Appendicitis during Appendicitis during pregnancypregnancy

Rinat Gabbay April 2002

Appendicitis: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

Pathogenesis:Pathogenesis:Appendiceal lumen obstruction : lymphoid hyperplasia fecaliths parasites foreign bodies crohn’s disease metastatic cancer carcinoid syndrome

Incidence during pregnancy:Incidence during pregnancy: Incidence 0.05% 1:1000 pregnant women - appendectomy 1:1500 proved appendicitis (Mazze & Kallen,1991)

1st trimester – 30% / 22%

2nd trimester – 45% / 27%

3rd trimester – 25% / 50% (Mourad,2000)

Incidence during pregnancy: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 Dec;30(6):1281-5)

symptoms :symptoms :

Pain – RLQ / RUQ / FlankAnorexiaVomitingNausea Pain migrationFever

Physical examination:Physical examination:

Tenderness – RLQ Rebound & Guarding (peritoneal signs) Rovsing sign Dunphy’s sign Psoas sign (retroperitoneal retrocecal appendix) Obturator sign (pelvic appendix) Rectal examination tenderness (cul-de-sac) Low grade fever

                                                                                                     

Psoassign

Obturatorsign

Lab:Lab:

CBC – WBC ( 80% 45% )CRP Urinalysis - mild pyuria

mild proteinuria

mild hematuria

D.D.:D.D.:surgicalsurgical: : gynecogyneco::

Renal stone Gastroenteritis Pancreatitis Cholecystitis Mesenteric adenitis Hernia Bowel obstruction

Preterm labor Placenta abruptio Chorioamnionitis Adnexal torsion Ectopic pregnancy Pelvic inflammatory Round lig. pain

Diagnostic problems: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

Diagnostic problems:Diagnostic problems:

Symptoms complex – physical changes

anorexia, nausea & vomiting in normal

pregnancyLab – relative leukocytosisImaging techniques

Diagnostic problems:Diagnostic problems:

Differential diagnosis:

pyelonephritis

renal colic

placental abtuptio

uterine myoma degeneration

Imaging:Imaging:

KUBBarium enemaGraded compression ultrasonographyHelical CT scan

Graded compression ultrasound:Graded compression ultrasound:

Normal appendix (<6mm) rules out appendicitis.

Nonpregnant – Sensitivity 85%

specificity 92%Pregnant – cecal displacement & uterine

imposition makes precise examination difficult (Williams,21 edition)

Acute appendicitis:Acute appendicitis:

                

                            

1.thickened

appendix 2.Caecum 3.Small amount of

pericaecal fluid 4.perippendicular

hyperemia

Helical CT scan:Helical CT scan:

Enlarged appendix, No filling with contrast material, Periappendiceal inflammatory changesNonpregnant patients – 98% sensitivityPregnant - useful, noninvasive & accurate

(Am J Obstet Gynecol 2001 Apr;184(5):954-7

Radiation ?

Diagnosis:Diagnosis:

“Pain in RLQ is the most common presenting syndrome of appendicitis in pregnancy regardless of gestational age “

(Am J Obstet Gynecol 2001 Jul;185(1):259-60)

“Physical examination is the most reliable tool for diagnosis” (Am Surg 2000 Jun;66(6):555-9)

“Fever and WBC are not clear indicators” (Am J Obstet Gynecol 2001 Jul;185(1):259-60)

Treatment:Treatment:

Suspicion

immediate surgical interventionDelay

generalized peritonitisAntimicrobial therapy:

2nd cephalosporin, perioperative, unless gangrene, perforation, phlegmon

Tocolytics:Tocolytics:Concept: calm the uterus from insult of

acute abdomenControversial Ritodrine ineffective

anti-prostaglandin side effects Ritodrine - tachycardia & vomitinganti-prostaglandin – anti-inflammatory &

antipyretic, fetal side effects (Annals of Saudi Med, Vol 18 No 2, 1998)

Surgery: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 – McBurney’s point (Am J Surg 2002 Jan;183(1):20-2)

laparoscopy: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)

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

of delay “of delay “

Babler 1908

Complications:Complications:

Gestational age Complication rate

(Tracey and Fletcher,2000)

Uterine contractions – 80% over 24wPreterm labor:

1. 3rd trimester

2. Perforated appendix & peritonitis

Complications: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 malformationNo stillborn infants

Perforated appendicitis:Perforated appendicitis:Incidence:

4 -19% nonpregnant patients

57% pregnant women (Tracey & Fletcher,2000)

Gestational age Perforations Peritonitis

Perforation Perforation –– why more ??? 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 Jun;66(6):555-9)

Perforation Perforation –– why more ??? why more ???

Position change of appendix

No containment of infection by omentum

Inability of omentum to isolate infection

More generalized peritonitis

White appendix:White appendix:

Nonpregnant –20%Pregnant – 20-50% ( higher in advanced

pregnancy)

Appendicitis during puerperium:Appendicitis during puerperium:

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

Prognosis:Prognosis:

Generally good :

Disease found

Surgery complications

The endThe end