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Surgical problems arising during pregnancy
Copyright, 1950 by The Amcricnn Journal of Surgery. Inc.
A
PRACTICAL
JOURNAL Fiftyninth
VOL. LXXX
SURGICAL
BUILT
ON
MERIT
Year of Publication
JULY,
NUMBER
1950
PROBLEMS ARISING
DURING
ONE
PREGNANCY
Acute appendicitis deserves special consideration. Many studies indicate that by far the greatest number of cases are recognized during early pregnancy. SecondIy, when appendicitis does occur late in pregnancy, it manifests itself in its more severe forms. Cases in which there are perforation peritonitis, premature Iabor and death occur more commonly during the latter months. It appears probable that appendicitis is nearIy as common in the latter as in the earIy months of pregnancy, but that the diagnosis is made less frequentIy as the patient approaches term. The reasons for this failure to make the diagnosis are varied. Primarily the presence of the gravid uterus interferes with the usual typica Iocalization of signs. Furthermore, correct evaluation of the multitude of vague abdomina1 signs and symptoms which tend to appear late in pregnancy is often diffrcuIt. Finally, many attacks of appendicitis subside spontaneousIy, leaving for the most part only the more serious instances of the disease to be recognized. The experience of many indicates that prompt surgica1 intervention in the early months bf pregnancy resuIts in insignificant materna1 morbidity and abortion incidences. Improved results then can be produced only by extending earIy operation to those patients manifesting signs of appendicitis in the Iast trimester of pregnancy. If a poIicy of earlier and more frequent operation is adopted for what may seem at the time reIativeIy benign symptoms and signs, it may be anticipated that a certain number of patients will be operated upon needIessIy. In view of the insignificant risk invoIved it is apparent that this
INOR operations, both gynecoIogic and general surgical, such as incision and drainage of abscesses and excision of benign tumors fail to present any significant surgical or obstetric problem. Consequently, further discussion of this category may be dismissed. IMajor non-abdominal operations, however, deserve somewhat more consideration. In cases in which the diagnosis of malignancy has been estabIished (e.g., breast tumors), necessary surgery and radiation therapy if indicated should be undertaken irrespective of pregnancy. Thyroid surgery and craniotomy for benign lesions may Iikewise be performed provided that the operative procedure cannot safeIy be deferred until the pregnancy has been terminated. A wide experience indicates that the adoption of such a policy is in the best interests of the patient and does not interfere with the pregnancy. Major abdominal operations may be divided into general surgical and gynecoIogic categories. The former group may be further subdivided into operations for acute appendicitis and those performed for other pathologic entities such as acute ChoIecystitis, intestinal obstruction, strangulated hernia, bowel perforation, abscess and maIignancy. The significant feature of the majority of these Iesions is that they represent acute problems requiring more or less immediate surgical intervention. With the institution of prompt surgical treatment excellent maternal results are usuaIIy obtained and the possibility of abortion minimized. With delay, however, compIications are encountered and fetal loss is increased.
M
I
2
EditoriaI
is a small price to pay compared to the tragedy following procrastination and subsequent rupture. A large experience indicates that ceIiotomy for removal of the unruptured appendix may be done without danger to mother or fetus. A McBurney incision at the point of maximum tenderness represents the most satisfactory method of approach. It may be done at term and if labor supervenes the following day, no untoward resuIts need be anticipated. Unavoidably the diagnosis of acute appendicitis will not always be substantiated. The following conditions may occasionaIIy be encountered: twisted ovarian cyst, salpingitis, pyelonephritis, torsion of fahopian tube or hydatid of Morgagni, pedunculated myoma, ectopic pregnancy. Experience indicates, however, that operation may be performed with relatively little danger of interrupting a norma pregnancy even if the diagnosis of appendicitis is not corroborated. Rarely the technica probIem involved will necessitate another incision for better exposure. Under such circumstances the McBurney wound is closed and the more desirable incision made without significantly adding to the morbidity. Gynecologic problems not infrequently are encountered in which the question of surgical intervention arises. Uterine myomas represent the most common tumors in the genital tract. AImost invariably these tumors undergo degeneration during pregnancy producing Iocal signs and symptoms. Myomectomy or, indeed, hysteromyomectomy is not infrequently the iII-advised treatment resorted to. Myomectomy is associated with a high incidence of abortion in a11 cases except those in which the tumor is pedunculated. Accordingly, operation should be deferred and palliative therapy used. Only under unusual and exceptional circumstances should myomectomy be performed during pregnancy. Errors in the past have occurred in those cases in which such operations were performed. Furthermore, in those cases in which patients are treated conservativeIy the delay is never regretted. The size, position or some other feature of the tumor may indicate the necessity for removal at the time of delivery. Ovarian tumors Iarger than 6 cm. in diameter
