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Certain disorders treated with surgery are difficult to diagnose during pregnancy. A high level of suspicion is required; assuming that all abdominal symptoms are pregnancy-related is an error.
Major surgery, particularly intra-abdominal, increases risk of preterm labor and fetal death. However, surgery is tolerated well by pregnant women and the fetus when appropriate supportive care and anesthesia (maintaining BP and oxygenation at normal levels) are provided, so physicians should not be reluctant to operate; delaying treatment of an abdominal emergency is far more dangerous.
Appendicitis
Appendicitis may occur during pregnancy but is more common immediately postpartum. Because the appendix rises in the abdomen as pregnancy progresses, pain and tenderness may not occur in the classic right lower quadrant location, and pain may be mild and cramping, mimicking pregnancy-related symptoms. Also, WBC count is normally somewhat elevated during pregnancy, making WBC count even less useful than usual. Serial clinical assessment and compression-graded ultrasonography are useful. Because diagnosis is often delayed, mortality rate from ruptured appendix is increased during pregnancy and particularly postpartum. Thus, if appendicitis is suspected, surgical evaluation (laparoscopy or laparotomy depending on the stage of pregnancy) should proceed without delay.
Benign ovarian cysts
These cysts are common during pregnancy. Cysts that occur during the first 14 to 16 wk are often corpus luteal cysts, which spontaneously resolve. Adnexal torsion may occur (see Benign Gynecologic Lesions: Adnexal Torsion). If adnexal torsion does not resolve, surgical therapy to unwind the adnexa or removal may be required. After 12 wk, cysts become difficult to palpate because the ovaries, with the uterus, rise out of the pelvis. Ovarian masses are evaluated first by ultrasonography (see Benign Gynecologic Lesions: Benign Ovarian Masses). Definitive evaluation (eg, excision) is delayed, if possible, until after 14 wk unless any of the following occur:
Gallbladder disease
This disease occurs occasionally. If possible, treatment is expectant; if women do not improve, immediate surgery is needed.
Intestinal obstruction
During pregnancy, intestinal obstruction may cause intestinal gangrene with peritonitis and maternal or fetal morbidity or mortality. If pregnant women have symptoms and signs of intestinal obstruction and risk factors (eg, previous abdominal surgery, intra-abdominal infection), prompt exploratory laparotomy is indicated.
Last full review/revision December 2008 by Sean C. Blackwell, MD
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