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■ If a postpartum patient goes into shock and yon see no bleeding, think of amniotic fluid embolism, uterine inversion, or concealed hemorrhage (e.g., uterine ruptnre with. Weeding into the peritoneal cavity)

Normal physiologic changes in pregnancy:

1. Laboratory tests: erythrocyte sedimentation rate is markedly elevated (worthless test in pregnancy). Thyroxine and thyroxine-binding globulin increase, but free thyroxine is normal. Hemoglobin increases, but plasma volume increases more, so net result: is a decreased hematocrit; and hemoglobin; BUN and creatinine decrease/GFR increases (high end of normal range for BUN/creatinine indicate renal disease in pregnancy); alkaline phosphatase increases markedly. Mild proteinuria and glycosuria are NORMAL in pregnancy, electrolytes and LFTs remain normal.

Z Cardiovascular changes: blood pressure decreases slightly, heart rate increases by 10-20 bpm, stroke volume increases, and cardiac output increases (up to 50%).

3. Pulmonary changes: minute ventilation increases because of increased tidal volume with the same or only slightly increased respiratory rate. Residual volume and carbon dioxide decrease (physiologic hyperventilation/respiratory alkalosis).

4. The average weight gain in pregnancy is 28 lb (12.5 kg). With a greater weight gain, think of diabetes mellitus. With a smaller weight gain, think of hyperemesis gravidarum or psychological or major systemic disease.

Note;: Treat asymptomatic bacterium in pregnancy (because of the high rate of progression to pyelonephritis) with penicillin, cephalosporin, or nitrofurantoin.

Hyperemesis gravidarum: intractable nausea and vomiting leading to dehydration and possible electrolyte disturbances,The condition presents in the first trimester, usually in younger patients with their first pregnancy and underlying social stressors or psychological problems. Treat with supportive care, including small, frequent meals and antiemetics (fairly safe in pregnancy) . Outpatient treatment sometimes is acceptable unless the patient lias severe dehydration and/or electrolyte disturbances, in which case admit for treatment.

Cholestasis of pregnancy: presents with itching, abnormal liver function tests, and/or jaundice during pregnancy.The only treatment is delivery, but cholestyramine may help with symptoms. Acute fatty liver of pregnancy is a more serious disorder that presents in the third trimester or after delivery and usually progresses to hepatic coma. Treatment includes IV fluids, IV glucose, and fresh frozen plasma. Vitamin. K does not work, because the liver is in. temporary failure.

Surgical conditions: Pregnant women can have the same surgical conditions as nonpregnant women, hi general, treat the disease regardless of pregnancy.This rule of thumb always works with acute surgical conditions (e.g., appendicitis, cholecystitis). With semiurgent conditions (e.g., ovarian neoplasm), it is best to wait until the second trimester, when the patient is most stable. Purely elective cases are avoided. Appendicitis may present with right upper quadrant pain or tenderness due to displacement of the appendix by the uterus. Do a laparotomy if you are unsure and the patient has peritoneal signs.

Fetal malpresentations: although under specific guidelines some frank and complete breeches may be delivered vaginally, it is acceptable to do a cesarean section for any breech presentation. With shoulder presentation or incomplete/footling breech, cesarean section is mandatory. For face and brow presentations, watchful waiting is best, as most convert to vertex presentations; if they do not convert , do a cesarean section,

Multiple gestations: if sex or blood type is different, twins are dizygotic. If the placentas are monochorionie, the twins are monozygotic. These three simple factors differentiate monozygotic from dizygotic twins in 80% of cases. The remaining 20% require HLA-typing studies. Complications of multiple gestations (the higher the number of fetuses, the higher the risk of most of these conditions) include the following:

1. Maternal: anemia, hypertension, premature labor, postpartum uterine atony, postpartum hem orrhage, preeclampsia

2. Fetal: polyhydramnios, malpresenration, placenta previa, abruptio placentae, velamentous cord insertion or vasa previa, PROM, prematurity, umbilical cord prolapse, IUGR, congen ital anomalies, increased perinatal morbidity and mortality.

