Appendicitis During Pregnancy

Prof. Aboubakr Elnashar

elnashar53@hotmail.com

Epidemiology
Anatomical changes

Pathophysiology Complications Diagnosis DD Surgery Conclusion

Epidemiology
 

Lifetime occurrence of 7% Peak incidence: 10-30y The most common cause of acute abdomen in pregnancy non-obstetric surgical intervention during pregnancy {Accounts for 25%} Suspected in: 1 in 1000 pregnant women (Mazze and
Klln, 1991)

Confirmed in: 65%

Incidence:
1 in 1500 pregnancies Reduced during pregnancy, especially in 3rd T {Protective effect of pregnancy?}
(Andersson &Lambe, 2001).

Same (Some studies) Equal in all three trimesters. 1st T: 30% 2nd T: 45% 3rd: 25%

Anatomical changes during pregnancy

I. Position of appendix: Gravid uterus displacement upward & outward

(Baer et al, 1932, many authors)

No change in location (Mourad et al, 2000; Hodjati et al ,2003) Degree of displacement, if any, is likely due to differing extent of cecal fixation.

Position of Appendix
(Baer et al, 1932)

12 W: McBurneys point 24 W: Iliac crest 36 W: RUQ

II. Gravid Uterus: The uterus enlarges 20 times: 1. Stretching of supporting ligaments & muscles. 2. Pressure on intra-abdominal structures & ant abd wall, prevents irritation of ant abd wall by inflamed intra-abdominal organs decreased perception of somatic pain & localization 3. Obstructs & inhibits the movement of the omentum (policeman of the abdomen): prevents omentum from localizing infection.

Pathophysiology
Appendicitis: inflammation of the vermiform appendix caused by an obstruction attributable to infection, structure, fecal mass, foreign body, or tumor

Complications
Increased with increasing gestational age. delay in diagnosis

1. Abortion: 15% 2. Fetal loss: 1.5-5.1% 3. Preterm labor: 13-22% 3rd T Perforated appendix & peritonitis 1st week after surgery

4. Perforation Non Pregnant: 4 -19% Pregnant: Highest in 3rd T 1st T: 8% 2nd T: 12% 3rd T: 20%
(Andersson and Lambe, 2001; Ueberrueck and associates ,2004)

Surgery delayed by >24 hrs from presentation: 66% risk of perforation: Surgery within 24 hrs of presentation with symptoms: No perforation
(Tamir et al, 1999)

Non-perforated appendix Fetal mortality: 1.5% Mat mortality: 0.1% Perforated appendix Fetal mortality: 5.1%-20% Maternal mortality: 1% {diffuse peritonitis} Preterm contractions: {localized peritonitis} 83%
(Augustin and Majerovic, 2006).

o Neonatal neurological injury {Sepsis}

(Mays et,1995)

Diagnosis
Mantrels score Difficult Symptoms Signs Lab Imaging

Non Pregnant

MANTRELS Migratory right iliac fossa pain Anorexia, Nausea/Vomiting Tenderness in the right iliac fossa Rebound pain Elevated temperature Leukocytosis Shift of leukocytes to the left of neutrophils

Pregnant: More difficult. 1. Nausea, vomiting, anorexia accompany normal pregnancy. 2. Uterus enlarges: appendix commonly moves upward and outward: pain& tenderness are "displaced" (Baer et al, 1932). challenged (Mourad et al, 2000). 3. Peritoneal signs often absent {lifting of abdominal wall by uterus} May not have typical symptom esp. in late pregnancy 4. Fever in less than majority

5.Elevated WBC normal in pregnancy 1st 2nd T: 16000 At labor: 20000 30000 <10000: more reassuring 6. Commonly confused with cholecystitis, preterm labor, pyelonephritis, renal colic, placental abruption, or degeneration of a uterine leiomyoma. There is no one reliable Sign or Symptom that can aid in the diagnosis of appendicitis in pregnancy.

