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Chapter 106

The Pregnant Patient

Juan L. Martinez-Poyer and N. Scott Adzick

Key Points

1 One of the most significant advances in the reduction of morbidity of prematurity has been the use

of antenatal corticosteroids.

2 To accommodate the fetus, placenta, and amniotic fluid, the uterus increases in size and weight and

its walls become thinner. By the end of the first trimester, the uterus moves out of the pelvis and by

20 weeks reaches the level of the umbilicus. By term, it almost reaches the liver.

3 The etiology of preterm labor is often multifactorial, but the onset of labor from fetal and uterine

stress from surgical manipulation is of most concern to the surgeon.

4 Initiation of tocolytic therapy for potential but unconfirmed preterm labor is discouraged.

5 Exposure to diagnostic levels of radiation carries little chance for spontaneous abortion,

teratogenesis, or growth retardation. The increased risk of future cancer, however, does exist and

must be weighted against the utility of information provided by the study.

6 Attributing abdominal pain to other etiologies, failure to pursue further investigation, and the

physicians’ fear of surgically induced premature labor all contribute to delayed diagnosis, higher

perforation rates, diffuse peritonitis, preterm labor, and fetal loss in pregnant patients with

appendicitis.

7 Cholecystectomy can be performed safely and effectively during pregnancy in all trimesters.

Nonoperative management of symptomatic cholelithiasis is associated with significant recurrent

bouts of symptoms, prolonged total parenteral nutrition, higher rates of preterm delivery, cesarean

section, and more technically difficult cholecystectomies.

8 Adhesions remain the most common cause of intestinal obstruction in the gravid patient, with 89%

to 100% of patients eventually requiring an operation.

9 Pregnant patients present with more advanced colorectal cancers than the population a whole. The

necessary treatment must balance oncology outcomes with effect on the pregnancy, and decisions

regarding the management of pregnancy include termination, iatrogenic prematurity, or intentional

delay in treatment.

The general surgeon at some point in his or her career will be asked to operate on an obstetrical patient

or be urgently consulted for intraoperative assistance with an unanticipated surgical finding or

complication. To provide the best support, it is imperative that he or she is knowledgeable of the

normal physiologic variations occurring during pregnancy, the frequency and nature of presentation of

surgical disease, the safety and utility of diagnostic imaging modalities, and the newest surgical

techniques to ensure the safety and well-being of the mother and the fetus. To achieve this goal, the

concerted effort and close working relationship between various specialties cannot be overemphasized.

This chapter reviews the current data on the presentation, frequency, and treatment of some common

surgical diseases during gestation, as well as their impact on pregnancy.

FETAL DEVELOPMENT

1 Human development begins immediately on fertilization of the oocyte by the sperm, but because in

many cases it is very difficult to determine the exact time of fertilization, pregnancy is generally dated

from the first day of the last menstrual period. However, dating using menstrual age is less accurate

than early ultrasonography dating because of reliance on recall, cycle length variability, and pregnancy

after cessation of oral contraceptives or following childbirth.1,2 Ultrasonography provides a better

estimate of the date of delivery than a reliable last menstrual period before 20 weeks of gestation, with

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