, also applied to the maternal
abdomen.
Response to altered uterine-placental perfusion
or decrease O2 content in maternal blood.

 FHR interpretation
Fetal tachicardia 10 min 160 bpm
Fetal bradycardia 10 min 110 bpm
Acceleration
Increase in the FHR of at least 15 bpm fpr at least 15
seconds.
Normal findings in second half of pregnancy.
Occur as a result of increased sympathetic and
decrease parasympathetic stimulation with fetal
movement.

 Deceleration
Usually accur intrapartum and related to the uterine
contractions ( periodic decelerations).
Classification:
Early
Simultaneous with the contraction.
Uniform, gradual drops in the FHR that mirror the uterine
contraction and reflect an increased vagal tone from a
transient increase in intracraneal pressure.

 Late
Starting when the contraction is in progress and
recovering after the contraction is over.
Poor uterine perfusion or decrease O2
Causes: Hypotension; IVC compression, blood loss or
regional anesthesia.
Variable
Variable in relation to the contraction.
Result from umbilical cord compression by uterine
contraction.
Isolated variable
Inadequate recovery between contractions.
Intervention may be indicate.

 Appendicitis affect 250,000 patient every year

in the US.
Is the most common nonobstetric indication
for operation during pregnancy
Average incidence if 1 in 1,500 deliveries.

Variation in signs and symtoms of appendicitis

during pregnancy (see table).

 Appendiceal lumen obstruction

Lymphoid hyperplasia
Feacaliths
Parasites
Foreign bodies
Crohn disease
Metastatic cancer
Carcinoid syndrome

Appendiceal lumen obstruction leads to an

increase in intraluminal pressure by blocking the
normal egress of mocus.
Progressive obstruction of venous outflow followed by
capillary and arterial thrombosis leads to mucosal
ulceration, trasmural wall necrosis and perforation.

First trimester

SIGNS AND
SYMPTOMS

Second
trimester

Third trimester

R+ LQ pain

100

50

14

R+ UQ pain

17

57

Guarding
(muscle spasm)

80

50

43

Nausea and
vomiting

53

60

23

Tenderness on
rectal
examination

60

17

Perforation rate

20

49

70

 PE:
Tenderness RLQ
Rebound & Guarding (peritoneal signs)
Rovsing sign
palpation of the LLQ results in more pain in the RLQ

Dumphys sign
increased abdominal pain with coughing

Psoas sign (retroperitoneal retroccal appendix)

passively extending the thigh of a patient lying on their
side with knees extend

Obturator sign (Pelvic appendix)

pain when there is flexion and internal rotation of the
hip

Rectal examination tenderness (Cul-de-sac)

Low grade fever

 Laboratory
WBC
2nd &3rd Trimester: 6,000-16,000
Absolute number: not reliable
Differential: levels of band cells can be reliable
indication of infection.

U/A

mild pyuria or mild hematuria: 20%

{extraluminal irritation of the ureter, not UTI}.
mild proteinuria

 A delay in diagnosis occurred in 18% of

patients in the second trimester.
In third trimester a delay was the rule.

Delay in operation with a high rate of

perforation.
49% in the second trimester
70% in the thrid

 Perforated appendicitis presents a greater infectious

risk.
Large uterus interferes with proper omental migration
throughout the abdominal cavity and prevents the walling
off the inflammatory process.
Increase vacularity of abdomen
Greater lymphatic drainage allows rapid dissemination of
infection.

Perforated appendicitis in pregnancy rapidly leads to

diffuse peritonitis, premature labor and fetal loss.
Rate of preterm labor and fetal loss 26 % to 66 %
compared with 0% to 5 % for uncomplicated appendicitis.

 Imaging modalities
Negative appendectomy rate:
-Clinical diagnosis alone: 54%
-Clinical, US & CT: 8%
1st Line:
US
2nd line:
CT (sensitivity 98%; specificity 98%)
MRI (sensitivity 100%)

33-year-old woman in 13th week of pregnancy with 2 days of right lower quadrant

26-year-old woman in 11th week of pregnancy with right lower quadrant

pain and clinical suspicion of appendicitis

 Reduce
insufflations
pressures of 8 to
12 mm Hg.
Decrease fetal
morbidity and
mortality.

Use open Hasson

technique of
trocar placement
under direct
visualization
rather than blind
insufflations with
a Veress needle.

 Advantages
Useful in diagnosis
Less post-op complication
Earlier mobilization & recovery: fewer thromboembolic
complications
Lower postoperative narcotic use: less fetal depression
Shorter hospital stay

Disadvantages

Experience limited
Co2 pneumoperitoneum:
uterine blood flow
Fetal acidosis
Premature labor

Guidelines for laparoscopic surgery during pregnancy

1. Defer operative intervention until the second trimester, when the fetal risk is
lower, whenever possible.
2. Pneumatic compression devices must be used because of he enhancement of
lower venous stasis with pneumoperitoneum and pregnancy induced
hypercoagulable state.
3. Fetal and uterine status, as well as maternal end-tidal CO2 and arterial blood
gases, should be monitored.

4. Use fluroscopy selectively and protect th uterus with lead shield if

intraoperative cholangiography is possible.
5. Given enlarged gravid uterus, abdominal access should be obtained using open
technique.
6. Dependent positioning should be used to shift the uterus off the inferior vena
cava.

Pneumoperitoneum pressures should be minimized and not allowed to exceed 15

mm Hg.
7. Obstetric consultation should be obtained before operation.

