APPENDICITIS IN

PREGNANCYSadaf Alipour

General SurgeonAssistant Professor

Tehran University of Medical Sciences

INTRODUCTION

The most common general surgical problem during pregnancy

Incidence %0.06- 0.1 percent, or 1 in 1500 deliveries

However, less in pregnant women than in age-matched nonpregnants

Slightly higher rate in T2 than T1, T3 or postpartum

More likely to rupture, especially in T3, possibly because of delay in Dx and intervention

CLINICAL MANIFESTATIONS(1)

 Similar to nonpregnants RLQ pain: the most common symptom Should alert the physician caring for

the pregnant to strongly consider apx Pain is close to McBurney's point in

most regardless of stage of Py although appendix migrates a few cm cephalad with the enlarging uterus

CLINICAL MANIFESTATIONS(2)

NL:Abdominal discomfort in Py due to enlarging uterus, fetal position or movement, Braxton-Hicks

Severe, sudden, constant pain with other symptoms (nausea, vomiting, vaginal bleeding) or in upper abdomen suggests a disease.

Peritoneal signs (rebound , guarding) never NL in Py

Nausea and vomiting: common in early Py, usu abate by early to middle T2 but not normal when with abdominal pain, fever, diarrhea, headache, or localized abdominal findings

CLINICAL MANIFESTATIONS(3)

Physiologic changes of Py may affect presentation

Uterus becomes abdominal, enlarging beyond pelvis by 12 weeks

Uterus impedes examination and affect NL location of pelvic and abdominal organs

CLINICAL MANIFESTATIONS (4)

Gravid uterus lifts anterior abdominal wall

Less direct contact between area of inflammation and parietal peritoneum

Less muscle response or guarding Less peritoneal findings than

nonpregnants The laxity of the abdominal wall may

also diminish peritoneal signs.

LABORATORY ASSESSMENT(1)

Normal Py in T1 and T2 : WBC =6000- 16,000 , may rise to 20,000 -30,000 during labor

Leukocytosis may NL in Py but bandemia not NL in Py and suggests infection until proven otherwise

Retrospective review of 66,993 deliveries with 67 with probable Dx of apx: in those with confirmed apx, mean WBC=16,400 -versus 14,000 for those without apx.

LABORATORY ASSESSMENT(2)

Inflamed appendix often close to bladder and ureter

Microscopic hematuria and pyuria in up to one-third of acute appendicitis

Pregnants with pyuria may be treated for UTI and forgo further investigation, delaying Dx of apx

DIAGNOSIS OF APX IN A LABORING PATIENT

Especially difficult, requires high index of suspicion.

Labor can be associated with pain that may be lateralized,

May fever, leukocytosis, and vomiting when chorioamnionitis during labor

IMAGING If Dx unclear after assessment

of complaints, examination, and lab: diagnostic imaging necessary as in nonpregnants

Thus, virtually all pregnant women will have an imaging study

ULTRASONOGRAPHY 

Choice for imaging of appendix in Py: graded compression ultrasonography

Allows visualization of uterus, placenta and ovarie

Can exclude other causes of RLQ pain Apx diagnosed if noncompressible

blind- ended tubular structure in RLQ with diameter greater than 6 mm .

As a general rule, if a normal appendix is not visualized, appendicitis cannot be excluded

US

overall sensitivity=%86 Specificity=%81 However, gravid uterus can

interfere with US, esp in the T3, leading to high negative laparotomy rate when US results inconclusive

In one small series, appendix could not be visualized with US in 22 of 23 pregnants with suspected apx

MRI (1)  Where available, useful for the next step in diagnostic uncertainty

MRI is an alternative to CT because it avoids exposure to ionizing radiation.

Observational data suggest that MRI can accurately diagnose appendicitis during pregnancy

MRI (2) Excellent modality for excluding apx in

Py with characteristic signs and symptoms when inconclusive US

Gadolinium not routinely administered because of theoretical fetal safety concerns, but may be used if essential .

If a prolonged wait before MRI, increasing risk of rupture over time should be considered and undue delays for imaging avoided.

MRI (3)

Sensitivity= %100 Specificity= %93 Positive predictive value = %61 Negative predictive value = %100

CT SCAN (1) Main findings of apx on CT:

RLQ inflammationEnlarged nonfilling tubular

structureAppendicolith.

