Maternal-neonatal Outcome in Pregnancies with Non-Obstetric Laparotomy During Pregnancy
In this study maternal and neonatal outcome evaluated in each
trimester of pregnancies with non obstetric laparotomies. In this descriptive-analytic
study, 100 pregnant women operated during pregnancy were evaluated. Based on
available data a questionnaire comprising general information, kind of surgery
as well as the maternal-neonatal outcome was fulfilled. These outcomes were
compared in the different gestational ages. In this study, 28 (28%), 48 (48%)
and 24 (24%) patients had been operated in the first, second and third trimester,
respectively. The patients of these three groups were matched for general characters.
Sixty one patients had appendectomy, 30 adnexal mass or torsion, 6% cholecystectomy,
3% abdominal mass. Maternal complications were recorded in 6, 3 and 9% patient
in 3rd, 2nd and 1st trimester of pregnancy, respectively. Abortion in first
trimester was 8.2%. Low apgar in fifth minute and asphyxia were higher in third
trimester. Appendectomy was the most common surgery in the pregnancy. Maternal
and fetal complications were higher in third and first trimester. Besides obstetric
and pediatric consultation before surgery are necessary for optimal safety of
the woman and the fetus.
Received: March 15, 2013;
Accepted: April 16, 2013;
Published: November 23, 2013
The rate of Non-obstetric abdominal surgery in pregnancy is about 1 every 500-635
pregnancy (Goldust and Rezaee, 2013; Lotti
et al., 2013; Shah et al., 2011).
There are some differences between pregnant and non pregnant patients according
to these surgeries (Goldust et al., 2013a; Goldust
et al., 2013b; Mohebbipour et al., 2012).
Anatomical displacement of the pregnant uterus and other organs, pelvic organ
congestion, hypercoagulability, physiological symptoms of normal pregnancy such
as nausea, vomiting, mild abdominal pain and constipation and finally fetus
exposure with drugs and anesthesiology situation are the causes of these differences.
(Burger et al., 2011; Goldust
et al., 2013c; Ngu et al., 2011) Limitation
for laboratory and imaging diagnostic test in pregnancy are other problems in
pregnant patients who need surgery (Gerli et al.,
2011; Goldust et al., 2013d; Vafaee
et al., 2012). In a previous study (Gurbuz et
al., 2004) authors asked about the role of laparoscopy in pregnancy,
while another study (Roux et al., 2011) gave
us pressure numbers. In a previous study (Reedy et al.,
1997) authors defined fetal outcomes and surveyed laparoscopic surgeons.
Authors in a previous study (Gheorghiu, 2009) defined
safety in appendectomies in pregnancy and in another study authors ( Carter
and Soper, 2004) compared laparoscopy with laparotomy. Therefore, there
are some difficulties in the diagnosis and management of these patients (Goldust
et al., 2012; Milan et al., 2011;
Sadighi et al., 2011). Poor fetal outcome and
maternal mortality from these surgeries are usually due to delay in diagnosis
and surgical intervention (Agholor et al., 2011;
Golfurushan et al., 2011; Sadeghpour
et al., 2011). Complications and technical problem are different
in each trimester (Fardiazar et al., 2012; Goldust
et al., 2011; Nikanfar et al., 2012).
A few studies about maternal and prenatal mortality in pregnant patient with
non obstetric abdominal surgery have been done in our country (Ganjpour
Sales et al., 2012; Kim et al., 2011;
Sadeghpour et al., 2012). This study was conducted
to establish the pattern of sign and symptom of disease and identify the factors
that are associated with fetal and maternal outcome in nonobstetric abdominal
surgery during pregnancy. The second objective was to determine the complications
of the surgeries in each trimester. The result of this study can help us to
notice about special factors in pregnancy and prevent of fetal and maternal
MATERIALS AND METHODS
In this descriptive-analytic study, 100 patients who had non-obstetric abdominal
surgery during pregnancy were selected at Alzahra Obstetric and Gynecology hospital,
Tabriz from 2007-2012. Most of these patients with surgical problem were admitted
in obstetric unit and then referred to surgical unite for operation. Written
consent was obtained from all the patients. This study was approved by ethic
committee of Tabriz university of medical sciences. Medical records were evaluated
for demographic information, clinical presentation, preoperative management,
preterm labor and maternal and fetal morbidity and mortality. SPSS version 16
was used as analysis software. All variables were compared in each 3 trimester
in pregnancy by using Chi-square and fishers
exact test. The students t test
was used for association between continuous variables and the outcome measures.
