Safety considerations for managing intra-abdominal conditions in the pregnant surgical patient 

Women of child bearing age may experience several health related issues during pregnancy. Whilst the majority of presentations may be a direct consequence of the pregnant state, nonetheless, they can experience other unrelated illnesses. The management of these illnesses must allow due consideration for the pregnant state in these patients. The first step in the patient pathway, therefore, must be to recognise and establish or rule out pregnancy in this patient population.  

Surgical illnesses in pregnant patients pose more serious risks and must be managed with due consideration for the both mother and baby. This blog highlights such considerations at various stages of the patient pathway from diagnosis to management to follow-up. Involvement of an obstetrics team from the outset is critical in delivering safe and effective care in this setting. 

Diagnosis: 

As above, it is important for clinicians to have a high clinical suspicion for pregnancy in child bearing women at the outset. With this in mind, once pregnancy has been established, due diligence must be observed to ensure safe investigations both in the emergent and elective settings. Elective settings can sometimes be more challenging than emergent ones, given the delay involved from requesting to execution of investigations, especially radiological. Similarly, prescriptions of medications should be ensured for safety in pregnancy. 

Surgical interventions: 

It is imperative to only consider the absolutely necessary and probably life-saving emergent surgical interventions for pregnant patients. Most elective surgical procedures can be safely postponed to the postpartum period, unless, this is for a cancer diagnosis. The second trimester is considered to be a relatively safer period to consider any surgical interventions due to the high risk of miscarriage in the first trimester and the fear of inducing premature labour in the third trimester. Moreover, access to the abdominal cavity can be very challenging in the third trimester due to the gravid uterus. It is a consideration to use a left tilt on the operative table to ease the pressure of the gravid uterus on the inferior vena cava. Minimally invasive approaches like laparoscopy offer better post-operative outcomes in terms of recovery and maintaining viability of the fetus. 

Emergency surgery: 

The most common emergency general surgical presentations include biliary related presentations including biliary colic and cholecystitis. The usual reason for this may be related to the change in diet and weight gain. The standard management of gall stone disease is a cholecystectomy and, it is possible to delay to the postpartum period with conservative measures including dietary precautions. If cholecystectomy is unavoidable due to associated complications such as pancreatitis or choledocholithiasis, then a minimally invasive approach in the second trimester may allow a relatively smoother peri-operative course. 

Similarly, acute appendicitis can be a common abdominal emergency presentation which would warrant appropriate management during pregnancy. There is an emerging body of evidence emerging lately to indicate the safety of conservative management of uncomplicated acute appendicitis with antibiotics. However, if surgical intervention is deemed necessary, then the choice should once again be minimally invasive. 

It is quite unusual for pregnant patients to present with left sided pathology like diverticulitis and most cases of uncomplicated and complicated diverticulitis may respond very well to aggressive conservative management including bowel rest and broad spectrum antibiotic cover. If intervention is needed, it may be possibly to pursue this minimally invasively. It is advisable to transfer the care of these patients to a specialist unit in a tertiary care setting to ensure adequate access to infrastructure and resources given the more profound nature of intervention and its potential negative impact on outcomes. 

Other emergency presentations include renal colic, and this presentation is generally managed conservatively, unless, there is a risk of obstructive uropathy necessitating intervention. Pain relief should be prescribed with caution for NSAIDs in pregnancy due to their potential side effect of patent ductus. 

Trauma is another emergent presentation which may necessitate surgical intervention as a life-saving measure. Certain solid organ injuries can be safely managed with interventional radiological embolization and these options should be accessed wherever feasible and available as a means of avoiding major surgical intervention in the pregnant trauma patient. 

Emergency attendance during Caesarean sections: 

This is a special situation, when surgical colleagues are required to attend to intra-operative complications related to bowel or other visceral injury resulting during a caesarean section. Depending on the nature of the facility, access to required resources like certain instruments, retractors and even assistance could be difficult and limited and colleagues must acquire as much information as possible beforehand to be able to prepare for suitably addressing the complication. Escalation of care may be required in the post-operative setting to high dependency or intensive care units and joint multi-disciplinary care is crucial.  

