APENDICITA IN SARCINAAPENDICITA IN SARCINA

Gurau CristinaGurau Cristinagr.207,rezidenta MF

Definitie:Definitie:

Apendicita este un sindrom abdominal acut sau cronic determinat de inflamația septică sau aseptică a apendicelui ileocecal.

Procesul inflamator apendicular acut debutează cu congestie și edem, și poate evolua până la gangrenă, cu perforație și peritonită localizată sau generalizată, sau poate evolua spre cronicizare cu apariția de leziuni degenerative în grosimea peretelui apendicular.

Apendicita este una din cele mai comune cauze de abdomen acut in sarcina. [1]

1. Horowitz MD, Gomej GA. Santiesteban R, Burkett G. Acute appendicitis during pregnancy. Arch Surg 1. Horowitz MD, Gomej GA. Santiesteban R, Burkett G. Acute appendicitis during pregnancy. Arch Surg 1985;120:1362-8.1985;120:1362-8.

INCIDENTA:INCIDENTA:

0.05% - 0.07% [2]

cazuri suspecte:cazuri suspecte: 1:600 - 1:1000 cazuri confirmate:cazuri confirmate: 1:800 - 1:1500 [3]

1st trimestru– 30% / 22% 2nd trimestru – 45% / 27% 3rd trimestru– 25% / 50% [1,2] Virsta Virsta < 18 ani >35 ani

2. Mourad J, Elliott JP, Erickson L, Lisboa L. Appendicitis in pregnancy: new information that contradicts long-held clinical beliefs. Am J Obstet Gynecol 2000; 182: 1027–9.

3. Mazze RI, Källén B. Appendectomy during pregnancy: a Swedish registry study of 778 cases. Obstet Gynecol 1991; 77:835.

PREVALENTA PREVALENTA (loc.apendex)(loc.apendex)

DIAGNOSTICDIAGNOSTIC

Rebound & GuardingRebound & Guarding(peritoneal signs)(peritoneal signs)

Psoas sign Psoas sign (retroperitoneal,(retroperitoneal,

retrocecal retrocecal appendix) appendix)

Obturator sign Obturator sign (pelvic appendix)(pelvic appendix) Rovsing sign Rovsing sign

(LLQ)(LLQ)

Dunphy’s signDunphy’s sign

Psoassign

Obturatorsign

an.sangeluian.sangelui

DIAGNOSTICDIAGNOSTIC

Leucocitoza : Leucocitoza : [2][2]

16 - 18 cll/16 - 18 cll/mm3 in mm3 in I-III-II trimest trimestruru

20 -20 - 30 c 30 cllll/mm3/mm3 III III trimestru si travaliutrimestru si travaliu

VSH ↑VSH ↑ Fibrinogen ↑Fibrinogen ↑

an. urineian. urinei* piurie ~20%* proteinurie* hematurie microscopica [4]

4.Cunningham FG, McCubbin JH. Appendicitis complicating pregnancy. Obstet Gynecol 1975; 45:415. 5. Sand M, Bechara FG, Holland-Letz T, et al. Diagnostic value of hyperbilirubinemia as a

predictive factor for appendiceal perforation in acute appendicitis. Am J Surg 2009; 198:193.6. THE IRAQI POSTGRADUATE MEDICAL JOURNAL VOL.6,NO4,2007

Tbili Tbili > > 1.0mg/dl1.0mg/dl [5][5]

CPRCPR ↑ (irelevant)[6]

USG USG apendix inflamat > 6 mm pereti ingrosati peri-apendix lichid/resturi fecaloide DD vizualizarea epansamentului peritoneal [7]

Avantaje: Avantaje: sensibilitate ↑ ~ 75-90 % specificitate ↑ ~ 75-100 % [8] relativ ieftin rapid noninvasiv [9]

!!! !!! Cu toate acestea , pe masura ce sarcina Cu toate acestea , pe masura ce sarcina avanseaza ,diagnosticul devine mai dificil, din cauza avanseaza ,diagnosticul devine mai dificil, din cauza schimbarii pozitiei apendix-lui,virstaschimbarii pozitiei apendix-lui,virsta

gestationala,BMI,flatulenta,perforatie,abilitatea med.USGgestationala,BMI,flatulenta,perforatie,abilitatea med.USG

7. Williams R, Shaw J. Ultrasound scanning in the diagnosis of acute appendicitis in pregnancy. Emerg Med J 2007; 24:359.7. Williams R, Shaw J. Ultrasound scanning in the diagnosis of acute appendicitis in pregnancy. Emerg Med J 2007; 24:359.8. Weiss CR, Macura KJ. Diagnosis of ruptured appendicitis: Role of magnetic resonance imaging. J Wom Imag 2003;5:192-8.8. Weiss CR, Macura KJ. Diagnosis of ruptured appendicitis: Role of magnetic resonance imaging. J Wom Imag 2003;5:192-8.9. Bezjian AA. Pelvic masses in pregnancy. Clin Obstet Gynecol 1984; 27:402-1 9. Bezjian AA. Pelvic masses in pregnancy. Clin Obstet Gynecol 1984; 27:402-1

DIAGNOSTICDIAGNOSTIC

DIAGNOSTICDIAGNOSTIC

1.appendix ingrosat

2.cecul

3.cantitate neinsemnata de lichid pericecal

4.hiperemie periapendiculara

DIAGNOSTICDIAGNOSTIC RMNRMNApendex inflamat > 6-7 mmPer appenducular fat stranding signprezenta de fecaloizi lichid/abceseflegmoaneDD

Avantaje:Avantaje: precizie 95 %sensibilitate 100 %specificitate 93 % [10]

se evita iradierea 10. Pedrosa I, Lafornara M, Pandharipande PV, et al. Pregnant patients suspected of having acute appendicitis: effect of 10. Pedrosa I, Lafornara M, Pandharipande PV, et al. Pregnant patients suspected of having acute appendicitis: effect of

MR imaging on negative laparotomy rate and appendiceal perforation rate. Radiology 2009; 250:749.MR imaging on negative laparotomy rate and appendiceal perforation rate. Radiology 2009; 250:749.