3. With vertex-vertex presentations, you can try vaginal delivery for both infants; with any other combination of presentations, do a cesarean section.

Acute abdomen: an inflamed peritoneum often leads to a laparotomy because it signifies a potentially life-threatening condition {important exceptions to laparotomy are pancreatitis, many cases of diverticulitis, a nd spontaneous bacterial peritonitis). The best physical confirmations of peritonitis are rebound tenderness and involuntary guarding. Voluntary guarding and tenderness to palpation are softer signs because both are often present in benign diseases. When you are in doubt and the patient -is stable, withhold pain medications (do not mask symptoms before you have a diagnosis), and do serial abdominal exams. If the patient is unstable or worsening, proceed to laparoscopy or laparotomy.

Localization of acute abdomen:

■ Right upper quadrant: think of gallbladder (cholecystitis, cholangitis) or liver (abscess)

m Left upper quadrant: think of spleen (rupture with blunt trauma)

h Right lower quadrant: think of appendix (appendicitis)

■ Left lower q uadrant: think of sigmoid colon (diverticulitis)

a Epigastric: think of stomach (penetrating ulcer) or pancreas (pancreatitis)

Gallbladder disease:

1. Cholecystitis: the classic patient is fat, forty, fertile, female, flatulent and now febrile (especially with gallstones on ultrasound or history of gallstones and/or gallstone-type symptoms, such as postprandial right upper quadrant colicky pain with bloating and/or nausea and vomiting). Look for Murphy's sign. Do a cholecystectomy.

2. Cholangitis: right upper quadrant pain, fever and shaking chilis, and jaundice. Patients often have a history of gallstones. Start antibiotics, and do a cholecystectomy,

3. Ultrasound is the best first imaging study for suspected gallbladder disease in the acute abdomen. For cholecystitis, a nuclear hepatobiliary/scintigraphy study (e.g., a hepato-iminodiacetic acid [HIDA] scan) clinches a difficult diagnosis (nonvisualization of the gallbladder).

Splenic rupture: history of blunt abdominal trauma, hypotension/tachycardia, shock, and Kerr's sign. Patients with Epstein-Barr virus infection should not play contact sports. Immunize all patients after splenectomy (see section on immunizations).

Appendicitis: peaks in 10-30-year-olds.The classic history is crampy, poorly localized periumbilical pain, followed by nausea and vomiting. Pain, then localizes to the right lower quadrant, and patients develop peritoneal signs with worsening of nausea and vomiting. Patients who are hungry and ask for food do not have appendicitis. Remember positive Rovsing's sign and McBurney point tenderness. Do an appendectomy.

McfUirney's point: usual point of maximal tenderness in right lower quadrant, (from James EC, Cony RJ, Perry JF: Principles of Basic Surgical Practice. Philadelphia, Hanley & Belfus, 1987, with permission.)

Diverticulitis: left; lower quadrant pain in a patient over 50 is diverticulitis unless you have a good reason to think otherwise. Treat medically with avoidance of oral ingestion. (NPO) and broad-spectrum antibiotics. If the disease is recurrent or refractory to medical therapy, consider sigmoid resection.

McfUirney's point: usual point of maximal tenderness in right lower quadrant, (from James EC, Cony RJ, Perry JF: Principles of Basic Surgical Practice. Philadelphia, Hanley & Belfus, 1987, with permission.)

Anterior

Pancreatitis: look for epigastric pain in an alcohol abuser or patient with history of gallstones. Pain may radiate to the back, and serum amylase or lipase, if given, is elevated- if they have-not been given, order them! Common symptoms include decreased bowel sounds, local ileus (sentinel loop of bowel on x-ray), and nausea and vomiting with anorexia. Treat with narcotics (meperidine, not morphine), NPO, nasogastric tube, IV fluids, and supportive care. Watch for complications of pseudocyst and pancreatic abscess, which may require surgical intervention.