Another aspect to consider is prospective planning for anticipated high risk Caesarean sections, allowing for surgical colleagues and equipment to be available from the outset. This may minimise intra-operative complications and minimise delays in case of complications. 

Elective surgery: 

With the recent increasing waiting times in the NHS, patients could conceive whilst awaiting elective procedures. Some patients may not recognise their pregnancy, especially in the very early stages, whilst others may not recognise the dangers of anaesthesia and surgery to the fetus. Testing for pregnancy on the day of the procedure is therefore a mandatory safeguard which must be embedded in the peri-operative pathway. It should be performed without exception for women of childbearing age, including those who are or have transitioned. Any elective procedure that can be delayed to the post-partum state, should be delayed.  

Challenges arise for elective procedures for malignant indications. Decision making in these settings must be multi-disciplinary with personalised and informed choices offered to patients. Various factors like the nature of urgency, prognosis, previous parity, social circumstances and patients’ emotional state and personal choices must be given due consideration. Discussions during the pre and peri-operative stage may need to include addressing the pregnancy, potentially even considering a medical termination. These are highly sensitive and emotive discussions and clinicians must exercise a high level of empathy and compassion when managing these scenarios. Inclusion of nursing colleagues during patient interactions is an extremely important aspect and allows for keeping the consultations pragmatic and better managed. 

Choice of operative approach: 

It is worthwhile giving consideration to the operative approach in pregnant patients. Depending on the gestational stage and the presenting clinical problem, certain factors must be accounted for to access the abdominal cavity. 

Minimally invasive surgical approach (MIS): 

Usually the MIS approach whether laparoscopic or robotic is safe, especially during the first and second trimester. Pneumoperitoneum required for MIS approaches could result in increase in intra-abdominal pressure with diaphragmatic splinting and potential reduction in the tidal volume, especially when this is combined with Trendelenburg’s position. Another disadvantage could be increased operative time and should be taken in to account with respect to prolonged exposure to anaesthetic and it’s negative consequences. The advantage of MIS is a lower post-operative surgical inflammatory response and a consequent swifter recovery with lower complications. It is worth mentioning that currently the robotic approach is not routine in emergent settings, and, if used during an elective setting, then consideration must be given to the extra-cavity movement of the robotic arms which may be precarious for the pregnant uterus, especially in upper abdominal procedures like cholecystectomy. 

Open approach: 

This is commonly in the form of a midline laparotomy, which is the most familiar technique for most surgical colleagues, especially in the emergent setting. It allows for swift and generous access to the abdominal cavity, especially in the trauma setting. Other approaches like a Kocher’s incision or a para-median incision are sparingly used these days and should only be adopted by those who routinely practice this. The potential disadvantages of the open approach include higher post-operative pain, longer recovery and risk of complications, including delayed complications like incisional herniae.  

Post-operative care: 

Depending on the nature of surgical intervention, the complexity of post-operative care varies. Care should be exercised on the choice of medications including pain relief, anti-emetics and antibiotics. 

Level 2 and Level 3 care could become more challenging with choice of medications, however, need for care escalation in indicative of the gravity of the clinical situation and clinicians may face some difficult decision making. At every stage, it is crucial to adopt a multi-disciplinary approach and a good patient-doctor relationship. 

Post-discharge community care: 

Clear and prompt communication from surgical teams is imperative in ensuring safe recovery in the community along with contributing to a positive patient experience. Timely reviews in clinic and appropriate follow up plans with prompt documentation avoid confusion and anxiety for patients. 

Conclusion: 

The pregnant patient requiring abdominal surgery should be managed in a multi-disciplinary setting, taking second opinions to validate decision making. Patients should be involved from the outset and given realistic expectations. Clear and prompt communication should be priority at all stages to facilitate patients’ experience and reduce medicolegal issues.  

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