appendicitis in pregnancy - copy (2) (1)

7/27/2019 Appendicitis in Pregnancy - Copy (2) (1)

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APPENDICITIS IN PREGNANCY

ABSTRACT

Appendicitis is a rare pregnancy associated surgical emergency, with appendectomy as the

most common non obstetrical surgical procedure in pregnancy. Diagnostic delay increases

maternal and fetal mortality thereby highlighting the need of quick diagnosis and surgery.

Two cases of appendicitis with pregnancy are presented in this paper with abdominal pain as

common presenting feature. Maternal mortality occurred in one of the patient as she came

late to our emergency indicating delay as the culprit.

INTRODUCTION

Appendicitis is the inflammation of appendix, rarely associated with pregnancy with an

estimated frequency of one case of acute appendicitis per 1500 pregnancies(1,2).This

represents an overall incidence of 0.05% to 0.07% . Appendectomy is a known most

common non obstetrical operative procedure in a pregnant patient(1) . Pregnancy continues to

obscure the accurate diagnosis of acute appendicitis due to gestational physiologicalchanges(1). Diagnostic delay increases the incidence of appendiceal perforation, hence

increasing maternal and fetal morbidity and mortality(1). Appendicitis can occur at any time

during gestation but is most common in the first and second trimester(1). The mortality of

appendicitis during pregnancy is the mortality of delay. Here we present two cases of acute

appendicitis who presented in pregnancy , out of which 1 patient had maternal mortality.

CASE REPORTS

CASE 1

Twenty six years old pregnant lady with previous one abortion admitted to the emergency at

34 weeks period of gestation with abdominal pain, vomitings and fever for 1 day. It was a

generalized abdominal pain, more in the epigastrium.On examination, she was febrile but

hemodynamically stable. She had epigastric abdominal distension with a live fetus in breech

presentation.It Her total leukocyte count was 9200 per cubic millimeters. Fluid in the

peritoneal cavity mainly around uterus & Morrison pouch , few dilated bowel loops and live

fetus were found on ultrasound.Clinical diagnosis of peritonitis was made. Patient was kept


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nil per oral on intravenous fluids. Ryles tube inserted and was kept on conservative

management . She received two doses of injection betamethasone for lung maturity. After

two days of conservative management,she was taken up for emergency cessarean section in

view of fetal distress. Intraoperatively, appendix was perforated and gangrenous with diffuse

pus flakes over the uterus, ovaries and gut loops. Appendectomy with peritoneal lavage done.

A liveborn boy baby weighing 2.12kg with APGAR score of 7,8 was extracted.

Postoperatively, she recovered well and discharged in a satisfactory condition with healthy

baby. Histopathological examination of appendiceal specimen was suggestive of appendicitis.

CASE 2

Twenty five years old pregnant lady came to the emergency with complaints of pain

abdomen, constipation and fever for past four days at 30+6 weeks of period of gestation. She

was hemodynamically stable, afebrile with no guarding and rigidity and was carrying a live

fetus on admission.On evaluation, her total leukocyte count was 10000, prothrombin index of

60%, and normal renal function tests.On ultrasonography, bilateral pleural effusion, dilated

bowel loops with free fluid in the peritoneal cavity with air foci in it suggestive of

pneumoperitoneum was found . Decision for laparotomy was taken in view of suspected

bowel perforation. Exploratory laparotomy followed by appendectomy, peritoneal lavage and

bagota bag application done. Intraoperatively, there was 100ml of purulent fluid in peritoneal

cavity,pus flakes were present in right paracolic gutter, appendix was inflamed and indurated

with suspicion of sealed perforation. Rest of the bowel loops and other viscera were normal.

Histopathology of appendicular specimen was suggestive of appendicitis.She received two

doses of betamethasone.On second postoperative day, her urine output decreased. She

developed respiratory distress for which she had to be intubated. Dialysis was initiated for

renal failure . She had cardiac arrest during dialysis and could not be revived.

DISCUSSION

The non-traumatic, acute abdomen in pregnancy is a cause of grave concern to the physician

in charge given that the lives of the pregnant lady and unborn child are at stake. The

differential diagnosis can be divided into gastrointestinal (acute appendicitis, acute

cholecystitis, acute pancreatitis, intestinal obstruction, ischemia, or perforation),

gynecological (ovarian cyst rupture, adnexal torsion, degenerating myoma) or obstetrical

(placental rupture, uterine rupture, hepatic rupture, ruptured ectopic pregnancy) etiologies(2).


