Acute appendicitis is the most common disease requiring surgical intervention, occurring in 1/800 to 1/1500 pregnancies. The rate of appendiceal perforation is significantly higher in pregnancy, presumably due to higher rates of atypical presentation and reluctance to perform appropriate imaging with delays in diagnosis and treatment. Timely diagnosis and treatment are critical because ruptured appendicitis is associated with significantly increased rates of fetal loss (36% vs 1.5%) as well as maternal morbidity and mortality compared with nonruptured appendicitis.

Clinical presentation may include any of the following: anorexia, nausea, vomiting, fever, abdominal pain, leukocytosis with or without bandemia, dysuria, and pyuria. It is important to assess for rebound tenderness and other indications of peritonitis during the physical exam, although these findings may only be present in 50% to 80% of pregnant patients. Nonclassical presentations including right upper quadrant or diffuse abdominal pain are more common in the pregnant patient secondary to anatomic changes. Particular care must be taken to expand the typical differential diagnosis for abdominal pain to consider pregnancy-related conditions, including preeclampsia, round ligament pain, ovarian torsion, preterm labor, placental abruption, and chorioamnionitis.

Diagnostic evaluation with graded compression ultrasonography should be the first-choice modality to evaluate for appendicitis in the pregnant patient, with a sensitivity of 67% to 100% and specificity of 83% to 96%. If ultrasound is inconclusive and appendicitis remains suspected, MRI or CT may be considered, although MRI (sensitivity, 94%; specificity, 97%) is generally preferred in an effort to limit fetal radiation exposure.

Management

• Appendectomy is the standard treatment; medical management with antibiotics alone is not typically recommended due to limited data on this strategy in pregnant patients. Surgery should not be postponed until the presentation of generalized peritonitis.

• In the case of ruptured appendicitis with active labor, cesarean delivery may be appropriate. A stable, nonseptic patient with a ruptured appendix in the later stages of labor may attempt a vaginal delivery.

• Perioperative antibiotics with a second-generation cephalosporin, extended spectrum penicillin, or triple antibiotic therapy (ampicillin, gentamicin, clindamycin) are administered in all cases and continued postoperatively until 24 to 48 hours afebrile in cases of peritonitis, perforation, or periappendiceal abscess.

• Laparoscopy may be useful if the diagnosis is uncertain (eg, with history of pelvic inflammatory disease) and especially in the first trimester. An open laparoscopic entry technique is advisable after 12 to 14 weeks' gestation due to the increased risk of uterine perforation on entering the abdomen.

• Laparotomy is indicated if suspicion for ruptured appendicitis is high, regardless of gestational age.

Acute cholecystitis is the next most common surgical disease in pregnancy, affecting about 1 in 1000 pregnant women. Delayed gallbladder emptying in response to hormonal changes predisposes to gallstone formation and biliary sludge, which can be seen in 7% of pregnant patients. The large majority of these patients will be asymptomatic. Approximately 10% of symptomatic patients will develop acute cholecystitis, which if left untreated may progress to cause serious complications such as gangrenous cholecystitis, gallbladder perforation, and cholecystoenteric fistulas.

Clinical presentation includes anorexia, nausea, vomiting, fever, and mild leukocytosis, which may also be present at baseline in pregnancy. Symptoms may be localized to the flank, right scapula, or shoulder. Murphy sign is seen less frequently in pregnancy or may be displaced.

Diagnostic evaluation consists of history and physical examination and laboratory tests (leukocyte count, serum amylase and lipase, total bilirubin, and liver function tests). A right upper quadrant ultrasound is highly accurate for the detection of acute cholecystitis and should be considered the first-line imaging modality. If there is high suspicion for a common bile duct stone, endoscopic retrograde cholangiopancreatography may be of both diagnostic and therapeutic benefit.

Management

• Conservative initial management includes bowel rest, intravenous hydration, analgesia, and fetal monitoring. A short course of indomethacin may be considered to decrease inflammation and relieve pain.

