Appendicitis during pregnancy

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Appendicitis during pregnancy

• Rinat Gabbay April 2002

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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

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Pathogenesis

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

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Incidence during pregnancy

• Incidence 0.05
• 11000 pregnant women - appendectomy
• 11500 proved appendicitis (Mazze
  Kallen,1991)
• 1st trimester 30 / 22
• 2nd trimester 45 / 27
• 3rd trimester 25 / 50
• (Mourad,2000)

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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 ?
• (Int J Epidemiol 2001 Dec30(6)1281-5)

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symptoms

• Pain RLQ / RUQ / Flank
• Anorexia
• Vomiting
• Nausea
• Pain migration
• Fever

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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

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Psoas sign
Obturator sign
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Lab

• CBC WBC ( 80 ? 45 )
• CRP
• Urinalysis - mild pyuria
• mild proteinuria
• mild hematuria

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D.D.surgical 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

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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

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Diagnostic problems

• Symptoms complex physical changes
• anorexia, nausea vomiting in normal
• pregnancy
• Lab relative leukocytosis
• Imaging techniques

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Diagnostic problems

• Differential diagnosis
• pyelonephritis
• renal colic
• placental abtuptio
• uterine myoma degeneration

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Imaging

• KUB
• Barium enema
• Graded compression ultrasonography
• Helical CT scan

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Graded compression ultrasound

• Normal appendix (
• Nonpregnant Sensitivity 85
• specificity 92
• Pregnant cecal displacement uterine
  imposition makes precise examination difficult
  (Williams,21 edition)

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

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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
  Apr184(5)954-7
• Radiation ?

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Diagnosis

• Pain in RLQ is the most common presenting
  syndrome of appendicitis in pregnancy regardless
  of gestational age
• (Am J
  Obstet Gynecol 2001 Jul185(1)259-60)
• Physical examination is the most reliable tool
  for diagnosis (Am Surg
  2000 Jun66(6)555-9)
• Fever and WBC are not clear indicators
• (Am J Obstet
  Gynecol 2001 Jul185(1)259-60)

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Treatment

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

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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
• (Annals of Saudi Med,
  Vol 18 No 2, 1998)

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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
  Jan183(1)20-2)

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laparoscopy

• Adv
• Less post-op complication

• Disadv
• 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 (Reedy and colleagues,1997)

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The mortality of appendicitis complicating
pregnancy is the mortality of delay

• 
  Babler 1908

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Complications

• Gestational age ? Complication rate
• (Tracey
  and Fletcher,2000)
• Uterine contractions 80 over 24w
• Preterm labor
• 1. 3rd trimester
• 2. Perforated appendix peritonitis

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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

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Perforated appendicitis

• Incidence
• 4 -19 nonpregnant patients
• 57 pregnant women (Tracey
  Fletcher,2000)
• Gestational age ? Perforations ?
• Peritonitis

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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
• (Am
  Surg 2000 Jun66(6)555-9)

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Perforation why more ???

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

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White appendix

• Nonpregnant 20
• Pregnant 20-50 ( higher in advanced pregnancy)

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Appendicitis during puerperium

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

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Prognosis

• Generally good
• Disease found
• Surgery complications

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The end