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Diagnosis of appendicitis in pregnancy is the largest challenge since the signs and symptoms

may vary depending on the trimester in which the patient presents(3).

Acute appendicitis is the most common non obstetric surgical complication occurring during

pregnancy(1).The diagnosis of appendicitis in a pregnant lady presents a unique challenge to

both the surgeon and gynaecologist. First, the diagnosis of pregnancy needs confirmation at

the time of presentation. Secondly, the anaemia and physiological changes that normally

occur during pregnancy alter the physical findings and laboratory values(total leucocyte

count) that are often used for diagnosis of appendicitis. Thirdly, cases of appendicitis that

occur during pregnancy can produce significant morbidity and mortality if not promptly

identified and treated. Guarding and rigidity are difficult to elicit in third trimester due to

stretched abdominal muscles(1). and Fourthly,the treating surgeon has limitations in the use

of certain diagnostic procedures because of possible teratogenicity like X-ray abdomen.

Finally the surgeon is treating two patients simultaneously, the mother and the fetus and must

be aware of the potential effects of treatment on both patients at all times(1).

The incidence of appendicitis during pregnancy is equal to non pregnant women of the same

age(1). In a study by Lt Col S Chawla, 60% cases were seen during first trimester and rest

during second trimester, although both of our patients presented in third trimester(1). Syed et

al found incidence of appendicitis as 30% in first trimester, 37% in second and 34% in third

trimester in their study(4).According to Mourad J, distribution of suspected appendicitis in

pregnancy was as follows: first trimester, (25%); second trimester, (40%); and third

trimester, (34%). (5)

.

Horowitz et al. have emphasized the diversity of clinical presentation and difficulty in the

diagnosis of acute appendicitis during pregnancy, especially near term. The most important

symptom in their review was abdominal pain(seen in both our patients), which became less

characteristic regarding its location and general description as pregnancy progresses. Right-

lower-quadrant pain was the most common presenting symptom regardless of gestational age

(first trimester, 86%; second trimester, 83%; and third trimester, 78%(5).74% patients

presented with right lower quadrant pain(3). Other symptoms (nausea and vomiting),

signs(body temperature and tachycardia) and laboratory tests (leucocytosis) failed to supply

sufficient and specific diagnostic tools in hands of the physician(5). The mean leukocyte

count in patients with proven appendicitis was 16.4 x 10(9)/L , in comparison with 14.0 x


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10(9)/L for patients with normal histologic findings indicating that fever and leukocytosis

are not clear indicators of appendicitis in pregnancy (5). Laboratory examination of blood and

urine may be of little diagnostic aid(1)

During first six months of pregnancy, symptoms of appendicitis are the same as in

nonpregnant woman. But, still these can be confused with morning sickness and ectopic

pregnancy during first trimester and twisted ovarian cyst in early second trimester(1). During

third trimester, patient complains of pain, higher and more lateral in the abdomen or right

flank as enlarged uterus leads to displacement and lateral rotation of caecum and appendix.

The appendix remains in the right iliac fossa during the first trimester, moves to the pelvic

brim during second trimester and reaches lower right upper quadrant in the third trimester.

Incidence of perforated diffuse peritonitis is high as infection cannot be localized due to

uterine contractions & inability of the omentum to reach inflamed appendix(1).The

abdominal wall is lifted away from the appendix by the enlarged uterus, adding to the

muscular laxity characteristic of pregnancy and leading to diminished irritation of parietal

peritoneum(1). Labour and delivery,because of the associated rapid diminution in the uterine

volume, will further aggravate the condition as the inner wall of the abscess cavity will be

torn away and all adhesions broken(6). The rate of perforated appendix is higher duringpregnancy as compared to non pregnant cases(43 vs 15%)(5) Perforation rates for pregnant

patients have been reported as high as 55% of cases, compared with 4% to 19% of the general

population(3) The risk of perforation increases with gestational age, and perforation in the

third trimester often results in preterm labour (3)

Both of our patients presented with appendiceal perforation and peritonitis

Premature labour was seen in only one patient in a study by Chawla et al(1). . Tocolytic

agents have been used successfully if premature contractions set in. Pregnancy complications

are not uncommon after appendectomies especially in the first trimester and when the organ

is perforated or gangrenous. The most encountered complication is spontaneous abortion with

high rate of 33% reported by Andersen and Nielsen(7). Second trimester appendectomy for

appendicitis was followed by premature delivery in 14%. However, no pregnancy

complications were observed following third trimester appendectomy for appendicitis(7).