Symptoms 1. Abdominal pain (almost always) Site: RLQ: Most reliable sx Most common even in 3rd T (Yan et al, 2009) 1st T: RLQ 2nd T: At level of umbilicus 3rd T: Diffuse or RUQ

2. Anorexia, nausea, vomiting: Neither sensitive nor specific. Sensitive predictors of appendicitis in the late pregnancy (Yan et al, 2009) 3. Fever: 50% Not sensitive

Signs All findings are less common in 3rd T 1. Abdominal tenderness (most common) Direct RLQ tenderness: ~100% Rebound tenderness: 55-75% less common in 3rd T 2. Abdominal rigidity: 50-65%

3. Classic signs No or little clinical significance in diagnosis (Pastore

et al, 2006)

Rovsing sign: palpation of the LLQ results in more pain in the RLQ Dunphy's sign: increased abdominal pain with coughing

Adler Sign: Appendicitis can be differentiated from adnexal or uterine pain. If the point of maximal tenderness shifts medially with repositioning on the left lateral side: etiology is adnexal or uterine (vs appendiceal).

Psoas sign (retroperitoneal retrocecal appendix)

passively extending the thigh of a patient lying on their side with knees extended

Obturator sign (pelvic appendix)

pain when there is flexion and internal rotation of the hip

Laboratory
1. WBC: 2nd &3rd T: 6,000-16,000 Early labor: 20,000-30,000 Absolute number: not reliable Differential: levels of band cells can be reliable indication of infection. 2. U/A: mild pyuria or mild hematuria: 20% {extraluminal irritation of the ureter, not UTI}. mild proteinuria 3. CRP (acute-phase protein)

Imaging:  Negative appendectomy rate: -Clinical diagnosis alone: 54% -Clinical, US & CT: 8%
 

1st Line: US 2nd line: CT MRI

US: TA or TV Graded compression sonography Non-pregnant: sensitivity 85% specificity 92% Pregnant: Difficult {cecal displacement and uterine imposition (Pedrosa et al, 2009). Easy, safe Operator dependent

Accuracy Accurate in 1st & 2nd T, difficult in 3rd T confirming the diagnosis in 3rd T: 40% (Yan et al,
2009)

PPV: 100% (provides confirmation of the diagnosis when it is positive). Normal US: can not rule out diagnosis 80% sensitive: non-perforating appendicitis 28% sensitive: perforated appendicitis

Scan RLQ w/ increasing pressure

to push bowel loops away Empty cecum of gas& fluid


Sonographic Criteria
Noncompressible > 7mm diameter < 6mm rules out appendicitis Mural thickening > 3mm Presence of appendiceal fecalith

CT: Helical CT scan:

Non pregnant patients Sensitivity: 98% Pregnant:
Sensitivity: >90%  Specificity: >95%


(Torbati et al, 2002; Wallace et al, 2008; Gearhart, 2008; Paulson, 2003; Raman, 2008)

Adv: Quicker, useful, noninvasive More sensitive & accurate than US

Radiation dose: 0.3 rad Specific views to decrease fetal radiation exposure Cumulative dose of 5 rad: safe Enlarged appendix No filling with contrast material Inflammatory changes

MRI No adverse effects on fetus

(Israel et al, 2008).

False-negative: 0% False-positive rate: 30% (Pedrosa et al, 2009) Sensitivity: up to 100% Specificity: 96% (Fielding and Chin, 2006). Cost Availability may be prohibitive.

Differential Diagnosis
Nonobstetric  Pyelonephritis  Urinary calculi  Cholecystitis  Cholelithiasis  Pancreatitis  Gastroenteritis  Mesenteric Adenitis  Pneumonia  Meckels Diverticulum  Peptic Ulcer Obstetric  Preterm Labor  Placental Abruption  Chorioamnionitis  Adnexal Torsion  Ectopic Pregnancy  PID  Round ligament pain  Uterine rupture

Surgery
Risk Indication Preoperative Anesthesia Operative Laparotomy Laparoscopy Postoperative

Risks of Operation 1. Abortion during first trimester 2. Preterm labor in third trimester Preterm labor & delivery uncommon: 5-14% Optimal time during 2nd T 3. Wound complications

Indication When appendicitis is suspected: prompt surgical exploration. Decision to operate on clinical grounds: 1. Accuracy of diagnosis  inversely proportional to gestation age. Correct diagnosis 1st T: 77% 2nd, 3rd T: 57% (Mazze and Klln, 1991) Acceptable negative laparotomy rates Non Pregnant: 15% Pregnant: 35%
(Augustin and Majerovic, 2006).

2. Risk of the surgical procedure: to mother & child it is minimal compared to risks of delayed treatment & appendix perforation.

