By Sarah McClellan, MPH, and Ceana Nezhat, M.D.
Historically, pregnancy has been a time of joy and apprehension. During the Renaissance, women would write out their wills as soon as they became pregnant.2 History, in fact, is full of maternal death. Thomas Jefferson lost his wife following childbirth in 1782. Princess Charlotte of Wales, granddaughter of King George III and cousin to Queen Victoria, died after giving birth to a stillborn in 1817, and Charlotte Bronte died of hyperemesis gravidarum in 1855. Today, education regarding maternal health in pregnancy falls short, demonstrating the lack of risk the modern world associates with childbearing.
Caesarean section can be traced back to ancient times. Its initial purpose was to retrieve the infant from a dead or dying mother, either in an attempt to save the baby or for religious purposes. Regardless, caesarean section was a measure of last resort, and the mother was not expected to survive.
Successful caesarean sections were typically carried out in remote rural areas rather than in urban hospitals. The first recorded successful caesarean section was performed by a sow gelder on his wife in Switzerland in 1500. Not only did both mother and baby survive, but fertility was also preserved and the woman went on to have 5 more children.3,4
There are several possible explanations as to why success was experienced more in remote rural areas. First, with the absence of professional care, caesarean sections were executed without delay in earlier stages of labor when women were stronger and the fetus was less distressed. Second, while hospitals of the day were riddled with infection, caesarean sections in rural areas were performed in homes, which were less contaminated.3
Today, fetal and infant safety and survival have taken priority over maternal health and well-being during pregnancy. Neonatal wards are staffed by highly trained specialists who are ready for the worst scenarios in infants, while mothers are tended to by nurses and doctors who expect the best and are unprepared when complications arise. Compared to the non-pregnant patient, research has shown the pregnant patient undergoing non-obstetric surgery has a higher risk of post-operative septicemia, pneumonia and urinary tract infections as well as approximately a 4-fold higher risk of in-hospital mortality following non-obstetric surgery.
Trends for maternal mortality mirror those for many other health statistics; developing regions account for ~99 percent of global maternal deaths, while the overall global maternal mortality ratio (MMR) has dropped 44 percent in the past 25 years.4 The United States, however, is the only developed country and one of only 11 countries worldwide to have a negative (-16.7 percent) change in MMR.4 A study published in Lancet in 2016 reported a 56 percent rise in MMR in the U.S. between 1990 (MMR=16.9 (95 percent UI 16.2-17.8)) and 2015 (MMR=26.4 (95 percent UI 24.6-28.4)).5 The reason behind this unexpected increase is unclear. MacDorman et al. estimates 79.9 percent of the observed increase was a result of improved surveillance.6 Other possible explanations for this could be poor communication between departments, lack of attention to mothers, advancing maternal age and/or the increasing number of pregnant women in the U.S. with a chronic disease.7
Since 2010, maternal deaths in California have dropped by half since promoting “tool kits” of child birthing safety tips made up of policies, procedures and checklists that reduce deaths and injuries to mothers. The American College of Obstetrics and Gynecology (ACOG) released a bulletin in 2013 addressing one of the leading causes of maternal mortality, high blood pressure, providing hospitals and doctors with step-by-step instructions for treatment.8
A few years later, in 2014, a group of the nation’s leading medical societies, including ACOG, created the Alliance for Innovation on Maternal Health (AIM) Program9 formalizing “safety bundles” or safety practices shown to reduce maternal injuries. “Safety bundles” detail treatment, safety equipment, training and internal reviews recommended for every maternity hospital. However, while there are no federal mandates or monitoring of hospital compliance to recommended “safety bundles,” a shift in healthcare and outcomes is unlikely to happen.
Changing trends in maternal age at first birth are of particular interest and importance due to varying risks of complications and maternal outcomes. In January 201610, the CDC reported mean age of first-time mothers increased 5.3 percent from 24.9 in 2000 to 26.3 in 2014. First births in women aged 30-34 rose from 16.5 percent to 21.1 percent (28 percent) followed by women aged 35+ from 7.4 percent to 9.1 percent (23 percent). Women aged 35+ were at greater odds of preterm delivery, hypertension, severe preeclampsia and superimposed preeclampsia. Furthermore, women aged >40 years at time of delivery were associated with increased odds of mild preeclampsia, poor fetal growth and fetal distress.11
Data released in 2017 revealed 26.5 percent of maternal mortality is associated with cardiovascular disease including cardiomyopathy. The obesity epidemic in the U.S. may also play a role due to its well-documented association with cardiovascular disease. A 2013 ACOG Committee opinion on obesity in pregnancy reported more than half of pregnant women are overweight or obese and 8 percent of reproductive-aged women are extremely obese.12 Furthermore, non-cardiovascular disease attributed to 14.5 percent of maternal deaths, followed by infection and sepsis (12.7 percent) and hemorrhage (11.4 percent).13
The general act of undergoing non-obstetric surgery while pregnant incurs risks of its own. In a recent study by Balinskaite et al, of all recorded pregnancies, less than 1 percent (47,628/6,484,280) underwent non-obstetric surgery. Abdominal surgery (any kind) was the most common surgical group (26.2 percent), and patients were found to have a high risk of miscarriage associated with hospital admission [aRR =1.90 (95 percent CI 1.81–1.99)] and preterm delivery [aRR = 1.62 (95 percent CI 1.54–1.70)] compared to women who did not undergo surgery while pregnant. Researchers estimated every 287 surgical operations were associated with one additional stillbirth, every 31 operations were associated with one additional pre-term delivery, every 39 were associated with an extra-low birth weight baby, every 25 associated with an additional caesarean section, and every 50 operations were associated with one additional long inpatient stay.14
Trauma, appendicitis, cholecystitis, pancreatitis, bowel obstruction and adnexal masses are some of the major non-obstetric abdominal indications for surgical intervention during pregnancy. Trauma is the leading cause of maternal death, accounting for approximately 50 percent of deaths during pregnancy. Approximately 7 percent of pregnant women will experience physical trauma.