Maternal mortality rate can reach 4% while fetal death can be seen in up to 43% of perforated

appendicitis,

accounting for the number one cause of fetal death during pregnancy(2)


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Fetal mortality is high due to septicaemia and prematurity(1). Rate of fetal loss increases

with rupture. An unruptured appendix carries a fetal loss of 1.5% to 9%, while this rate

increases up to 36% with perforation(3).. Abdominal or pelvic ultrasound identifies inflamed

appendix in only 39% of cases(1).There is a definitive role of diagnostic laparoscopy in

patients with right lower quadrant pain with positive pregnancy test, equivocal evidence of

uterine enlargement and in patients with past history of menstrual irregularity or pelvic

inflammatory disease and will reduce rate of negative laparotomy and rules out ectopic

pregnancy or salpingitis(1). The accuracy of diagnostic tools for appendicitis during

pregnancy is known to be low: abdominal ultrasonography is often inconclusive . Computed

tomography of the appendix should not be considered during pregnancy because of radiation

exposure to the fetus(1). Recently, the role of magnetic resonance imaging (MRI) in the

diagnostic workup of pregnant women with abdominal complaints was studied.MRI has

been proven to be safe during pregnancy and has a high sensitivity for appendicitis (97% to

100%) in patients with an inconclusive ultrasound. Disadvantages of the imaging technique

are the high cost, limited availability, and learning curve in interpretation of the images. MRI

has not yet been implemented as the standard workup for acute appendicitis in many

hospitals.(8)

Appendectomy should be performed on suspicion of the presence of appendicitis just as if

pregnancy was not present. . Location of incision is modified with the more advanced

gestational age towards right upper quadrant at the point of maximum tenderness. If surgery

is performed before appendix ruptures, surgery does not disturb the pregnancy(1). Once acute

appendicitis is suspected in a pregnant patient, close working relationship between

surgeon,obstetrician and anaesthesiologist must be maintained to minimize maternal and fetal

morbidity and mortality.Early operation for acute appendicitis should be performed whenever

diagnosis is considered. A grossly normal appearing appendix during surgery should be

removed as for the non-pregnant population to avoid confusion and eliminate appendicitis

from the differential diagnosis for future right lower quadrant pain(2). Due to difficulty in the

diagnosis of acute appendicitis in a pregnant patient, a higher negative laparotomy rate in

these patients (20-35%) is acceptable as compared to nonpregnant patients(15%). Incidence

of perforation increases to 66% if there is delay in removing the appendix after diagnosis has

been made, leading to grave consequences (1). There is often a tendency amongst

obstetricians to relate cases of pain abdomen during pregnancy with the genital organs

leading to late referrals and diagnosis. (7). Maternal mortality is almost zero and is nearly


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always associated with unconfirmed perforation and peritonitis as seen in our second case.

Overall fetal mortality is 2-8.5% but increases to 35% in perforation and peritonitis(1).The

rate of negative appendectomy was considerably higher in pregnant compared with

nonpregnant women (23% versus 18%). (9)

To conclude, appendicitis in pregnancy has always been a difficult problem compared to

nonpregnant patients.It has no single diagnostic symptom, sign or laboratory finding.The

combination of symptoms and clinical judgement is still vital in deciding which patient needs

surgical treatment. Early appendectomy is the secret of success and is the treatment of choice

recommended at all stages of pregnancy. Negative laparotomy is acceptable than delay in

decision of surgery. Removal of the appendix is warranted even if grossly normal during

the operation.