P values were obtained in this respect to determine the strength and statistical
significance of the association. Statistical significance was determined at
the 5% level (p<0.05).
A total of 100 patients had non obstetric abdominal surgery in pregnancy, 28
were in first, 48 second, 24 third trimester. The patients age ranged
from 23 years to 39 years and the mean of age was 25.01±3.1. There were
no significant differences among groups for demographic and obstetric characters.
Table 1 and 2 shows the summary of clinical
presentation of pregnant patients who had abdominal surgeries. Abdominal pain
is the most common reason for presentation (100%). Other symptoms include nausea
and vomiting (77%) and fever (33.9%). The common signs seen in these patients
include generalized tenderness (78%), localized tenderness (38%), abdominal
mass (4%) and vaginal bleeding (2%). Appendectomies were done in 61 patients,
including 46.4, 56.2 and 87.5% in each trimester respectively. Appendectomy
was higher significantly in third trimester (p = 0.035) 30 patients had adnexal
mass or torsion, including 42.8, 35.4 and 4.1% in each trimester respectively.
Surgery for adnexal mass or torsion was higher significantly in the first trimester
(p = 0.025) Other surgeries include cholecystectomy (6%), abdominal mass(3%)
and bowel obstruction (1%). Preoperative and postoperative diagnosis was similar
in all patients but there was adnexal torsion in one patient who diagnosed appendicitis
before surgery. The mean duration of surgery was 72.61±22.69 min in the
first group, 67.08±22.38 min in the second group and 72.08±12.76
in the third group. There was no significant difference among these groups (p
= 0.149) Complications of the first day after surgery were seen in 7 patients
and complications of the second to seventh days after surgery were seen in 10
patients. Complication of the second to seventh days after surgery was significantly
higher in the third trimester (p = 0.002) There were no uterine or other organ
damage and fetal death during surgeries. All patient had taken prophylactic
or treatment antibiotic. Nine ( 32.1%) of patients in the first group, 14 (9.2%)
patients in the second group and 16 (66.7%) patients in the third group had
taken tocolytic therapy (mostly progesterone supp) for prevention of preterm
labor. Prescription of tocolytic was significantly higher in the third group
(p = 0.006). No corticosteroid prescription was recorded for lung maturation
of fetus. Maternal complications following surgical procedure during pregnancy
were reported in 7 patients in first hours after surgery and 10 patients in
2nd to 10th days post operative. Complications between 2nd to 10th days were
significantly higher in third groups (p = 0.002). Maternal death was no recorded
in these patients. The delivery of first group was in 37.21±2.69 weeks,
second group in 38.56±1.60 and third group in 37.54±2.00. There
was no significant difference between three groups (p = 0.523) 32.1% in first
group. 22.9% in sec group and 41.6% in third group had cesarean section.
|| Comparison of demographic and medical characters among pregnant
women with non obstetric abdominal surgery
|| Signs and Symptoms in pregnant patient with non bstetric
|| Neonatal outcome in pregnancies with non obstetric abdominal
Operative delivery was not significant difference between three group (p =
0.251) Ante partum or intra partum asphyxia was recorded in 3 patients in third
trimester. Fetal heart rate monitoring was used in 15% of patients after surgery.
Continue FHR monitoring was not used in patients (Table 3).