shouId be removed during pregnancv. In general operation is better delayed until at Ieast the sixteenth week in case it may be necessary to sacrifice the corpus Iuteum. Twisting of the pedicle or other complication may demand immediate intervention at any time. Benign tumors are always best resected, leaving as much norma ovarian tissue as possible. The advisability of being conservative at such a time cannot be stressed too strongly. Carcinoma of the cervix is occasionaIIy during pregnancy. The disease recognized should be treated in what appears to be the best interests of the patient. In the first half of pregnancy this usuaIIy implies loss of the fetus. During late pregnancy cesarean section is often indicated followed by the most appropriate treatment of the tumor depending on the stage of the growth. The outlook in the future for patients who for various reasons present themseIves with peritonitis will be far better than in the past for several reasons. First, the use of antibiotics and sulfonamides wiI1 contribute to reducing the septic process. Second, continuous enteric suction represents a great improvement in treating adynamic intestina1 obstruction. Third, a better understanding of water, electrolyte and protein balance will aid in overcoming the acute illness. Fourth, the limitation of intervention to the surgical problem involved without attempted termination of the pregnancy has been found to give infiniteIy better results than were obtained when cesarean section or induction of Iabor was carried out. Abortion folIowing surgery appears to be directIy related to uterine manipulation, the extent of peritonitis and the remova of the corpus Iuteum in early pregnancy. Surgery per se and anesthesia have no direct relationship to threatened abortion. Consequently in an uncomplicated appendectomy there is no apparent tendency for the’patient to abort. Sedation and narcotics are of value in the postoperative phase to keep the patient comfortabIe. There is no concIusive evidence to justify the use of progesterone or other hormones to prevent the abortion during the postoperative period. R. GORDON DOUGLAS, M.D.
American
Journal
of Surger-y
A
PRACTICAL
JOURNAL Fiftyninth
VOL. LXXX
SURGICAL
BUILT
ON
MERIT
Year of Publication
JULY,
NUMBER
1950
PROBLEMS ARISING
DURING
ONE
PREGNANCY
Acute appendicitis deserves special consideration. Many studies indicate that by far the greatest number of cases are recognized during early pregnancy. SecondIy, when appendicitis does occur late in pregnancy, it manifests itself in its more severe forms. Cases in which there are perforation peritonitis, premature Iabor and death occur more commonly during the latter months. It appears probable that appendicitis is nearIy as common in the latter as in the earIy months of pregnancy, but that the diagnosis is made less frequentIy as the patient approaches term. The reasons for this failure to make the diagnosis are varied. Primarily the presence of the gravid uterus interferes with the usual typica Iocalization of signs. Furthermore, correct evaluation of the multitude of vague abdomina1 signs and symptoms which tend to appear late in pregnancy is often diffrcuIt. Finally, many attacks of appendicitis subside spontaneousIy, leaving for the most part only the more serious instances of the disease to be recognized. The experience of many indicates that prompt surgica1 intervention in the early months bf pregnancy resuIts in insignificant materna1 morbidity and abortion incidences. Improved results then can be produced only by extending earIy operation to those patients manifesting signs of appendicitis in the Iast trimester of pregnancy. If a poIicy of earlier and more frequent operation is adopted for what may seem at the time reIativeIy benign symptoms and signs, it may be anticipated that a certain number of patients will be operated upon needIessIy. In view of the insignificant risk invoIved it is apparent that this
INOR operations, both gynecoIogic and general surgical, such as incision and drainage of abscesses and excision of benign tumors fail to present any significant surgical or obstetric problem. Consequently, further discussion of this category may be dismissed. IMajor non-abdominal operations, however, deserve somewhat more consideration. In cases in which the diagnosis of malignancy has been estabIished (e.g., breast tumors), necessary surgery and radiation therapy if indicated should be undertaken irrespective of pregnancy. Thyroid surgery and craniotomy for benign lesions may Iikewise be performed provided that the operative procedure cannot safeIy be deferred until the pregnancy has been terminated. A wide experience indicates that the adoption of such a policy is in the best interests of the patient and does not interfere with the pregnancy. Major abdominal operations may be divided into general surgical and gynecoIogic categories. The former group may be further subdivided into operations for acute appendicitis and those performed for other pathologic entities such as acute ChoIecystitis, intestinal obstruction, strangulated hernia, bowel perforation, abscess and maIignancy. The significant feature of the majority of these Iesions is that they represent acute problems requiring more or less immediate surgical intervention. With the institution of prompt surgical treatment excellent maternal results are usuaIIy obtained and the possibility of abortion minimized. With delay, however, compIications are encountered and fetal loss is increased.
