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:
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•(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.
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