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REFERENCES

1. Chawla S., Vardhan S., Jog S.S. Appendicitis During Pregnancy MJAFI 2003; 59: 212-

215

2. Murariu D, Tatsuno B, M Hua Cori-An and Takamani R Case Report and Management

of Suspected Acute Appendicitis in Pregnancy Hawaii Med. J. 2011 Feb 70(2):30-32

3. Pastore PA , Loomis DN, Sauret J Appendicitis in Pregnancy J. Am Board Fam Med.

2006 Nov-Dec. , vol 19; no. 6: 621-626

4. Kazim SF , Pal KM Appendicitis in pregnancy: Experience of thirty eight patients

diagnosed and managed at a tertiary care hospital in Karachi Int J Surg Aug 2009 vol 7;issue

4:365-7

5. Mourad J, Elliott JP, Erickson L, Lisboa L Appendicitis in Pregnancy: new information

that contradicts long-held clinical beliefs Am J. Obstet Gynecol 2000 May;182(5): 1027-9

6. Easton A.L.T. Appendicitis in Pregnancy Postgrad Med J1957 33: 272-286

7. Andersen B, Nielsen TF Appendicitis in Pregnancy: Diagnosis, Management and

Complications Acta Obstetricia et Gynaecologica Scandinavica Oct 1999, vol. 78; issue 9:

pgs 758-762

8. Ivan Pedrosa, Deborah Levine, Aimee D. Eyvazzadeh, Bettina Siewert, Long Ngo , Neil

M. Rofsky MR Imaging Evaluation of Acute Appendicitis in Pregnancy March 2006

Radiology, 238, 891-899.

9. McGory M.L., Zingmond D.S. , Tillou A., Hiatt J.R., Ko C.Y.,MCryer H. Negative

Appendectomy in a Pregnant Patient is Associated With a Substantial risk of Fetal Loss

Am Coll Surg 2007;205:534540.

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http://radiology.rsna.org/search?author1=Ivan+Pedrosa&sortspec=date&submit=Submithttp://radiology.rsna.org/search?author1=Deborah+Levine&sortspec=date&submit=Submithttp://radiology.rsna.org/search?author1=Aimee+D.+Eyvazzadeh&sortspec=date&submit=Submithttp://radiology.rsna.org/search?author1=Bettina+Siewert&sortspec=date&submit=Submithttp://radiology.rsna.org/search?author1=Long+Ngo&sortspec=date&submit=Submithttp://radiology.rsna.org/search?author1=Neil+M.+Rofsky&sortspec=date&submit=Submithttp://radiology.rsna.org/search?author1=Neil+M.+Rofsky&sortspec=date&submit=Submithttp://radiology.rsna.org/search?author1=Neil+M.+Rofsky&sortspec=date&submit=Submithttp://radiology.rsna.org/search?author1=Neil+M.+Rofsky&sortspec=date&submit=Submithttp://radiology.rsna.org/search?author1=Long+Ngo&sortspec=date&submit=Submithttp://radiology.rsna.org/search?author1=Bettina+Siewert&sortspec=date&submit=Submithttp://radiology.rsna.org/search?author1=Aimee+D.+Eyvazzadeh&sortspec=date&submit=Submithttp://radiology.rsna.org/search?author1=Deborah+Levine&sortspec=date&submit=Submithttp://radiology.rsna.org/search?author1=Ivan+Pedrosa&sortspec=date&submit=Submit


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Thus, laparoscopy has several diagnostic and navigational qualities. First, the appendix is

easily localized, and additional incisions may be planned accordingly, reducing the risk of

uterine irritability due to manipulation and traction. Second, in case of a normal appendix the

procedure can be terminated. Third, with good visualization of other abdominal organs, the

procedure offers an opportunity for a different diagnosis.

Laparoscopic appendectomy has the additional advantage of reduced postoperative pain

compared to pain with open appendectomy, resulting in less fetal depression due to a

reduction in pain medication, less maternal hypoventilation, and thromboembolic risk

reduction, because of early mobilization and fewer wound complications. Fetal loss rate after

laparoscopic appendectomy in pregnant patients was considerably higher than that for open

appendectomy (7% versus 3%, p_0.05).(10)

The rate of perforated appendix is higher during pregnancy as compared to non pregnant

cases(43 vs 15%) Perforation rates for pregnant patients have been reported as high as 55%

of cases, compared with 4% to 19% of the general population(7) . Of 23 patients at > or =24

weeks' gestational age, 19 (83%) had contractions and an additional 3 patients (13%) had preterm

labor with documented cervical change. One patient was delivered in the immediate postoperative

period because of abruptio placenta

appendicitis in pregnancy - copy (2) (1)

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