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Acute Appendicitis in Pregnancy
Transcript of Acute Appendicitis in Pregnancy
Most common non-obstetrical surgical pathology encountered during pregnancy.
Diagnosis and management complicated by:
- Common physiologic abdominal/GI discomfort of pregnancy.
- Anatomic changes secondary to enlarging uterus.
- Physiologic leukocytosis of pregnancy.
Incidence of 1/800 to 1/1500 pregnancies.
- Lower incidence than in age-matched, non-pregnant women.
- 2nd trimester incidence higher than 3rd trimester.
- Higher rates of appendiceal rupture in pregnant women.
Classically presents as periumbilical pain
migrating to the RLQ, anorexia, nausea, vomiting, and fever.
In pregnancy, many may present with unusual symptoms:
- Heartburn, constipation/diarrhea, malaise, dysuria.
- Pain on vaginal and/or rectal exam.
- By 5 months, appendix significantly displaced by gravid uterus; pain may migrate to mid-upper right quadrant, and exams may show less rebound tenderness and guarding.
Mild leukocytosis prevalent throughout pregnancy.
- May be as high as 17.0 in 3rd trimester.
Mourad et al. found that mean WBC was:
- 16.4 for proven appendicitis.
- 14.0 for histologically normal appendices.
In <20% of patients, microscopic hematuria and pyuria.
Elevated CRP, non-specific marker for inflammation.
Mild elevation of total bilirubin as marker for perforation .
- Sensitivity 70%, specificity 86%.
Ultrasonography, the modality of choice.
- Positive if noncompressible, blind-ended, tubular structure in RLQ with a diameter >6-7mm.
- If normal, cannot exclude unless alternative pathology found.
MRI, if initial investigations inconclusive.
- Alternative to CT without radiation.
- Sensitivity 91%, specificity 98%.
- High cost, variable availability, increased delays.
CT scan, with appropriate protocol to minimize fetal radiation exposure, as a last resort imaging.
Definitive management: appendectomy and antibiotics.
Prompt and aggressive investigation/treatment required:
- Perforation increases risk of fetal loss (36% vs 1.5%) .
- Generalized peritonitis increases risk of fetal loss
(10.9% vs. 2.6%) and premature labor (11% vs. 4%) .
- Higher rate of negative laparotomy acceptable.
- Normal appearing appendix should be removed.
Generally, no need for concurrent C-section.
Risk of wound dehiscence low during labor/delivery.
Acute appendicitis is the most common general surgical problem in pregnancy.
Be wary of atypical presentations.
- i.e. RUQ pain, baseline leukocytosis, confounding symptoms & signs.
Graded compression U/S suggested.
- MRI if inconclusive, CT if MRI unavailable.
Prompt surgical treatment as delays >24 hours increase risk of perforation.
Uncertain diagnosis: low midline vertical incision.
1. Mourad J, Elliott JP, Erickson L, Lisboa L. Appendicitis in pregnancy: new information that contradicts long-held clinical beliefs. American journal of obstetrics and gynecology. 2000 May;182(5):1027-9. PubMed PMID: 10819817.
2. Sand M, Bechara FG, Holland-Letz T, Sand D, Mehnert G, Mann B. Diagnostic value of hyperbilirubinemia as a predictive factor for appendiceal perforation in acute appendicitis. Am J Surg. 2009;198(2):193. PubMed PMID: 19306980
William S. Lao, M.D., C.M.
PGY-3 General Surgery
University of Ottawa
- Acutely ill, risk of intraperitoneal dissemination of pus, fecal material.
- Increased risk of premature labor, delivery, fetal loss.
- Requires urgent laparotomy, irrigation, and drainage.
- Certain diagnosis: transverse incision at McBurney's/tenderness point.
- Uncertain diagnosis: lower midline vertical incision.
- Laparoscopic appendectomy.
Allows for C-section
Avoid manipulation of uterus
Slight left lateral positioning
Open entry and direct visualization for trocars
Avoid cervical instruments
Intraabdominal pressure <12mmHg
PP = Postpartum
Preeclampsia, HELLP syndrome
Physiologic changes of pregnancy
3. Babaknia A, Parsa H, Woodruff JD. Appendicitis during pregnancy. Obstet Gynecol 1977; 50:40.
4. Cohen-Kerem R, Railton C, Oren D, et al: Pregnancy outcome following non-obstetric surgical intervention. Am J Surg 2005; 190:467-473.
- Long duration perforation with chronic symptoms, phlegmon/abscess.
- Increased inflammation and adhesions, hostile surgical environment.
- Nonoperative management with antibiotics, IV fluids, bowel rest.
- Risk of recurrence; requires monitoring for sepsis and preterm labor.
- Data in pregnancy sparse.
Be aware of IVC compression!