Common causes of hospitalization were abdominal pain and tenderness. Although
physiological changes that normally occur during pregnancy alter the physical
findings and laboratory features of abdomen problem, these signs and symptoms
were detected commonly in other studies (Carter et al.,
2009; Shakeri et al., 2013; Vahedi
et al., 2012). In a previous study, authors reported that abdominal
pain and tenderness were common in appendicitis in pregnancy. In their study
signs and symptoms of patients were pain, nausea and vomiting, fever, dysuria,
abdominal tenderness, respectively (Malzoni et al.,
2010). In our study pre and post operative diagnosis were the same in most
cases (except 1 patient) and there was no delay in diagnosis in most cases (except
2 patients). Surgical problem in pregnancy can result in potential delay in
diagnosis and management. It is important to differentiate abdominal pain due
to general surgical problem from labor pain in late pregnancy (Karzar
et al., 2012; Nourizadeh et al., 2013;
Seyyednejad et al., 2012). In this study most
frequent surgery was appendicitis, mass and torsion of adnexa and cholesistectomy.
These causes are in accordance to other studies (Duru et
al., 2007; Farhoudi et al., 2012; Schietroma
et al., 2007). In a previous study, authors reported appendicitis,
GB disease, renal calciuria and trauma as the causes of abdominal surgery in
pregnancy (Ahmad et al., 2007). In another study,
appendicitis was reported in 50% of patients and ovarian cysts, mesenteric adenitis
and uterine myoma were causes of 50% of rest patient (Huber
et al., 2007). About 46% of the women in our study were in the trimester
of the pregnancy at presentation. Recent studies have shown a preponderance
of acute abdominal emergency in pregnancy in the second trimester (Drozgyik
et al., 2007; Salehi et al., 2013c;
Salehi et al., 2013a). As shown in this study,
the gestational age significantly affect the fetal loss (p = 0.048). At the
second trimester, the uterus is big and may not be safely manipulated during
surgery. As noted in previous studies, appendicitis is the most common cause
of non-obstetric surgical emergency in our series (Fardiazar
et al., 2013; Ganjpour Sales et al.,
2013; Mossa et al., 2005). However, we observed
more cases of complicated appendicitis than uncomplicated ones. Maternal and
fetal health is in serious jeopardy as a result of generalized peritonitis that
set in quickly because of reduced space for the omentum to contain the spread
(Daghigh et al., 2013; Salehi
et al., 2013b; Soleimanpour et al., 2013).
The high incidence of maternal and fetal mortality recorded in this study can
easily be explained by the increased complicated cases in our study. The high
incidence of complicated cases could be due to late presentation to the health
facility. Most women may confuse the symptoms of pregnancy with symptoms of
abdominal catastrophe, in addition, to poor health seeking behaviors already
documented in previous studies (Nemati et al., 2013;
Qadim et al., 2013; Wiegerinck
et al., 2005). In support of this issue, poor health seeking behavior
is the fact that only about 30% of our patients booked in any health facility
before the illness started. It was not surprising to find that fetal outcome
was significantly affected by the booking status (p<0.0001). Majority of
the mothers that died and those with adverse pregnancy outcome were not booked
before presentation. This underscores the significance of improved advocacy
of early booking in pregnancy in our country. Cost of hospital services is another
important factor which may be responsible for late presentation in the hospital
(Razi et al., 2013; Salehi
et al., 2013d; Yousefi et al., 2013).
Appendectomy was the most common surgery in the pregnancy. Maternal and fetal
complications were higher in third and first trimester; therefore best time
for surgery is second trimester. Rate of abortion was higher in first trimester;
therefore prophylaxis of abortion is suggested. Fetal complications were higher
in third trimester; so fetal monitoring during and after surgery and prevention
of maternal hypothermia and hypovolemia were recommended too. Besides obstetric
and pediatric consultation before surgery are necessary for optimal safety of
the woman and the fetus.
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