The most common non-obstetric surgical condition during pregnancy is acute appendicitis, and roughly 1 in 500 pregnant women require surgery. Acute cholecystitis is the second most frequently reported non-obstetric emergency in pregnancy, with approximately 40 percent of acute cases requiring surgery. The incidence of acute pancreatitis in pregnancy ranges from 1 in 1,066 live births to 1 in 3,000 pregnancies. Acute pancreatitis appears to be more prevalent with advancing gestational age and occurs more commonly in the third trimester or during the postpartum period. Bowel obstruction, or more specifically, adhesive small bowel disease and volvulus, is the third highest cause of surgical admissions in pregnant patients.1
Elective surgery is generally avoided during pregnancy if observational and medical management are possible. Ideally, it is best to perform surgeries during the second trimester, as risks from teratogenicity and preterm labor are lower. However, carefully planned non-obstetric surgery may be performed during any trimester, if required, while still ensuring the safety of both patients, mother and fetus.
Any physician contemplating surgery on a gravid patient should obtain an obstetric consultation prior to surgery, if possible, as obstetricians are uniquely qualified and familiar with the physiological changes in pregnancy and the pathophysiology of obstetric disorders.15 If possible, a multidisciplinary approach is recommended, including an obstetrician during all non-obstetric surgeries during pregnancy.
The configuration of a safe and effective operating room, active monitoring of patient positioning and adherence to appropriate protocols for prophylactic measures for peripheral neuropathy are vital components when performing non-obstetric surgery.
1. Ceana Nezhat (ed), Kavic MS, Lanzafame RJ, Lindsay MK, Polk TM (assoc eds). Non-Obstetric Surgery during Pregnancy: A Comprehensive Guide. New York: Springer. In Press.
2. Victoria and Albert Museum. Renaissance childbirth. 2016. [cited 2017 Nov 2]. Available from: http://www.vam.ac.uk/content/articles/r/renaissance-childbirth/
3. Sewell JE. Cesarean Section – A Brief History. NIH U.S. National Library of Medicine [Internet]. 1993 April 30 [cited 2017 Aug 15]. Available from: https:// www.nlm.nih.gov/exhibition/cesarean/index.html
4. Drife J. The start of life: a history of obstetrics. Postgrad Med J 2002;78:311– 315.
5. Kassebaum N et al. Global, regional, and national levels of maternal mortality, 1990-2015: A Systematic analysis for the Global Burden of Disease Study 2015. Lancet. 2016; Oct 8; 388: 1775-1812.
6. World Health Organization (WHO). Trends in maternal mortality: 1990 to 2015: estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. 2015.
7. Campbell KH, Savtiz D, Werner EF, Pettker CM, Goffman D, Chazotte C, et al. Maternal morbidity and risk of death at delivery hospitalization. Obstet Gynecol. 2013 Sep,122(3):627-33. doi: 10.1097/AOG.0b013e3182a06f4e
8. American College of Obstetricians and Gynecologists. Hypertension in pregnancy. Washington, DC: American College of Obstetricians and Gynecologists; 2013.
9. Council on Patient Safety in Women’s Health Care. Alliance for Innovation on Maternal Health. Accessed: July 27, 2018. Available from: https://safehealth- careforeverywoman.org/aim-program/ World Health Organization (WHO). Trends in maternal mortality: 1990 to 2015: estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. 2015.
10. Mathews TJ, Hamilton BE. Mean Age of Mothers in on the Rise: United States, 2000-2014. Centers for Disease Control and Prevention. 2016 Jan; NCHS Data Brief No. 232. Available from: https://www.cdc.gov/nchs/data/databriefs/db232. pdf
11. Cavazos-Rehg PA, Krauss MJ, Spitznagel EL, Bommarito K, Madden T, Olsen MA, et al. Maternal age and risk of labor and delivery complications. Matern Child Health J. 2015 June; 19(6): 1202–1211. doi:10.1007/s10995-014-1624-7.
12. Obesity and pregnancy. Committee Opinion No. 549. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2013 Jan;121(1):213-7.
13. Creanga AA, Syverson C, Seed K, Callaghan WM. Pregnancy-related mortality in the United States, 2011-2013. Obstet and Gynecol. Aug 2017;130(2):366-373.
14. Balinskaite V, Bottle A, Sodhi V, Rivers A, Bennett PR, Brett SJ, et al. The Risk of Adverse Pregnancy Outcomes Following Nonobstetric Surgery During Pregnancy: Estimates From a Retrospective Cohort Study of 6.5 Million Pregnancies. Ann Surg. 2017 Aug;266(2):260-266. doi: 10.1097/SLA.0000000000001976
15. Gabbe SG, Niebyl JR, Simpson JL, editors. Obstetrics Normal & Problem Pregnancies. 2nd ed. New York: Churchill Livingstone; 1991.