Appendicitis during pregnancy

Appendicitis:
The most common surgical condition of the abdomen  Lifetime occurrence of 7%  Peak incidence 10-30y
 

The most common nonobstetric surgical intervention during pregnancy

Pathogenesis:


Appendiceal lumen obstruction : lymphoid hyperplasia fecaliths parasites foreign bodies crohns disease metastatic cancer carcinoid syndrome

Incidence during pregnancy:

 

Incidence 0.05% 1:1000 pregnant women - appendectomy 1:1500 proved appendicitis (Mazze & Kallen,1991) 1st trimester 30% / 22% 2nd trimester 45% / 27% 3rd trimester 25% / 50%
(Mourad,2000)

Incidence during pregnancy:

Suggested relation with female sex hormones incidence variations during the menstrual cycle .  Reduced incidence of appendicitis during pregnancy, especially in third trimester  Protective effect of pregnancy ?


symptoms :
Pain RLQ / RUQ / Flank  Anorexia  Vomiting  Nausea  Pain migration  Fever


Physical examination:
       

Tenderness RLQ Rebound & Guarding (peritoneal signs) Rovsing sign Dunphys sign Psoas sign (retroperitoneal retrocecal appendix) Obturator sign (pelvic appendix) Rectal examination tenderness (cul-de-sac) Low grade fever

Psoas sign

Obturator sign

Lab:
CBC WBC ( 80% 45% )  CRP  Urinalysis - mild pyuria mild proteinuria mild hematuria


D.D.:
surgical: surgical:
      

gyneco: gyneco:
      

Renal stone Gastroenteritis Pancreatitis Cholecystitis Mesenteric adenitis Hernia Bowel obstruction

Preterm labor Placenta abruptio Chorioamnionitis Adnexal torsion Ectopic pregnancy Pelvic inflammatory Round lig. pain

Diagnostic problems:


Position of appendix:
normally 70% intraperitoneal 30% pelvic, retroileal, retrocolic pregnancy anatomical changes gravid uterus displacement upward & outward flank pain (3rd trimester) (Baer,1932) increased separation of peritoneum decreased perception of somatic pain and localization

Diagnostic problems:
Symptoms complex physical changes anorexia, nausea & vomiting in normal pregnancy  Lab relative leukocytosis  Imaging techniques


Diagnostic problems:


Differential diagnosis: pyelonephritis renal colic placental abtuptio uterine myoma degeneration

Imaging:
KUB  Barium enema  Graded compression ultrasonography  Helical CT scan


Graded compression ultrasound:

Normal appendix (<6mm) rules out appendicitis.  Nonpregnant Sensitivity 85% specificity 92%  Pregnant cecal displacement & uterine imposition makes precise examination difficult (Williams,21 edition)


Acute appendicitis:




1.thickened appendix  2.Caecum  3.Small amount of pericaecal fluid  4.perippendicular hyperemia

Helical CT scan:
Enlarged appendix,  No filling with contrast material,  Periappendiceal inflammatory changes  Nonpregnant patients 98% sensitivity  Pregnant - useful, noninvasive & accurate

(Am J Obstet Gynecol 2001 Apr;184(5):954-7

Radiation ?

Diagnosis:


Pain in RLQ is the most common presenting syndrome of appendicitis in pregnancy regardless of gestational age
(Am J Obstet Gynecol 2001 Jul;185(1):259-60)

Physical examination is the most reliable tool for diagnosis (Am Surg 2000 Jun;66(6):555-9) Fever and WBC are not clear indicators

Treatment:
Suspicion immediate surgical intervention  Delay generalized peritonitis  Antimicrobial therapy: 2nd cephalosporin, perioperative, unless gangrene, perforation, phlegmon


Tocolytics:
Concept: calm the uterus from insult of acute abdomen  Controversial  Ritodrine ineffective anti-prostaglandin side effects  Ritodrine - tachycardia & vomiting  anti-prostaglandin anti-inflammatory & antipyretic, fetal side effects


Surgery:
Uncomplicated / complicated surgical procedure pregnancy outcome  Perinatal morbidity in nonobstetrical surgery in pregnancy tributable to the disease itself

(Mazze and Kallen,1989)

Laparotomy Incision choice in all trimesters McBurneys point (Am J Surg 2002 Jan;183(1):20-2)

laparoscopy:


Adv:

Disadv:

Less post-op complication

Co2 pneumoperitoneum: Dec. uterine blood flow Fetal acidosis Premature labor

Safe especially in 1st half of pregnancy (size of gravid uterus) Similar perinatal outcomes compared to laparotomies

The mortality of appendicitis complicating pregnancy is the mortality of delay

Complications:


Gestational age

Complication rate
(Tracey and Fletcher,2000)

Uterine contractions 80% over 24w  Preterm labor: 1. 3rd trimester 2. Perforated appendix & peritonitis


Complications:
Abortion , Fetal loss ~ 15% (1st trimester)  Decreased birth weight  Other surgical complication wound infection, atelectasis etc.


No increased infertility (Viktrup and Hee,1998)  No congenital malformation  No stillborn infants



Perforated appendicitis:


Incidence: 4 -19% nonpregnant patients 57% pregnant women (Tracey & Fletcher,2000) Gestational age Perforations Peritonitis

Perforation why more ???

No direct cause and effect relationship between prolonged duration of symptoms and perforation  No relationship between time to operative intervention and perforation


Anatomical explanation

Perforation why more ???



Position change of appendix No containment of infection by omentum Inability of omentum to isolate infection More generalized peritonitis

White appendix:
Nonpregnant 20%  Pregnant 20-50% ( higher in advanced pregnancy)


Appendicitis during puerperium:



Appendicitis can stimulate labor after the uterus empties there is diffuse peritonitis

Prognosis:


Generally good : Disease found Surgery complications

The end