Perforated nicer: patients often have no history of alcohol consumption or gallstones. X-ray classically shows free air under the diaphragm, and patients have a history of peptic ulcer dis ease. Treat with surgery.

Small bowel obstruction: symptoms include bilious vomiting (seen early), abdominal distention, constipation, hyperactive bowel sounds (liigh-pitched, rushing sounds), and pain that usually is poorly localized. X-ray shows multiple air- fluid levels. Patients often have a history of previous surgery; the most common cause of small bowel obstructions in adults is adhesions, which usually develop from prior surgery In children, think of Meckel's di verticulum or incarcerated hernia. Start treatment with NPO, nasogastric tube, and IV fluids. If symptoms do not resolve or peritoneal signs occur, laparotomy is needed to relieve the obstruction.

Large bowel obstruction: gradually increasing abdominal pain, abdominal distention, constipation, feculent vomiting (seen late). In older patients the most common causes are volvulus and diverticulitis, but colon cancer is a possibility. Treat early with NPO and nasogastric tube. A sigmoid volvulus often can be decompressed with an endoscope. Other causes or re fractory cases require surgery to relieve the obstruction. In children, watch for Hirschsprung's disease.

Four types of hernia (all are treated with surgical repair) :

1. Indirect: most common type in both sexes and all age groups. Hernia sac travels through the inner and outer inguinal rings (protrusion begins lateral to the inferior epigastric vessels) and into the scrotum because of a patent processus vaginalis (congenital defect).

Z. Direct: hernia (no sac) protrudes medial to the inferior epigastric vessels because of weakness in the abdominal musculature of Hesselbach's triangle.

X Femoral: more common in women. Hernia (no sac) goes through the femoral ring onto the anterior thigh (located bdow the inguinal ring). This type is most susceptible to incarceration and strangulation.

4. Incisional: after any wound (especially surgical), a her nia can occur through the site of the incision.

«Incarceration: when herniated organs become trapped and swollen or edematous. Incarcerated hernias are the most common cause of small bowel obstruction in a patient who has never had abdominal surgery and the second most common cause in patients who have had abdominal surgery.

: n Strangulation: the entrapment becomes so severe that the blood supply is cut off; necro sis may occur. Strangulation is a surgical emergency; the patient may present with symptoms of small bowel obstruction and shock.

Important preoperative and postoperative points:

1. Before surgery the patient should avoid oral ingestion for at least 8 hours to reduce the risk of aspiration. For this reason, general anesthesia is dangerous in obstetrics, because patients have not been NPO when they go into labor.

2. Spirometry and a good history are the best preoperative tests for assessment of pulmonary function. Spirometry evaluates forced vital capacity (FVC), forced expiratory volume in one second (I'T.V.), FEV(/FVC (%), and maximal voluntary ventilation.

3. Use compressive or elastic stockings, early ambulation, and/or low-dose heparin to help prevent deep vein thrombosis and pulmonary embolism. Warfarin often is used for or thopedic procedures.

4. The most common cause of postoperative fever in the first; 24 hours is atelectasis. Treat or prevent with early ambulation, chest physiotherapy and percussion, incentive spirometry, and proper pain control. Both too much pain and too many narcotics increase risk of at eleetasis.

5. " Water, wind, walk, wound, and weird drugs" helps to recall causes of postoperative fever. Water urinary tract infection, wind - atelectasis or pneumonia, walk -- deep vein thrombosis, wound = surgical wound infection, and weird drugs drug fever, If daily fever spikes occur, think about an intraabdominal abscess. Order a CT scan to locate; drainage is required.

0. Fascial or wound dehiscence: occurs 5-1 0 days postoperatively. Look for leakage of se.ro-.sanguinous fluid from the wound, particularly after the patient coughs or strains, which is often associated with infection. Treat with, antibiotics (if secondary to infection) and re-closure of the incision.

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