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Appendicitis during pregnancy

Appendicitis during pregnancy. Rinat Gabbay April 2002. 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:. Appendiceal lumen obstruction :

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Appendicitis during pregnancy

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  1. Appendicitis during pregnancy Rinat Gabbay April 2002

  2. 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

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

  4. 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)

  5. 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)

  6. symptoms : • Pain – RLQ / RUQ / Flank • Anorexia • Vomiting • Nausea • Pain migration • Fever

  7. 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

  8. Psoas sign Obturator sign

  9. Lab: • CBC – WBC ( 80%  45% ) • CRP • Urinalysis - mild pyuria mild proteinuria mild hematuria

  10. Renal stone Gastroenteritis Pancreatitis Cholecystitis Mesenteric adenitis Hernia Bowel obstruction Preterm labor Placenta abruptio Chorioamnionitis Adnexal torsion Ectopic pregnancy Pelvic inflammatory Round lig. pain D.D.:surgical: gyneco:

  11. 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

  12. Diagnostic problems: • Symptoms complex – physical changes anorexia, nausea & vomiting in normal pregnancy • Lab – relative leukocytosis • Imaging techniques

  13. Diagnostic problems: • Differential diagnosis: pyelonephritis renal colic placental abtuptio uterine myoma degeneration

  14. Imaging: • KUB • Barium enema • Graded compression ultrasonography • Helical CT scan

  15. 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)

  16. Acute appendicitis:

  17. 1.thickened appendix • 2.Caecum • 3.Small amount of pericaecal fluid • 4.perippendicular hyperemia

  18. Helical CT scan: • Enlarged appendix, • No filling with contrast material, • Periappendiceal inflammatory changes • Nonpregnant patients – 98% sensitivity • Pregnant - useful, noninvasive & accurate (Am J Obstet Gynecol 2001 Apr;184(5):954-7 • Radiation ?

  19. 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)

  20. Treatment: • Suspicion  immediate surgical intervention • Delay  generalized peritonitis • Antimicrobial therapy: 2nd cephalosporin, perioperative, unless gangrene, perforation, phlegmon

  21. Tocolytics: • Concept: calm the uterus from insult of acute abdomen • Controversial • Ritodrine ineffective anti-prostaglandin side effects • Ritodrine - tachycardia & vomiting • anti-prostaglandin – anti-inflammatory & antipyretic, fetal side effects (Annals of Saudi Med, Vol 18 No 2, 1998)

  22. 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)

  23. 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)

  24. “The mortality of appendicitis complicating pregnancy is the mortality of delay “ Babler 1908

  25. Complications: • Gestational age  Complication rate (Tracey and Fletcher,2000) • Uterine contractions – 80% over 24w • Preterm labor: 1. 3rd trimester 2. Perforated appendix & peritonitis

  26. 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 malformation • No stillborn infants

  27. Perforated appendicitis: • Incidence: 4 -19% nonpregnant patients 57% pregnant women (Tracey & Fletcher,2000) • Gestational age  Perforations  Peritonitis

  28. Perforation – 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)

  29. Perforation – why more ??? • Position change of appendix No containment of infection by omentum Inability of omentum to isolate infection More generalized peritonitis

  30. White appendix: • Nonpregnant –20% • Pregnant – 20-50% ( higher in advanced pregnancy)

  31. Appendicitis during puerperium: • Appendicitis can stimulate labor – after the uterus empties there is diffuse peritonitis

  32. Prognosis: • Generally good : Disease found Surgery complications

  33. The end

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