CT SCAN (2) Modifications of CT protocol can

limit fetal exposure to less than 3 mGy (30 mGy for carcinogenesis in fetus)

Standard abdominal CT with oral and IV contrast or a specialized appendiceal CT protocol can also be used, but are associated with higher fetal radiation exposure (20 to 40 mGy)

CT SCAN (3) Overall sensitivity= %94

Specificity= % 95

We suggest CT when clinic and US are inconclusive and MRI is not available

MANAGEMENT APPROACH AND OUTCOME 

Decision for laparotomy should be based on clinic, imaging results, and clinical judgment

Lab not particularly useful ecxept for R/O of alternate diagnoses

Delaying Sx for more than 24 h increases risk of perforation (%14-43 of such patients)

INCISION

When Dx relatively certain: transverse incision at McBurney's point, or more commonly, over point of maximal tenderness

When Dx less certain: lower midline vertical incision

LAPAROSCOPY(1)

Several case reports and small case series: laparoscopic appendectomy in Py feasible in all trimesters and with few complications

One systematic review: higher rate of fetal loss with laparoscopy than open appendectomy, but data were from retrospective series

LAPAROSCOPY(2)

Decision to proceed to laparoscopy based on:

skill and experience of surgeon

clinical factors such as size of gravid uterus.

COMPLICATIONS (1)

Risk of fetal loss higher in perforated apx (%36 versus %1.5) or when generalized peritonitis or abscess (fetal loss:% 6 versus %2; early delivery: %11 versus %4).

Given diagnostic difficulties and significant risk of fetal mortality with perforation, a higher negative laparotomy rate (20 to 35 percent) compared to nonpregnant women has generally been considered to be acceptable.

COMPLICATIONS (2)

Maternal morbidity low except in perforated apx

Py related complications frequent in T1 and T2

Spontaneous abortion %33 percent in T1

Premature delivery %14 in T2 No pregnancy complications in T3

TYPE OF DELIVERY

C/S rarely indicated at time of appendectomy

Risk of dehiscence during labor and vaginal delivery not increased when fascia appropriately reapproximated

PROGNOSIS

Good long-term prognosis

No increased risk of infertility or other complications

PERFORATED APPENDIX

 Free perforation causes intraperitoneal dissemination of pus and fecal material

Patients quite ill and may be septic Increased risk of preterm labor and

delivery and fetal loss Urgent laparotomy necessary with

appendectomy and irrigation and drainage of the peritoneal cavity

IN NONPREGNANTS WITH LONG DURATION OF SYMPTOMS (MORE THAN FIVE DAYS)

When contained perforation: treated with ABs , IV fluids, bowel rest, and close monitoring

Many will respond since it has already been "walled-off.“

Although there is good evidence to support this approach in nonpregnant individuals, there is only limited evidence in pregnant women.

CONSERVATIVE TX OF APX IN PY Report of 2 patients: ABs (ampi, genta,clinda),IV

fluids, and bowel rest: improvement of symptoms over 2-3 d

In one: interval apy 2 m after NVD In the other: apy at c/s (breech with preterm labor In both: avoidance of glucocorticoids and tocolytics

due to concerns of suppressing manifestations of worsening infection and delaying delivery if intraamniotic infection was also present.

Until further experience, these should be followed closely in hospital to monitor for maternal sepsis and preterm labor.

SUMMARY AND RECOMMENDATIONS

Apx: most common general Sx problem in Py, clinic and Dx similar to nonpregnant

RLQ pain within a few cm of McBurney's : most common symptom

Nausea/vomiting: both apx and NL Py. In apx, following pain, in Py usu no pain.

US: the best - noncompressible 6mm or more blind ended tubular structure in RLQ

If clinic and US inconclusive: MRI, When MRI not available: CT

Decision to proceed to Sx based on imaging and clinical judgment.

Lab not particularly useful other than R/O other diagnoses.

Delaying Sx more than 24 hours increases risk of perforation.

When Dx relatively certain:transverse incision over point of maximal tenderness . When less certain: lower midline vertical incision

REFERENCES

1- Schwartz Principles of Surgery (book) 2-UptoDate (online)

THANK YOU