Appendicitis in PregnancyAppendicitis in Pregnancy

Peter O’LearyPeter O’Leary

CaseCase• 27 year old27 year old• 11 weeks gestation11 weeks gestation• Abdominal pain for 36 hoursAbdominal pain for 36 hours

– Crampy generalised abdominal pain initiallyCrampy generalised abdominal pain initially– Moved to the Right Iliac FossaMoved to the Right Iliac Fossa

• Nausea Nausea • Poor appetitePoor appetite

O/EO/E• Tender over McBurneys pointTender over McBurneys point• Rovsings +veRovsings +ve• WCC = 8.9WCC = 8.9• CRP = 95CRP = 95• US abdomen - AppendicitisUS abdomen - Appendicitis• Treatment – Open appendicectomyTreatment – Open appendicectomy

Appendicitis in PregnancyAppendicitis in Pregnancy

• Most common general surgical problem Most common general surgical problem during pregnancyduring pregnancy

• Occurs in approx 1 in 1500 deliveriesOccurs in approx 1 in 1500 deliveries– 11stst trimester – 30% trimester – 30% – 22ndnd trimester – 45% trimester – 45%– 33rdrd trimester – 25% trimester – 25%

• Rupture more likely in the third trimester, Rupture more likely in the third trimester, possibly due to the delay in diagnosis and possibly due to the delay in diagnosis and interventionintervention

IncidenceIncidence

• Suggested relation with female sex Suggested relation with female sex hormones hormones

• Reduced incidence in pregnancy, Reduced incidence in pregnancy, especially in the third trimesterespecially in the third trimester

• ? Protective effect of pregnancy? Protective effect of pregnancy (Int J Epidemiol 2001 Dec;30(6):1281-5)(Int J Epidemiol 2001 Dec;30(6):1281-5)

PathogenesisPathogenesis

• Appendiceal lumen obstructionAppendiceal lumen obstruction– Lymphoid hyperplasiaLymphoid hyperplasia– FaecalithsFaecaliths– ParasitesParasites– Foreign bodiesForeign bodies– Crohns diseaseCrohns disease– Metastatic cancerMetastatic cancer– Carcinoid syndromeCarcinoid syndrome

SymptomsSymptoms• Similar to those in non pregnant individualsSimilar to those in non pregnant individuals• Right lower quadrant painRight lower quadrant pain• Older studies suggest that the location of the appendix moves Older studies suggest that the location of the appendix moves

upwards as the uterus enlarges upwards as the uterus enlarges – Umbilicus level in second trimesterUmbilicus level in second trimester– Right Upper Quadrant in the third trimesterRight Upper Quadrant in the third trimester

• Refuted by subsequent studies which show the most common Refuted by subsequent studies which show the most common symptoms of appendicitis ie right lower quadrant pain occur within symptoms of appendicitis ie right lower quadrant pain occur within a few centimetres of McBurneys pointa few centimetres of McBurneys point

((Int J Gynaecol Obstet. 2003 Jun;81(3):245-7)Int J Gynaecol Obstet. 2003 Jun;81(3):245-7)• Pain migrationPain migration• NauseaNausea• VomitingVomiting• FeverFever• AnorexiaAnorexia

Physical examinationPhysical examination• RLQ tendernessRLQ tenderness• Rebound and guarding may be less prominent Rebound and guarding may be less prominent

than in non pregnant women than in non pregnant women – The gravid uterus lifts and stretches the anterior wall The gravid uterus lifts and stretches the anterior wall

away from the inflamed appendix away from the inflamed appendix ((Clin Obstet Gynaecol. 2000 Feb;14(1):89-102)Clin Obstet Gynaecol. 2000 Feb;14(1):89-102)

• Rovsing’s signRovsing’s sign• Dunphy’s signDunphy’s sign• Obturator sign (pelvic appendix)Obturator sign (pelvic appendix)• Psoas sign (retroperitoneal retrocaecal appendix) Psoas sign (retroperitoneal retrocaecal appendix)

is less common in pregnant femalesis less common in pregnant females• Rectal examination tendernessRectal examination tenderness

Obturator

sign

Psoas

sign

InvestigationsInvestigations• Confound the diagnosisConfound the diagnosis• WCC 6 to 16 cells/mm3 in the first and second trimesterWCC 6 to 16 cells/mm3 in the first and second trimester• 20 to 30 cells/mm3 during labour20 to 30 cells/mm3 during labour• Mourad et alMourad et al

– 66,993 consecutive pregnancies66,993 consecutive pregnancies– 67 probable appendicitis67 probable appendicitis– Confirmed appendicitis – mean leucocyte count of 16,400Confirmed appendicitis – mean leucocyte count of 16,400– Normal appendix – mean leucocyte count of 14,000Normal appendix – mean leucocyte count of 14,000

• CRPCRP• UrinanalysisUrinanalysis

– Mild pyuriaMild pyuria– Mild ProteinuriaMild Proteinuria– Microscopic haematuriaMicroscopic haematuria

• An inflamed appendix in close proximity to the bladder or ureter An inflamed appendix in close proximity to the bladder or ureter

InvestigationsInvestigations- - Graded Compression UltrasonographyGraded Compression Ultrasonography

• Gold standard for imaging in Gold standard for imaging in preganacypreganacy

• Tersawa et al – Reported sensitivity Tersawa et al – Reported sensitivity of 86% and specificity of 81%of 86% and specificity of 81%