3. Perforation occurs twice as often in 3rd T as 1st or 2nd Delay in surgery > 24 h after presentation: marked increase in rate of perforation: 0% vs. 66%
(Horowitz et al 1995)

Preoperative keep NPO IV drip is used to hydrate IV antimicrobial therapy: 2nd or 3rd generation cephalosporin Discontinued after surgery unless Gangrene Perforation Periappendiceal phlegmon Without generalized peritonitis: prognosis is excellent.

Diffuse Peritonitis

(Augustin & Majerovic, 2006).

1. IV Cefuroxime, ampicillin, metronidazole, and oxygen pre-operatively. 2. Immediate C-section can be considered, depending on gestational age of fetus. 3. Preoperative intubation & ventilation in cases of fetal hypoxia.

Anesthesia
IV Inhaled anesthetics: Not associated w/ teratogenicity Potential teratogens best avoided Local/Regional anesthetics: NO association w/ fetal malformations Risk of hypotension: decrease uterine blood flow Minimize: adequate fluids, lateral position

Operative
Laparotomy or Laparoscopy Depends on 1. Gestational age 2. Skill of the surgeon

Laparotomy 1. Tilt table 30 to left

{Decrease pressure to IVC Facilitate exposure of cecum}

2. Incision
McBurneys point: <20 wks Point of maximum tenderness low midline: diffuse peritonitis, or doubt about diagnosis Rt. Paraumbilicus 3. Minimal uterine manipulation {decrease risk of irritability & preterm labor} 4. Seldom CS is indicated at the time of appendectomy.

Laparoscopy During the 1st half of pregnancy: similar perinatal outcomes (Reedy etal,1997) During 2nd half of pregnancy: controversy most experienced surgeons. (Barnes and colleagues, 2004;
Rollins and associates, 2004; Parangi et al, 2007)

Advantages
1. Useful in diagnosis 2. Less post-op complication 3. Earlier mobilization & recovery: fewer thromboembolic complications 4. Lower postoperative narcotic use: less fetal depression 5. Shorter hospital stay

Disadvantages
1. Experience limited 2. Co2 pneumoperitoneum: uterine blood flow Fetal acidosis Premature labor

Postoperative 1. Preterm contractions are common but progression to labor is rare. Observe uterine contraction 2. Tocolytics Recommended by some S.E: Ritodrine: tachycardia & vomiting Anti-prostaglandin: fetal side effects

Conclusion
1. The symptoms of appendicitis mimic symptoms of normal pregnancy, namely, anorexia, nausea, vomiting & abdominal discomfort. 2. Delay of surgery correlates to more advanced disease with an increased risk of perforation. This, in turn, contributes to an increased risk of further complications including abortion or premature labor & higher maternal complication rates. 3. Prompt diagnosis may improve the perinatal outcome. 4. Early surgical intervention is essential.

References 1. Mazze RI, Kallen B. Appendectomy during pregnancy: a Swedish registry study of 778 cases. Obstet Gynecol 1991;77:835-40. 2. Andersson RE, Lambe M. Incidence of appendicitis during pregnancy. Int J Epidemiol 2001;30:1281. 3. Baer JL, Reis RA, Arens RA. Appendicitis in pregnancy with changes in position and axis of normal appendix in pregnancy. JAMA 1932;98:1359.. 4. Mourad J, Elliott J, Erickson L, Lisboa L. Appendicitis in pregnancy: new information that contradicts long-held clinical beliefs. Am J Obstet Gynecol 2000;182:1027-9. 5. Tamir IL. Acute appendicitis in the pregnant patient. Am J Surg1990;160:571-6. 6. Lyass S, Pikarsky A, Eisenberg VH, Elchalal U, Schenker JG, Reissman P. Is laparoscopic appendectomy safe in pregnant women? Surg Endosc. 2001;15:3779. 7. Wallace C, Petrov M, Soybel D, Ferzoco S, Ashley S. Influence of imaging on the negative appendectomy rate in pregnancy. Surg 2008;12: 46-50. 8. Horowitz MD, Gomez GA, Santiesteban R, Burkett G. Acute appendicitis during pregnancy. Diagnosis and management. Arch Surg 1985;120:13627. 9. Rollins M, Chan K, Price R Laparoscopy for appendicitis and cholelithiasis during pregnancy: a new standard of care. Surg Endosc. 2004; 18: 237-41. 10. Yan T, Tat L Risk factors of postoperative infections in adults with complicated appendicitis. Surg Laparosc Endosc Percutan Tech. 2009; 19: 244-8.