M
I
2
EditoriaI
is a small price to pay compared to the tragedy following procrastination and subsequent rupture. A large experience indicates that ceIiotomy for removal of the unruptured appendix may be done without danger to mother or fetus. A McBurney incision at the point of maximum tenderness represents the most satisfactory method of approach. It may be done at term and if labor supervenes the following day, no untoward resuIts need be anticipated. Unavoidably the diagnosis of acute appendicitis will not always be substantiated. The following conditions may occasionaIIy be encountered: twisted ovarian cyst, salpingitis, pyelonephritis, torsion of fahopian tube or hydatid of Morgagni, pedunculated myoma, ectopic pregnancy. Experience indicates, however, that operation may be performed with relatively little danger of interrupting a norma pregnancy even if the diagnosis of appendicitis is not corroborated. Rarely the technica probIem involved will necessitate another incision for better exposure. Under such circumstances the McBurney wound is closed and the more desirable incision made without significantly adding to the morbidity. Gynecologic problems not infrequently are encountered in which the question of surgical intervention arises. Uterine myomas represent the most common tumors in the genital tract. AImost invariably these tumors undergo degeneration during pregnancy producing Iocal signs and symptoms. Myomectomy or, indeed, hysteromyomectomy is not infrequently the iII-advised treatment resorted to. Myomectomy is associated with a high incidence of abortion in a11 cases except those in which the tumor is pedunculated. Accordingly, operation should be deferred and palliative therapy used. Only under unusual and exceptional circumstances should myomectomy be performed during pregnancy. Errors in the past have occurred in those cases in which such operations were performed. Furthermore, in those cases in which patients are treated conservativeIy the delay is never regretted. The size, position or some other feature of the tumor may indicate the necessity for removal at the time of delivery. Ovarian tumors Iarger than 6 cm. in diameter
shouId be removed during pregnancv. In general operation is better delayed until at Ieast the sixteenth week in case it may be necessary to sacrifice the corpus Iuteum. Twisting of the pedicle or other complication may demand immediate intervention at any time. Benign tumors are always best resected, leaving as much norma ovarian tissue as possible. The advisability of being conservative at such a time cannot be stressed too strongly. Carcinoma of the cervix is occasionaIIy during pregnancy. The disease recognized should be treated in what appears to be the best interests of the patient. In the first half of pregnancy this usuaIIy implies loss of the fetus. During late pregnancy cesarean section is often indicated followed by the most appropriate treatment of the tumor depending on the stage of the growth. The outlook in the future for patients who for various reasons present themseIves with peritonitis will be far better than in the past for several reasons. First, the use of antibiotics and sulfonamides wiI1 contribute to reducing the septic process. Second, continuous enteric suction represents a great improvement in treating adynamic intestina1 obstruction. Third, a better understanding of water, electrolyte and protein balance will aid in overcoming the acute illness. Fourth, the limitation of intervention to the surgical problem involved without attempted termination of the pregnancy has been found to give infiniteIy better results than were obtained when cesarean section or induction of Iabor was carried out. Abortion folIowing surgery appears to be directIy related to uterine manipulation, the extent of peritonitis and the remova of the corpus Iuteum in early pregnancy. Surgery per se and anesthesia have no direct relationship to threatened abortion. Consequently in an uncomplicated appendectomy there is no apparent tendency for the’patient to abort. Sedation and narcotics are of value in the postoperative phase to keep the patient comfortabIe. There is no concIusive evidence to justify the use of progesterone or other hormones to prevent the abortion during the postoperative period. R. GORDON DOUGLAS, M.D.
American
Journal
of Surger-y