• Appendicitis diagnosed if Appendicitis diagnosed if •A non compressible blind ending tube is A non compressible blind ending tube is

present in the right lower quadrant present in the right lower quadrant

•Diameter > 6mmDiameter > 6mm

InvestigationsInvestigations- - Graded Compression UltrasonographyGraded Compression Ultrasonography

Computed Computed TomographyTomography

– Sensitivity reported as 94% and specificity as Sensitivity reported as 94% and specificity as 95% 95%

– Features suggestive of appendicitisFeatures suggestive of appendicitis• Right lower quadrant inflammationRight lower quadrant inflammation

• Enlarged, non-filling tubular structureEnlarged, non-filling tubular structure

• +/- appendicolith+/- appendicolith

– Standard CT protocol v Modified CT protocolStandard CT protocol v Modified CT protocol– Foetal radiation exposure is approx 300 millirads Foetal radiation exposure is approx 300 millirads

in the modified protocolin the modified protocol– This is well below doses known to cause adverse This is well below doses known to cause adverse

foetal effectsfoetal effects

Computed Computed TomographyTomography

MRIMRI

• Avoids Radiation exposureAvoids Radiation exposure

• Sensivity 100%, Specificity 93.6%Sensivity 100%, Specificity 93.6% (Radiology. 2006 Mar;238(3):891-9)(Radiology. 2006 Mar;238(3):891-9)

• Gadolinium should not be usedGadolinium should not be used– Crosses the placentaCrosses the placenta

Differential DiagnosisDifferential Diagnosis

• Similar to non pregnant adultsSimilar to non pregnant adults

• Preganacy related differentials include Preganacy related differentials include – Round Ligament SyndromeRound Ligament Syndrome– Preterm LabourPreterm Labour– AbruptionAbruption– EctopicEctopic– Uterine ruptureUterine rupture– ChorioamnionitisChorioamnionitis– Adnexel torsionAdnexel torsion

Surgical managementSurgical management• Raised clinical suspicion or diagnosis of Raised clinical suspicion or diagnosis of

appendicitis with imaging requires prompt appendicitis with imaging requires prompt surgical interventionsurgical intervention

• Tocolytic agent use is controversialTocolytic agent use is controversial– Not recommended unless complications occurNot recommended unless complications occur

• Transverse incision at McBurney’s point is Transverse incision at McBurney’s point is indicated when the diagnosis is clearindicated when the diagnosis is clear

(Am J Surg. 2002 Jan;183(1):20-2)(Am J Surg. 2002 Jan;183(1):20-2)• A lower midline incision is suggested in the A lower midline incision is suggested in the

literature when the diagnosis is not clearliterature when the diagnosis is not clear– Accommodates unexpected surgical findings Accommodates unexpected surgical findings – Can accommodate a caesarean section if Can accommodate a caesarean section if

requiredrequired

““Laparoscopy is safe and Laparoscopy is safe and effective”effective”

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

Society of American Gastrointestinal and Endoscopic Surgeons 2007 Society of American Gastrointestinal and Endoscopic Surgeons 2007

• Can be used in any trimesterCan be used in any trimester• No increased risk to mother or foetusNo increased risk to mother or foetus• No gestational age limitNo gestational age limit• AdvantagesAdvantages

– Less wound infectionsLess wound infections– Decreased foetal depression secondary to analgesiaDecreased foetal depression secondary to analgesia– Shorter hospital stayShorter hospital stay– Decreased risk of thromboembolic eventsDecreased risk of thromboembolic events

• DisadvantagesDisadvantages– Decreased uterine blood flowDecreased uterine blood flow– Fetal acidosisFetal acidosis– Premature labour Premature labour – Long term effects on children have not been well studied Long term effects on children have not been well studied

• Modification of laparoscopic technique Modification of laparoscopic technique – Slight left lateral positioning of patients during the second half of preganacySlight left lateral positioning of patients during the second half of preganacy– Placement of trocars under direct visualisationPlacement of trocars under direct visualisation– Limit intra abdominal pressure to <12mmHgLimit intra abdominal pressure to <12mmHg

ComplicationsComplications

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

Babler 1908

ComplicationsComplications

• 25% of pregnant women with appendicitis will develop a 25% of pregnant women with appendicitis will develop a perforated appendixperforated appendix

• A 66% perforation incidence has been reported when A 66% perforation incidence has been reported when surgery is delayed by more than 24 hourssurgery is delayed by more than 24 hours

• This is compared to a 0% perforation incidence when This is compared to a 0% perforation incidence when surgical management is initiated in the first 24 hourssurgical management is initiated in the first 24 hours

• Perforation is twice as likely to occur in the third trimester Perforation is twice as likely to occur in the third trimester compared to the first and second trimestercompared to the first and second trimester

• The risk of fetal loss is higher when the appendix has The risk of fetal loss is higher when the appendix has ruptured – (36% versus 1.5%) ruptured – (36% versus 1.5%)

• Maternal morbidity is low when the appendix has rupturedMaternal morbidity is low when the appendix has ruptured ((Am J Surg, 1990. Am J Surg, 1990. 160160(6): p. 571-5; discussion 575-6)(6): p. 571-5; discussion 575-6)

ComplicationsComplications• More recently it has been suggested that there is More recently it has been suggested that there is

no direct “cause and effect” relationship between no direct “cause and effect” relationship between prolonged symptoms and perforationprolonged symptoms and perforation

• An anatomical explanation is offered instead– Gravid uterus results in the omentum being unable to

isolate infection

Am Surg 2000 Jun;66(6):555-9Am Surg 2000 Jun;66(6):555-9

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