166 Obstetrics and Gynecology Board Review •••
❍ What is the most common symptom of appendicitis in pregnancy?
Right lower quadrant pain is the most common presentation in all three trimesters. The dictum that appendicitis
presents as right upper quadrant pain during the third trimester has not been validated by studies.
❍ Why is acute appendicitis more hazardous to the mother during pregnancy than in the nonpregnant state?
Local perforation may be contained by the uterine wall on one side and result in premature delivery with free
perforation and generalized peritonitis after the uterus empties and pulls away from the appendiceal abscess.
❍ Why should a normal appendix found at laparotomy during pregnancy not be removed?
Removal of a normal appendix has been associated with a tripling of the risk of fetal loss.
❍ What is the cause of acute granulomatous peritonitis in pregnancy or the puerperium?
Rupture of fetal contents into the peritoneum or meconium spillage during cesarean delivery.
❍ Name the maternal and fetal risks experienced by obese women during pregnancy.^7
In pregnancy, obese women are at higher risk of gestational diabetes, preeclampsia, cesarean delivery, and
infectious morbidity. Fetal risks include congenital anomalies, growth abnormalities particularly fetal macrosomia,
miscarriage, stillbirth, and neonatal death.
❍ What is the benefit of exercise for obese pregnant women?
Exercise is beneficial for the primary prevention of gestational diabetes, especially in women with a BMI >33. It
is also useful in maintaining euglycemia in gestational diabetes patients who fail diet control alone. The following
relative contraindications to aerobic exercise should be kept in mind: extreme morbid obesity, poorly controlled
type 1 diabetes, history of extremely sedentary lifestyle, and orthopedic limitations
❍ What effects does bariatric surgery have on future fertility?^7
Subsequent weight loss after bariatric surgery leads to higher fertility rates secondary to improvements of
conditions such as polycystic ovarian syndrome, anovulation, and irregular menses. Studies have shown higher
number of unintended pregnancies occurring after the procedure relating to decreased absorption of OCPs from
anatomical and physiological alterations. It is advisable to wait 12 to 24 months after surgery before conceiving so
that the fetus is not exposed to rapid maternal weight loss; as well as to supplement with vitamin B12, folate, iron,
and calcium.
❍ What are risks and benefits of various abdominal imaging modalities in pregnancy?^8
Nonionizing radiation that includes ultrasonography and magnetic resonance imaging is considered safe. However,
the sensitivity of an ultrasound is highly dependent on patient anatomy and operator proficiency. Gadolinium
contrast should be avoided during the first trimester. Ionizing radiation such as plain X-rays, fluoroscopy,
angiography, computed tomography, and nuclear medicine may lead to adverse fetal outcomes. However, concern
about possible effects should not prevent medically indicated diagnostic procedures; when necessary, techniques
such as positional alterations, use of protective shields, and limiting exposure time.
❍ What are the some effects of ionizing radiation on the fetus?^9
Based on case reports and past experience, especially from Japanese atomic bomb survivors, potential deleterious
consequences of ionizing radiation include pregnancy loss (miscarriage, stillbirth), malformation, disturbances of
growth or development, and mutagenic and carcinogenic effects?