DIAGNOSTICDIAGNOSTIC

DIAGNOSTICDIAGNOSTIC

A.A. post-post-ilealileal

B.B. pre-ileal pre-ileal C.C. subcecal subcecal

D D pelvicpelvic

E.E. retrocecal retrocecal

DIAGNOSTICDIAGNOSTIC CTCT !!! !!! 3 mGy3 mGy

[11][11]

11. Ames Castro M, Shipp TD, Castro EE, Ouzounian J, Rao J. The use of helical 11. Ames Castro M, Shipp TD, Castro EE, Ouzounian J, Rao J. The use of helical computed tomography in pregnancy for the diagnosis of acute appendicitis. Am J computed tomography in pregnancy for the diagnosis of acute appendicitis. Am J

Obstet Gynecol. 2001;184(5):954-7.Obstet Gynecol. 2001;184(5):954-7.

Diagnostic Diagnostic

DiferentialDiferential

Non-Obstetricale & Non-Obstetricale & Non-GinecologiceNon-Ginecologice Infecții ale Infecții ale

tractului urinartractului urinar PancreatitaPancreatita Colecistita Colecistita

acutaacuta GastroenteritaGastroenterita Ulcer peptic Ulcer peptic

perforatperforat Calcul renalCalcul renal PielonefritaPielonefrita

Obstetricale & Obstetricale & GinecologiceGinecologice

Sarcina extrauterinaSarcina extrauterina Avortul spontan Avortul spontan (gestație timpurie)(gestație timpurie)

Chist ovarian Chist ovarian perforat/torsionatperforat/torsionat

Boala inflamatorie Boala inflamatorie pelvinapelvina

Travaliu prematur Travaliu prematur (gestație avansată)(gestație avansată)

Decolare de Decolare de placentaplacenta

Leiomiom uterin Leiomiom uterin

CONDUITA & TRATAMENTCONDUITA & TRATAMENT

CONDUITA & TRATAMENTCONDUITA & TRATAMENT Interventie chirurgicala in 20-24 h incizie Mac BurneyInterventie chirurgicala in 20-24 h incizie Mac Burney d/a 36 h =16%-36%d/a 36 h =16%-36% La fiecare interval de 10-12 h ↑ rata de perforatie cu 5 La fiecare interval de 10-12 h ↑ rata de perforatie cu 5

% % [12][12]

Administrarea de AB (Cefalosporine de II G) cu scop Administrarea de AB (Cefalosporine de II G) cu scop profilactic si de tratament in caz de profilactic si de tratament in caz de perforatie,peritonita,gangrena apendix-lui.perforatie,peritonita,gangrena apendix-lui.

Cefalosporine + Metronidazol (in apendicita Cefalosporine + Metronidazol (in apendicita complicata cu perforatie)complicata cu perforatie)

Pentru ameliorarea simptomelor se utilizeaza Pentru ameliorarea simptomelor se utilizeaza analgezice si tocoliticeanalgezice si tocolitice

IsoxuprineIsoxuprine HCG (empiric)HCG (empiric) [13][13]

12. Pastore PA, Loomis DM, Sauret J. Appendicitis in pregnancy. J Am Board Fam Med 2006; 19:621-6.12. Pastore PA, Loomis DM, Sauret J. Appendicitis in pregnancy. J Am Board Fam Med 2006; 19:621-6. 13. Anderson BR, Kallehave FL, Anderson HK. Antibiotic versus placebo for prevention of post operative 13. Anderson BR, Kallehave FL, Anderson HK. Antibiotic versus placebo for prevention of post operative

infection after appendicectomy. Cochrane Database Syst Rev 2005; (3):CD001439. infection after appendicectomy. Cochrane Database Syst Rev 2005; (3):CD001439.

““LaparoscopLaparoscopiaia este sigura sieste sigura si efectiv efectivaa”” [14][14]

Avantaje: Poate fi utilizat în orice trimestru Fara limita de varsta gestationala Risc scazut de infectii Zile de stationar mai putine Risc scazut de trombembolism

Dezavantaje:Dezavantaje: Scaderea fluxului sanguin uterin Acidoza fetala Travaliu prematur• Efectele asupra copiilor pe termen lung nu au fost bine studiate

Modificarea tehnicii laparoscopice:Modificarea tehnicii laparoscopice: Pozitionarea laterala stanga in a II trimestru Plasarea trocare sub vizualizare directa Limita presiunii abdominale intra la <12mmHg

CONDUITA & TRATAMENTCONDUITA & TRATAMENT

14. Guidelines for diagnosis, treatment and use of laparoscopy for surgical problems during pregnancy –

Society of American Gastrointestinal and Endoscopic Surgeons 2007

“The mortality of appendicitis complicating pregnancy is the mortality of delay “

Babler 1908Babler 1908