OG12.10 | Gynaecological and Surgical Disorders in Pregnancy — Summary & Reflection

KEY TAKEAWAYS

Surgical and gynaecological disorders in pregnancy are diagnostically challenging because the gravid uterus displaces abdominal organs, physiological leukocytosis is normal, and peritoneal signs are attenuated by stretched abdominal musculature.

Key conditions:
• Appendicitis — commonest non-obstetric surgical emergency; appendix displaced upward and to the right by the uterus; fetal mortality rises sharply with perforation; requires prompt surgical intervention.
• Ovarian torsion — acute-onset unilateral pain; USS-Doppler diagnosis (absent flow confirms but present flow does not exclude torsion); laparoscopic detorsion preferred.
• Fibroid red degeneration — localised pain over fibroid, self-limiting, managed conservatively.
• Acute cholecystitis — progesterone-driven biliary stasis + oestrogen-driven cholesterol supersaturation → gallstones; second-trimester laparoscopic cholecystectomy for persistent/recurrent cases.
• Intestinal obstruction — adhesions from prior surgery commonest cause; nasogastric decompression and early surgical review.

Investigation principles: ultrasound first-line; MRI (without gadolinium) for inconclusive USS; CT only when MRI unavailable and diagnosis is critical.

Management principles: second trimester is the safest surgical window; never delay emergency surgery regardless of trimester; laparoscopic approach preferred in first–second trimester; left lateral tilt for anaesthesia; perioperative tocolysis and fetal surveillance from 20 weeks.

Maternal principle: the greatest fetal risk is not the surgery itself but the sepsis and haemodynamic compromise from a delayed surgical diagnosis.

REFLECT

Consider a scenario where you are the most senior doctor available at a district hospital at night. A 28-week primigravida presents with signs and symptoms suspicious of appendicitis. The nearest tertiary centre with MRI is 4 hours away by road. Explore your decision-making: What clinical parameters will guide your decision to operate? How will you counsel the patient and her family about the maternal and fetal risks of operating versus waiting? What resources and specialists will you mobilise? This scenario tests not just your clinical knowledge but your ability to act under uncertainty and resource constraints — a core competency of a district-level doctor.