Management of Biliary Disease in the Pregnant Patient · CASE PRESENTATION 23yo obese g4p3 F 28wks pregnant with 3 days back pain and RUQ pain after meals since 10 wks gestation PMH:

L I D I E L A J O I E , M D

S U N Y D O W N S T A T E

S U R G E R Y G R A N D R O U N D S

J U L Y 1 2 , 2 0 1 2

Management of Biliary Disease in the Pregnant Patient

www.downstatesurgery.org

CASE PRESENTATION

23yo obese g4p3 F 28wks pregnant with 3 days back pain and RUQ pain after meals since 10 wks gestation

PMH: mild gallstone pancreatitis at 20wks gestation

PSH: none

Labs: WBC 11 bili 1.3 alk phos 265 AST/ALT 100/79 lipase 2599


RUQ US: gallstones. No gallbladder wall thickening, pericholecystic fluid, or sonographic Murphys sign, CBD 4mm


MANAGEMENT

Amylase, lipase, bilirubin returned to normal after 2 days NPO

Underwent open cholecystectomy with fetal heart rate monitoring

Findings: chronic cholecystitis

Postoperative course: diet advanced, discharged home POD 5


BACKGROUND

Non-obstetric surgery is necessary in up to 1% of pregnancies in the US each year

Cholecystectomy for symptomatic cholelithiasis is second to appendectomy as the most common nonobstetric surgical procedure performed during pregnancy

Complications from nonoperative management of gallstone disease result in an increase in maternal & fetal mortality

For expectantly managed gallstone pancreatitis, maternal mortality of 15% and fetal mortality of 60% have been reported


PHYSIOLOGIC CHANGES IN PREGNANCY

Abdominal discomfort, nausea, vomiting, diarrhea, and constipation are often encountered in pregnancy in the absence of intra-abdominal pathology

MATERNAL PHYSIOLOGIC CHANGES

Increased cardiac output

Increased heart rate

Decreased blood pressure

Decreased FRC

Delayed gastric emptying

Increased alkaline phosphatase (200)

Increased WBC (14K)


PHYSIOLOGIC CHANGES IN PREGNANCY

Gallbladder volume doubles in the 2nd & 3rd trimesters

Gallbladder emptying is markedly slower than in the nonpregnant state

Up to 4% of pregnant patients have gallstones on routine obstetric ultrasound

Only 1 in 1000 pregnant patients develops symptoms


DIFFERENTIAL DIAGNOSIS OF RUQ PAIN IN THE PREGNANT PATIENT

Gastroesophageal reflux

Peptic ulcer disease

Acute cholecystitis

Biliary colic

Acute pancreatitis

Hepatitis

Acute fatty liver of pregnancy

HELLP syndrome

Preeclampsia

Pneumothorax

Pneumonia

Acute appendicitis

Hepatic adenoma

hemangioma


DIAGNOSTIC IMAGING

Ultrasound remains the initial imaging study of choice in the evaluation of the pregnant woman presenting with acute abominal pain


DIAGNOSTIC IMAGING

Radiation exposure > 15 rads may lead to chromosomal mutations, neurologic abnormalities, mental retardation, and risk for leukemia especially between 10 to 17 wks gestation

Examination type

Est fetal radiation dose (cGy)

Chest X ray 0.00007

Abdominal CT 2.6

HIDA scan 0.15

Cholangiography 0.5

ERCP 2-12

Fluoroscopy 20 rads/min


U L T R A S O N O G R A P H I C I M A G I N G D U R I N G P R E G N A N C Y I S S A F E A N D U S E F U L I N I D E N T I F Y I N G T H E E T I O L O G Y O F A C U T E A B D O M I N A L P A I N I N T H E P R E G N A N T P A T I E N T

E X P E D I T I O U S A N D A C C U R A T E D I A G N O S I S S H O U L D T A K E

P R E C E D E N C E O V E R C O N C E R N S F O R I O N I Z I N G R A D I A T I O N . C U M U L A T I V E R A D I A T I O N D O S A G E S H O U L D B E L I M I T E D T O

5 - 1 0 R A D S D U R I N G P R E G N A N C Y

I N T R A O P E R A T I V E A N D E N D O S C O P I C C H O L A N G I O G R A P H Y E X P O S E S T H E M O T H E R A N D F E T U S T O M I N I M A L

R A D I A T I O N A N D M A Y B E U S E D S E L E C T I V E L Y D U R I N G P R E G N A N C Y . T H E L O W E R A B D O M E N S H O U L D B E

S H E I L D E D W H E N P E R F O R M I N G C H O L A N G I O G R A P H Y

SAGES GUIDELINES: IMAGING TECHNIQUES DURING

PREGNANCY


OPERATIVE CONSIDERATIONS www.downstatesurgery.org

OPERATIVE MODIFICATIONS IN PREGNANCY

Aortocaval compression by the gravid uterus in the supine position in the latter half of pregnancy can be overcome by placing a wedge under the right hip during positioning

Initial abdominal access can be accomplished with open, veress needle or optical trocar techniques

Camera port must be placed in supraumbilical position later in pregnancy, and remaining ports placed under direct visualization


L A P A R O S C O P I C T R E A T M E N T O F A C U T E A B D O M I N A L D I S E A S E S H A S T H E S A M E I N D I C A T I O N S I N P R E G N A N T

