Don't Let Them Be Dumb If Your Patient's Got a Bun

Normal Changes in Pregnancy:

• Hormonal changes:

  • HCG peaks at 13 weeks and then decreases again, plateauing at about 20 weeks

    • Greatest cause of nausea/vomiting (75% of pregnant patients)

    • Pathologic if causes weight loss > 5% or after 20 weeks

    • Treatment per ACOG (stepwise):

      • Ginger

      • B12 + doxylamine

      • Promethazine

      • Metoclopramide/Ondansetron

  • Estrogen slowly increases throughout pregnancy

    • Increases bile production

  • Progesterone slowly increases throughout pregnancy

    • Smooth muscle relaxant

      • GERD (80% of pregnant patients)

        • Treatment per ACOG: Both H2 blockers and PPIs are ok

      • Constipation

      • Increases risk of pyelonephritis

        • Asymptomatic bacteriuria should be treated for this reason

        • NNT to prevent pyelonephritis: 7

        • NNT to prevent preterm birth: 9

    • Increases body basal temperature

• Uterine growth

  • Compresses

    • Lungs, decreases FRC and increases RR

    • Stomach, contributing to GERD

    • Ureters (asymptomatic hydronephrosis in 80% of pregnant patients)

    • Colon, causing constipation

  • Stretches the round ligament

    • Worst in second trimester

    • Movement-limited

    • Improves with acetaminophen.

• Increased oxygen demand

  • Increases respiratory rate

    • Respiratory alkalosis

  • Increases plasma blood volume

    • Relative anemia

  • Increases cardiac output

    • Increases heart rate

Data on Imaging

• Ultrasound:

Pathology	Sensitivity	Specificity
Cholecystitis	85	65-86
Appendicitis	51-69	65-85
Torsion	58	86

• MRI:

Pathology	Sensitivity	Specificity
Choledocholithiasis	equivalent to nonpregnant patients	equivalent to nonpregnant patients
Appendicitis	92	98
Torsion	80	not reported

• CT:

  • Standard scans vary wildly in terms of radiation to conceptus

    • CT Abdomen: 2-10 mGy CT Pelvis: 10-50 mGy

  • Teratogenicity: At 50 mGy and less, there is no risk of teratogenicity, developmental delay, or early pregnancy loss

  • Childhood cancers: For every 10mGy exposed to a conceptus, 1/1000 children will develop a childhood cancer that they would not have otherwise

    • Context:

      • Background rate of childhood cancer is 1000

      • Background rate of radiation is 1 mGy

  • Minimizing radiation

    • No abdominal shielding

    • Work with radiology to create focused protocols

      • Focused areas of scan

      • Addition of PO contrast with fewer slices

    • Contrast carries a theoretical risk of thyroid problems, but no documented cases as of yet.

  • Recommended language to discuss this with your patients:

    • This diagnostic scan will not cause birth defects or pregnancy loss

    • For every 400-1000* times this scan is done in pregnancy, theoretically, one child would develop a cancer that they would not have developed otherwise

      • *actual NNH depends on best calculated mGy of scan.

    • I believe the risk of missing a life-threatening or pregnancy-threatening diagnosis is (equal to/less than/greater than) than the risk of radiation.

Can't Miss Pathologies

• Appendicitis:

  • By the numbers:

    • #1 cause of nonobstetric surgical emergencies in pregnancy

    • 1/500 pregnancies

    • Twice the risk of perforation/peritonitis when compared to nonpregnant counterparts

  • Management:

    • Antibiotics

    • Operative approach with OBGYN for fetal monitoring

    • Conservative approach associated with higher morbidity/mortality and recurrence during pregnancy

• Cholecystitis:

  • By the numbers:

    • #2 cause of nonobstetric surgical emergencies in pregnancy

    • Pregnant patients are at higher risk because of increase in bile acid production and cholestasis

  • Management:

    • Antibiotics

    • Operative approach with OBGYN for fetal monitoring

    • Conservative approach associated with increased complications and failure rates

      • 50% of pregnant patients still receive conservative approach despite best available data

• Small bowel obstruction:

  • By the numbers:

    • #3 cause of nonobstetric surgical emergencies in pregnancy

    • High rates of mortality

      • Fetal mortality 20%

      • Maternal mortality 6%, increasing to 20% in 3rd trimester

    • 60-70% adhesions

    • 25% cecal volvulus

    • Remainder: Intussusception

      • Increasing rise in anastomotic intussusception s/p gastric bypass

  • Management:

    • Volvulus and intussusception require surgery, not GI

      • Not enough room to insufflate

    • Other causes of small bowel obstructions often managed medically

• Ovarian Torsion

  • By the numbers:

    • Increased risk in pregnancy

      • 1/1800 patients

    • Highest risk in 1st trimester, ovarian stimulation

  • Management:

    • Laparoscopy

• HELLP

  • By the numbers:

    • Characterized by:

      • Hemolysis

      • Elevated Liver enzymes (usually less than 500)

      • Low Platelets (less than 100)

    • Accounts for 10-15% of pre-ecclampsia

    • 20% can start with normal BP

  • Management:

    • Pre-eclampsia management

      • Magnesium

      • BP management PRN

    • Correct coagulopathy

      • consider exchange transfusion

    • Steroids

    • Feared complication: subcapsular liver hematoma

      • Maternal, fetal mortality > 50

• Interpartner violence

  • By the numbers:

    • 5% of pregnancies

      • Increased risk in young maternal age and lower maternal education

    • Twice as likely to visit ED

  • Management

    • Must screen

      • STaT or OVAT are recommended.

References:

•Abbasi N, Patenaude V, Abenhaim HA. Management and outcomes of acute appendicitis in pregnancy-population-based study of over 7000 cases. BJOG. 2014 Nov;121(12):1509-14.

•(2018) ACOG Practice Bulletin No. 189 Summary: Nausea And Vomiting Of Pregnancy. Obstetrics & Gynecology, 131 (1), 190-1933.

•American College of Radiology. ACR-SPR practice parameter for imaging pregnant or potentially pregnant patients with ionizing radiation

•Bouyou J et al. Abdominal emergencies during pregnancy. J Visc Surg. 2015 Dec;152(6 Suppl):S105-15.

•Cheung K, Lafayette R. Renal Physiology of Pregnancy. Advances in Chronic Kidney Disease. 2013 May;20(3):209-214

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