• Antibiotics are warranted if symptoms persist for 12 to 24 hours or there is suspicion for infection. Recommended empiric antibiotic regimens include ampicillin/sulbactam (Unasyn), piperacillin/tazobactam (Zosyn), or ceftriaxone plus metronidazole (Flagyl).

• Surgical management is indicated for sepsis, suspected perforation, or failure of conservative therapy. Even in uncomplicated cases, definitive surgery during the initial hospitalization is a reasonable option given the high risk of recurrence when treated conservatively. When feasible, a laparoscopic approach is the preferred technique.

• Intraoperative cholangiography can be safely performed if necessary with the use of fetal shielding techniques.

• Percutaneous gallbladder decompression has been reported for management of more severe cases or in poor surgical candidates.

Bowel obstruction during pregnancy is most commonly caused by adhesions (60%) or volvulus (25%).

Conservative management includes bowel rest, intravenous hydration, and nasogastric suction. Proceed with surgical management if the patient develops an acute abdomen.

Torsion occurs when an adnexal mass twists on its vascular pedicle. A disproportionate share of these cases occurs in pregnancy (up to one quarter of all torsion cases). Common causes of adnexal torsion include corpus luteum cysts, theca-lutein cysts, paratubal cysts, dermoids, and ovulation induction. Complications of torsion include adnexal infarction, chemical peritonitis, and preterm labor.

Clinical presentation includes acute pain (usually unilateral) with or without diaphoresis, nausea, and vomiting. An adnexal mass may be palpable.

Diagnostic evaluation is by history, physical examination, and ultrasonography with Doppler flow to evaluate the adnexa. It is important to note that normal Doppler flow does not exclude the possibility of torsion.

Conservative management is indicated for ruptured corpus luteum cysts in hemodynamically stable patients. Corpus luteum cysts usually involute by 16 weeks' gestation.

Operative management is indicated for acute abdomen, torsion, or infarction.

• Cysts that are persistent, larger than 6 cm, or contain solid elements may require surgery. A laparoscopic approach is often used in the management of adnexal masses in pregnancy.

• If the ovarian corpus luteum is disrupted, progestins can be used up to 10 weeks of pregnancy to prevent miscarriage

About 1 in 3000 pregnant women in the United States are affected by breast cancer. Pregnant patients tend to be diagnosed late. The average delay between symptoms and diagnosis is 5 months.

Diagnostic evaluation is similar to that of nonpregnant patient.

• Mammography, with abdominal shielding, is safe in pregnancy; however, there is a 50% false-negative rate.

• Breast ultrasonography may differentiate solid and cystic masses without radiation exposure but may also give false-negative results.

• A clinically suspicious breast mass, even with negative imaging, should be biopsied, regardless of pregnancy status. Fine needle aspiration and core biopsy are safe in pregnancy.

Management: See chapter 34.

Bariatric surgery is increasingly common among reproductive-age women.

Conception should be delayed for 12 to 24 months after bariatric surgery, during the period of most rapid weight loss. In patients who undergo bariatric surgery with a malabsorption component, such as a Roux-en-Y, there is a higher rate of oral contraceptive failure.

Limited data on pregnancy after bariatric surgery suggest that there is no increase in adverse fetal outcomes. Complications such as gestational diabetes, preeclampsia, and fetal macrosomia may be less common in patients following bariatric surgery than in their obese counterparts but may still occur with greater frequency than the general population.

Patients who have had gastric banding may need band adjustment during pregnancy.

Bariatric surgery patients should be appropriately counseled about nutritional goals and risks. Vitamin and mineral deficiencies, including vitamin B₁, B₆, B₁₂; folate; vitamin D; iron; and calcium, should be assessed and appropriately treated. In the absence of any deficiencies, blood count, iron, ferritin, calcium, and vitamin D levels can be considered each trimester. Folic acid, vitamin B₁₂, calcium, vitamin D, and iron supplements are recommended.

Complications of bariatric surgery, such as anastomotic leak, bowel obstruction, and band erosion, may manifest as nausea, vomiting, and abdominal pain.

Use of nonsteroidal anti-inflammatory drugs should be avoided.