 Acute cholecystitis in the second most

common general surgery diagnosis during
pregnancy.
Progesterone induced relaxation of the
gallbladder combined with estrogen induced
supersaturation of bile predispose to gallstone
formation.

 The risk for development of gallstones is

related to the number of pregnancies,
doubling after two pregnancies and nearly
quadrupling after four.
Incidence of acute cholecystitis during
pregnancy is relatively low 1 to 8 in 10,000
pregnancies (0.01% to 0.08%).

 Symptoms of cystic duct obstruction:

Crampy RUQ or epigastric pain after a meal can
last several minutes to hours.
May radiate to the back
Nausea
Vomiting

Tenderness on palpation of the RUQ=acute

cholecystitis

 Labs
Normal leukocytosis
Elevated alkaline phophatase during pregnancy.
Increase bilirubin
Visible jauncide

Diff. DX
Hepatitis
Acute fatty liver of pregnancy
appendicitis

 Dx
History
PE
Ultrasonography 97% accurate

Gallbladder wall thickening

Pericholecystic fluid
Pain on palpation with the ultrasound transducer
Sonographic Murphy sign (is confirmatory of
inflamation)

 Management

Maintained on IV hydratation
Treated with antibiotic for signs of infection.
A low fat diet
The surgery was reserved for those with persistent
symptoms, severe toxicity, sepsis, peritonitis or
obstructive jaundice.

Complication of gallstones
Choledocholithiasis
pancreatitis

 Laparoscopic cholecystectomy
Is a safe and reliable modality
Removing the diseased gallbladder eliminates the
potential for recurence
The minimal uterine retraction need with
laparoscopic.
Access to the RUQ should decrease the risk for
preterm labor.

 The incidence of premature uterine contraction with

laparoscopic cholecystectomy has been reported at 0% to
21%.
Usually well controled with tocolytics.
Spontaneous abortion ranging from 0% to 7%.

Open cholecystectomy
Rate of premature labor ranges from 0% to 40%.
Spontaneous abortion or premature birth rate of up to
22%.
Second trimester is the optimal time.
Organogenesis is complete
Gravid uterus is not yet large enough to impinge on the operating
field.

 Choledocholithiasis
A bilirubin above 1.5 mg/dL, a dilatad common bile
duct or gallstone pancreatitis.
Endoscopic retrograde cholangiopancreatograpy
(ERCP) can be performed safely in pregnancy.
Scatter radiation on the order of 4 mrads during whole
examination.
Evaluation of the biliary tree, stone retrieval, and
sphincteroctomy can be performed.

Other methods avoid radiation:

Endoscopic ultrasonogaphy
Endoscopic papillotomy under ultrasonographic control
Magnetic resonance cholangiography

 1 in every 68,000 deliveries.

Adhesions remain the most common cause of
intestinal obstruction in gravid patient.
Volvulus is much more common complication.

Cause of intestinal obstruction complication

pregnancy and the puerperium in 66 patients.
Adhesions
Volvulus
Sigmoid
Cecal
midgut
Volvulus around vitellointestinal band
Intussusception
Hernia
Carcinoma
Appendicitis
Idiopathic

# and %
39 (59%)
15 (23%)
7
3
3

2
3 (5%)
2 (3%)
1 (1%)
1 (1%)
5 (8%)

 Obstruction during pregnancy classically presents

during three peak periods.
The first peak
The 4 a 5 months of gestation as the uterus becomes an
intra abdominal organ stretching any previously formed
adhesions.

The second peak

during the 8 a 9 months, when the fetal head descends into
the pelvis, decreases the uterine size.

The third peak

After delivery as the sudden decrease in uterine size
drastically change the association of adhesions to
surrounding bowel.

 Presentation and Dx
Abdominal pain and vomiting
Proximal small bowel obstruction
Results in short period between vomiting episodes with poorly
localized, crampy upper abdominal pain.

Colonic obstruction
Present with less frequent feculent vomiting and lower abdominal
pain.

Tachycardia and hypotension are also late signs suggesting

bowel compromise and shock.
Labs
Significant leukocytosis can occur with necrosis and bowel
strangulation.

 Rx
Serial films every 4 to 6 hrs usually show
progressive changes confirming the dx.

Reference

Nature Reviews Molecular Cell Biology 4. Review: MRI: volumetric imaging for vital imaging and atlas
construction. http://www.nature.com/focus/cellbioimaging/content/images/nrm1195_f1.html .SS10
SS16. 2003.
American Academy of Family Physicians. Clinical Interpretations of Fetal Monitor Patterns and the
Detailed Implications Regarding Fetal Health: May 1, 1999.
Appendicitis in Pregnancy: Methods. http://www.medscape.com/viewarticle/549510_4
Acute appendicit is: Pregnancy complicates this diagnosis
http://www.jaapa.com/acute-appendicitis-pregnancy-complicates-this-diagnosis/article/130146/
Lodewijk P. Cobben. MRI for Clinically Suspected Appendicitis During Pregnancy. September 2004 vol.
183 no. 3 671-675 http://www.ajronline.org/content/183/3/671.full
Stavros Zarkadas. LAPAROSCOPIC APPROACH IN ACUTE ABDOMINAL PROCESSES DURING
PREGNANCY.
http://www.laparoscopyhospital.com/laparoscopy_for_acute_abdomen_in_pregnancy.html