A N D N O N - P R E G N A N T P A T I E N T S

L A P A R O S C O P Y C A N B E S A F E L Y P E R F O R M E D D U R I N G A N Y T R I M E S T E R O F P R E G N A N C Y

I N S U F F L A T I O N P R E S S U R E O F 1 0 - 1 5 M M H G C A N B E S A F E L Y U S E D F O R L A P A R O S C O P Y I N T H E P R E G N A N T

P A T I E N T

SAGES GUIDELINES: SURGICAL TECHNIQUES


MANAGEMENT OF BILIARY DISEASE

Diagnosis made based on same symptoms, laboratory & radiographic criteria

Biliary Colic

Acute cholecystitis

Choledocholithiasis

Gallstone pancreatitis

Cholangitis


SURGICAL OUTCOMES

In a review of 12K patients, maternal mortality was 0.006% and miscarriage rate 5.8% after nonobstetric surgery

0%

10%

20%

30%

40%

50%

1st trimester 2nd trimester 3rd trimester

Open Cholecystectomy

spontaneous abortion

preterm labor


ADVANTAGES TO LAPAROSCOPY

DISADVANTAGES TO LAPAROSCOPY

Decreased fetal narcosis Lower rates of wound

infections & hernias Diminished maternal

hypoventilation Decreased uterine

manipulation Faster recovery Decreased risk of ileus

Risk of uterine injury during trocar placement

Decreased uterine blood flow

Increased risk of fetal acidosis from CO2 pneumoperitoneum

Decreased visualization with gravid uterus

LAPAROSCOPY VS. LAPAROTOMY www.downstatesurgery.org

L A P A R O S C O P I C C H O L E C Y S T E C T O M Y I S T H E T R E A T M E N T O F C H O I C E I N T H E P R E G N A N T P A T I E N T , R E G A R D L E S S O F

T R I M E S T E R

C H O L E D O C H O L I T H I A S I S D U R I N G P R E G N A N C Y M A Y B E M A N A G E D W I T H P R E O P E R A T I V E E R C P W I T H

S P H I N C T E R O T O M Y F O L L O W E D B Y L A P A R O S C O P I C C H O L E C Y S T E C T O M Y , L A P A R O S C O P I C C B D E X P L O R A T I O N ,

O R P O S T O P E R A T I V E E R C P

SAGES GUIDELINES: MANAGEMENT OF BILIARY

DISEASE IN PREGNANCY


ANESTHETIC CONCERNS

Based on direct effects of anesthetic agents and effects of maternal hypotension on fetus

No definitive evidence to link anesthesia with fetal outcome, but given that differentiation of the major organ systems occurs in the 1st trimester, delaying semielective surgical procedures until the 2nd trimester may theoretically reduce risk for teratogenicity

Risk for preterm delivery is highest in the 3rd trimester

Delays in treatment have also been shown to increase the chance of preterm labor


PERIOPERATIVE MEDICATIONS

SAFE AVOIDED

ACETAMINOPHEN

NSAIDS

MORPHINE or FENTANYL PCA

Decrease respiratory depression & drug transfer to fetus

1ST & 2ND GEN CEPHALOSPORINS

CIPROFLOXACIN


FETAL MONITORING

Before and after surgery if 1st or 2nd trimester

Continuous intraoperative monitoring in late 2nd and in 3rd trimester whenever possible

Transvaginal ultrasound can be used during abdominal operations


F E T A L H E A R T M O N I T O R I N G S H O U L D O C C U R P R E O P E R A T I V E L Y A N D P O S T O P E R A T I V E L Y I N T H E

S E T T I N G O F U R G E N T A B D O M I N A L S U R G E R Y D U R I N G P R E G N A N C Y

T O C O L Y T I C S S H O U L D N O T B E U S E D P R O P H Y L A C T I C A L L Y I N P R E G N A N T W O M E N U N D E R G O I N G S U R G E R Y B Y T

S H O U L D B E C O N S I D E R E D P E R I O P E R A T I V E L Y W H E N S I G N S O F P R E T E R M L A B O R A R E P R E S E N T

SAGES GUIDELINES: PERIOPERATIVE CARE


Question 1

Which of the following physiologic changes does NOT occur during pregnancy? A: dilutional anemia

B: mild, compensated respiratory acidosis

C: increased cardiac output

D: decreased gastric and intestinal motility


Question 2

During pregnancy, when is the optimal time to perform abdominal operations? A: 5 to 9 weeks

B: 10 to 13 weeks

C: 15 to 18 weeks

D: 26 to 28 weeks

E: after 32 weeks


Question 3

Regarding laparoscopy during pregnancy, which of the following is recommended? A: Antibiotic prophylaxis with a fluoroquinolone

B: Right lateral decubitus position

C: Limiting carbon dioxide pneumoperitoneum to 12 mmHg

D: Using an umbilical entry site for laparoscopy for gestational ages beyond 24 weeks

E: Performing open rather than laparoscopic procedures after 24 weeks gestation


Documents

Management of Biliary Disease in the Pregnant Patient · CASE PRESENTATION 23yo obese g4p3 F 28wks pregnant with 3 days back pain and RUQ pain after meals since 10 wks gestation PMH: