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REVIEW ARTICLE
Year : 2013  |  Volume : 3  |  Issue : 1  |  Page : 6-10

Acute appendicitis in pregnancy


Department of Surgery, Ahmadu Bello University, Zaria, Nigeria

Date of Web Publication28-Aug-2013

Correspondence Address:
Stephen E Garba
Department of Surgery, Ahmadu Bello University, Zaria
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-9596.117120

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  Abstract 

Background: Frequently, a general surgeon is called upon to consider the diagnosis of appendicitis in a girl or woman who is pregnant or has recently delivered. The burden of clinical decision-making and execution of treatment would rest on the general surgeon, with other specialists playing peripheral, but important supportive roles. This condition is relatively rare in pregnancy. A delay in operative intervention is often incurred in view of the risk of general anesthesia and operation on the fate of the pregnancy. Promptly diagnosed in a patient who sought medical assistance early in the evolution of the disease, acute appendicitis in pregnancy (AAP) should not pose an operative challenge to the contemporary surgeon or risk to the woman and her unborn child. It is the aim of this review to appraise AAP in the light of contemporary evidence based medicine and to demystify it with a view to encouraging general surgeons to boldly confront a potentially lethal disease and not to add to the patient's suffering by hiding behind unnecessary laboratory and imaging investigations.
Materials and Methods: Many search engines are used such as MedLine, PubMed and Google scholar to search out discussions related to AAP. All the acquired information was processed to arrive at the conclusions drawn here in this essay.
Results: AAP can be promptly diagnosed and treated with high index of suspicion. Awareness of this condition in pregnant patients must be high. The condition if diagnosed early and treated promptly can have a good outcome.
Conclusion: Acute appendicitis is a relatively rare condition in pregnancy; surgeons must have a high index of suspicion as early diagnosis and treatment are important factors in a safe outcome of this condition.

Keywords: Acute abdomen, acute appendicitis, fetal outcome, early diagnosis, pregnancy


How to cite this article:
Sanda RB, Garba SE. Acute appendicitis in pregnancy. Arch Int Surg 2013;3:6-10

How to cite this URL:
Sanda RB, Garba SE. Acute appendicitis in pregnancy. Arch Int Surg [serial online] 2013 [cited 2024 Mar 29];3:6-10. Available from: https://www.archintsurg.org/text.asp?2013/3/1/6/117120

"The mortality of appendicitis complicating pregnancy and the puerperium is the mortality of delay"

Edmund A. Babler, (1874-1930)


  Introduction Top


Every once in a while, a family physician, an emergency physician or an obstetrician would call on the services of a general surgeon to consider the diagnosis of appendicitis in a girl or woman who is pregnant or recently delivered. The burden of clinical decision-making and execution of treatment would rest on the general surgeon, with other specialists playing peripheral, but important supportive roles. If treatment is to be delivered in a timely manner, the surgeon needs to have fairly good experience with appendectomy and confident in his/her ability to perform the operation. The majority of general surgeons do not have extensive experience with this condition by virtue of its relative rarity in pregnancy, delays in operative intervention is often incurred in view of the risk of general anesthesia and operation on the fate of the pregnancy. How quickly the diagnosis is confirmed or reasonably ascertained will determine the success or failure of the treatment. Promptly diagnosed in a patient who sought medical assistance early in the evolution of the disease, acute appendicitis in pregnancy (AAP) should not pose an operative challenge to the contemporary surgeon or risk to the woman and her unborn child. This outlook, however, was until recently, a grim prospect.


  Epidemiology Top


It has been hypothesized that the incidence of appendicitis is no different in the pregnant state than outside it implying that pregnancy does not protect against the disease. [1],[2],[3],[4],[5] If so, it can reasonably be assumed that it is possible to estimate the incidence of AAP by deducing from the proportion of pregnant females in the general population at a given point in time. Another way would be by determining the percentage of appendectomy in pregnant or recently delivered women in a hospital out of the total number of appendectomies performed in the same hospital over a given period. From empirical observation however, the present authors believe that appendicitis is less common in pregnancy than in the general population. A Swedish study found that appendicitis occurred in pregnancy lesser than should be expected if the foregoing hypothesis was true. [3]

A measure of AAP in any population, which can be used to compare the incidence of the disease around the world, is the ratio of AAP to the total number of deliveries in the same hospital in a given period. The normal value falls between 1:1000 and 1:1500 [2],[4],[5],[6],[7],[8] [Table 1] shows the frequency of AAP in different countries around the world. The peak incidence of appendicitis in the general population is within the age-group that corresponds with the peak of fertility or in the second and third decades of life for females. For the individual case of appendicitis, the determinants of outcome come down to just three factors: Early presentation to hospital, the speed with which the diagnosis is established and the promptness of executing appendectomy as a definitive treatment.
Table 1: Comparative incidence of AAP in different regions of the world

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Clinical presentation

The symptomatology of appendicitis does not appear to be significantly different in pregnancy in comparison to the non-pregnant state. Abdominal pain, anorexia, nausea and vomiting appear early in the majority of patients at the time of presentation to hospital. The location of the pain is initially in the central abdominal area regardless of the gestational stage of the pregnancy, which is on the basis of the fact that visceral sensation are carried along the autonomic nerves and referred to the relevant dermatomal area corresponding to the derivatives of the mid-gut during the embryonal stage of development. Radiation and migration of the pain occurring later in the course of the illness will depend on the trimester of pregnancy and the anatomical position of the appendix in the individual case. Right hypochondrial, lumbar or pelvic pains are all possible pictures. Other symptoms such as diarrhea with tenesmus, constipation, dysuria, urgency and urinary frequency have all been observed. Fever is a late symptom in AAP.

Tilting the patient to the left lateral position displaces the uterus from the right iliac fossa and allows the examiner to detect and characterize tenderness in that region. Bearing in mind that in many instances, especially when the appendix is long, the proximal part of the appendix may not be inflamed and so, the location of the tenderness will depend on the location of the distal part of the appendix, which could occasionally be located as high up as in the right hypochondrium. A retrocecal appendix may present with little or no abdominal tenderness. In this location, it may be difficult to distinguish appendicitis from a right pyelonephritis or cystitis as urinalysis reports in this situation have been found to be unhelpful in distinguishing these conditions from AAP.

Laboratory and imaging investigations

Leucocytosis should be interpreted with caution as the pregnant state induces a non-pathologic increase in total leucocyte count with relative lymphocytosis. Marked neutrophilia and raised acute phase protein levels, which are non-specific markers of inflammation should raise suspicion of AAP as differential diagnosis in a pregnant woman presenting with any of the symptoms mentioned above if abdominal pain is one of them. Urinalysis, especially in a patient presenting with urinary symptoms, may reveal proteinuria, hematuria and nitrituria. Microscopy may also reveal heavy pyuria necessitating urine culture and sensitivity testing. This is precisely the situation where delay in operative intervention may appear to be justified as the laboratory picture would seem to favor urinary tract infection.

Abdominal ultrasound scan is ubiquitous in hospitals and one should be available in the emergency room and a sonographer available on demand. Edema of the right kidney with or without distension of the intra-renal collecting systems and hydronephrosis should make a case for pyelonephritis. Conversely, a right hydronephrosis occurring because an inflamed appendix abuts the ureter at any level on its course to the bladder may cause a diagnostic confusion. Free fluid collection within the pelvic peritoneum even in small amounts should raise the profile of appendicitis as the culprit. Abdominal X-rays may occasionally detect a calcified fecalith within the lumen of the appendix and raise the prospect of that organ as harboring the offending pathology, but it must be noted that the presence of a radiologically-detectable fecalith is not synonymous with appendicitis. An important clue that an abdominal X-ray may provide is to locate the cecum by demonstrating its gas-filled outline, which is of paramount importance in the placement of the surgical incision in the event that an open appendectomy is elected. However, the risk posed to the fetus by the ionizing radiations in X-rays must be weighed against any potential benefits and should be strictly restricted to the third trimester if at all used.

Laparoscopy is frequently utilized as a diagnostic tool in acute abdominal conditions where its superior visualization can distinguish between appendicitis and other female pathology such as a hemorrhagic ruptured Graafian follicle on the right side in the female. With respect to AAP however, this use of laparoscopy to confirm a suspected diagnosis should probably not be employed as a diagnostic tool, but be regarded as an operative procedure being an invasive procedure, which requires general anesthesia in every case.

Pre-operative management

The management of AAP can best be elucidated by dividing it into three phases: Pre-operative, operative and post-operative management. Each phase should flow smoothly into the next. An assured and unhurried discussion by the operating surgeon backed by the patient's own obstetrician or gynecologist, the anesthetist and nurses at her bedside will give patient the confidence that the decision to subject her to an operative procedure that could potentially put her pregnancy at risk has not been taken lightly.

Coexisting medical conditions such as diabetes, hypertension, renal disease, heart disease, asthma, etc. have to be addressed. Thromboprophylaxis in patients at risk of deep vein thrombosis is advised. It is a good clinical practice to select and use antibiotics based on sensitivity testing with the minimum number necessary to cover the usual organisms. Begin antibiotic therapy pre-operatively with a view to reducing septic complications. [5],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18] A combination of a penicillin such as ampicillin, amoxicillin- clavulanate, piperacillin-sulbactam or a first or second generation cephalosporin such as cephradine or cefuroxime along with metronidazole is safe. [6],[12],[19],[20] Metronidazole has been in use for over five decades and the observed teratogenicity in preclinical studies in some species of animals has not been observed in humans possibly because it poorly crosses the placenta. The use of metronidazole in the second and third trimesters of pregnancy is safe, but should not be used in the first trimester. [7],[21],[22] Transfusion is almost never needed in appendectomy for AAP even in late pregnancy since the anticipated blood loss is inconsequential in a healthy subject, but grouping and cross matching should be done.

During the late second and the third trimester, an important consideration is fetal lung maturity. For this reason, the use of dexamethasone to accelerate the maturity of fetal type II pneumocytes to aid the production of surfactant has been used. There appears to be some sound empirical evidence that this intervention does prevent neonatal acute respiratory distress syndrome if the pregnancy can be sustained for a week or more. For this reason, tocolytic agents like Ritodrine, Salbutamol and Indomethacin have been used, but the subject remains a controversy. Proponents [2],[4],[8],[23],[24],[25] do not agree on their indication as agents to raise the threshold for an activation of the myometrium that would allow the uterus to go into sustained propulsive contractility leading to premature labor.

Operative management

General anesthesia is to be preferred, but epidural or spinal anesthesia may be considered in the presence of a justifiable medical condition and not because of patient preference. In the first and early second trimesters of pregnancy, patient can safely be placed in a flat supine position without consequences, but by the latter part of the second as well as the third trimesters, the gravid uterus would be large enough to impinge on both common iliac veins and the lower part of the inferior vena cava to cause a diminution of venous return to the heart resulting in low cardiac output, a condition known as the supine hypotensive syndrome. To assuage or prevent this unwanted condition, it is advisable to place a small, but rigid pillow under the patient's right buttocks to tilt the uterus to the left. This could then be augmented with a slight tilt of the operating table to the left making sure that the patient does not slide off the table during the procedure. This maneuver not only relieves pressure on the aforementioned vessels, but enables the surgeon good access to the cecum and the base of the appendix even in situations where the appendix is anatomically in the retrocecal position.

A lot has been written in the medical literature that with advancing pregnancy, the position of the appendix shifts progressively superior and posterior in location. Thus, the advice goes, the incision should be modified by placing it superiorly toward the right costal margins. In reality, such advice has not been supported by evidence. Some authors have challenged this dogma. [9],[10] Our experience suggests that the anatomic location of the appendix is not remarkably different even in late pregnancy than in the non-pregnant state [Figure 1].
Figure 1: Open appendectomy in a third trimester pregnancy. Note that the base of the appendix is at a considerable distance from the umbilicus, which in this example is outside the frame of the picture

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McBurney's point incision will be slightly more medial to the depth of the base of the appendix in the third trimester. In our experience, the anatomical location of the appendix can best be approached by placing an incision about 2-3 cm above the junction of the lateral fourth or fifth of the ilio umbilical line. It is a practical advantage for the operating surgeon to accompany the patient during abdominal ultrasonography when he/she can ask the sonographer to position the sonar probe over the lower boundary of the cecum if visualized and a skin marking over this position made with an indelible marker to guide the surgeon subsequently in the placement of the incision.

On opening the abdominal wall through the grid iron incision, the surgeon's first task is to identify the cecum or the lower ascending colon and follow the tenia coli, which to the base of the appendix. Muscle-cutting procedures like the Rutherford-Morrison procedure is inadvisable in the pregnant woman particularly in the first and second trimesters as the growing uterus will stretch the anterior abdominal muscles progressively and an incisional hernia is likely to result. In such situation, the surgeon should determine that the cecum is superior to the incision. The skin incision should then be extended cephalad by a few centimeters and then a new muscle-separating incision of the classic grid-iron variety be conducted in the new position.

The surgeon should make an impression with regards to the intensity of inflammation, exudation and perforation of the appendix. The importance of this intraoperative assessment is to help the surgeon decide on the duration of antibiotic therapy. An inflamed appendix that is not perforated [Figure 1] may not need more than 72 h of antibiotic use and if fever and leucocytosis persist, ultrasonography to identify intra-peritoneal collection or drainage of fascial collection rather than prolongation of antibiotic use should be the desired options. Collection of peritoneal swab for microscopy, culture and sensitivity testing is important and will serve to guide subsequent antibiotic therapy and should always be done. When closing the incision, some surgeons apply stitches to the abdominal wall muscles transversus abdominis, the internal oblique and the external oblique aponeurosis to approximate them. As it applies to the first two muscle fibers listed above, such stitches should be just tight enough to bring the muscle fibers together. The ischemia induced by tight stitches could cause the muscle to split and leave the patient with an incisional hernia. The use of small caliber non-absorbable subcuticular sutures is advisable.

Mopping of pus and fecal material with a piece of gauze is sufficient even when perforated. The addition of dilute povidone iodine to the cleansing solution has been advocated by some and adverse ill-effect if any has not been demonstrated. Should drains be placed in the wound? Opinions vary. Apart from the fact that drains are inefficient in draining more than their immediate area, the presence of the foreign body that is the drain so close to the uterus may irritate the myometrium to induce labor so we do not recommend it.

Laparoscopy as an investigative tool is probably safe in the first and second trimesters, but with high risk in the third. Its use is based on the premise that visualization establishes the diagnosis of appendicitis in all cases. That is not usually the case, since the appendix that appears to the naked eye as normal has sometimes been found to be inflamed at histopathologic studies. Laparoscopic appendectomy has gained momentum in the last two decades or so and is increasingly being used in later stages of pregnancy. The bottom line is that a woman undergoing appendectomy in late pregnancy is entitled to an honest counsel in order to make an informed decision. One clear advantage of laparoscopic appendectomy over the open variety is that should the scar be extended in the latter the risk of incisional hernia is high in comparison to laparoscopic appendectomy.

Post-operative management

The post-operative management of AAP is essentially the continuation of previous active management. As soon as the patient recovers sufficiently from anesthesia, leg exercises and ambulation should be resumed to combat venous thrombosis. This mobility along with the assumption of a semi-recumbent position in bed help to localize any complicating intra-peritoneal collections to the pelvis where image-guided drainage is much more feasible than in the sub-diaphragmatic space. Early ambulation is encouraged. Oral intake of fluids should be commenced within the initial 12 h of operation starting with sips of fruit juice. If nausea and vomiting persist beyond a few hours post-operatively, cautious use of 5-hydroxytryptamine receptor antagonists may be considered in the second and third trimester pregnancies.

Controversies

Prophylactic appendectomy during cesarian section has been proposed as a means of preventing AAP. Presumably the appendectomy is performed by obstetricians and gynecologists. This surgical campaign has not been studied in terms of its effectiveness in reducing AAP in the general population. Advocates of this procedure have justified it citing its apparent innocuousness. [14],[16] A randomized controlled study comparing 45 study and 48 control subjects concluded that elective appendectomy during cesarian section did not increase in-patient morbidity. [4],[5] There are advocates of elective termination of pregnancy in the presence of appendicitis. [1] This implies induction of abortion in early pregnancy and cesarian section in late pregnancy. Critics insist that a cesarian section should only be performed in the presence of an obstetric indication [4] Termination of pregnancy by abortion in order to perform an appendectomy is a hard sell proposition that is not supported by evidence and should not be performed. Performing cesarian section in late pregnancy, except after 38 weeks, is tantamount to transferring the mother's problems to her neonate by exposing it to the risk of respiratory distress syndrome and other complications of prematurity.

 
  References Top

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