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Acute Appendicitis in Pregnancy

A review of current guidelines in the management of appendicitis in pregnancy.
by

William Lao

on 17 November 2016

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Transcript of Acute Appendicitis in Pregnancy

Acute Appendicitis in Pregnancy
Introduction
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.
Clinical presentation
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.
Laboratory Investigations
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%.
Imaging
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.
- Operator-dependent.
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.
Management
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.
Conclusion
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
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

Perforated Appendix
Free perforation
- Acutely ill, risk of intraperitoneal dissemination of pus, fecal material.
- Increased risk of premature labor, delivery, fetal loss.
- Requires urgent laparotomy, irrigation, and drainage.
Negative laparotomy
Perforation
Preterm labor
Fetal demise
Balancing Risks
Surgical Approach
Abdominal access:
- Certain diagnosis: transverse incision at McBurney's/tenderness point.
- Uncertain diagnosis: lower midline vertical incision.
- Laparoscopic appendectomy.
Allows for C-section
Adequate exposure
Avoid manipulation of uterus
Slight left lateral positioning
Open entry and direct visualization for trocars
Avoid cervical instruments
Intraabdominal pressure <12mmHg
PP = Postpartum
2
Differential Diagnosis
Ectopic pregnancy
Preeclampsia, HELLP syndrome
Pyelonephritis,
cholecystitis
Obstetrical emergencies
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.
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Walled-off perforation
- 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.
Thank you!
E. coli!
Be aware of IVC compression!
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