Presentation on theme: "Appendicitis in pregnancy"— Presentation transcript:
1Appendicitis in pregnancy Sadaf AlipourGeneral SurgeonAssistant ProfessorTehran University of Medical Sciences
2INTRODUCTION The most common general surgical problem during pregnancy Incidence % percent, or 1 in 1500 deliveriesHowever, less in pregnant women than in age-matched nonpregnantsSlightly higher rate in T2 than T1, T3 or postpartumMore likely to rupture, especially in T3, possibly because of delay in Dx and intervention
3CLINICAL MANIFESTATIONS(1) Similar to nonpregnantsRLQ pain: the most common symptomShould alert the physician caring for the pregnant to strongly consider apxPain is close to McBurney's point in most regardless of stage of Py although appendix migrates a few cm cephalad with the enlarging uterus
4CLINICAL MANIFESTATIONS(2) NL:Abdominal discomfort in Py due to enlarging uterus, fetal position or movement, Braxton-HicksSevere, sudden, constant pain with other symptoms (nausea, vomiting, vaginal bleeding) or in upper abdomen suggests a disease.Peritoneal signs (rebound , guarding) never NL in PyNausea and vomiting: common in early Py, usu abate by early to middle T2 but not normal when with abdominal pain, fever, diarrhea, headache, or localized abdominal findings
5CLINICAL MANIFESTATIONS(3) Physiologic changes of Py may affect presentationUterus becomes abdominal, enlarging beyond pelvis by 12 weeksUterus impedes examination and affect NL location of pelvic and abdominal organs
6CLINICAL MANIFESTATIONS (4) Gravid uterus lifts anterior abdominal wallLess direct contact between area of inflammation and parietal peritoneumLess muscle response or guardingLess peritoneal findings than nonpregnantsThe laxity of the abdominal wall may also diminish peritoneal signs.
7Laboratory assessment(1) Normal Py in T1 and T2 : WBC = ,000 , may rise to 20, ,000 during laborLeukocytosis may NL in Py but bandemia not NL in Py and suggests infection until proven otherwiseRetrospective review of 66,993 deliveries with 67 with probable Dx of apx: in those with confirmed apx, mean WBC=16,400 -versus 14,000 for those without apx.
8Laboratory assessment(2) Inflamed appendix often close to bladder and ureterMicroscopic hematuria and pyuria in up to one-third of acute appendicitisPregnants with pyuria may be treated for UTI and forgo further investigation, delaying Dx of apx
9diagnosis of apX in a laboring patient Especially difficult, requires high index of suspicion.Labor can be associated with pain that may be lateralized,May fever, leukocytosis, and vomiting when chorioamnionitis during labor
10ImagingIf Dx unclear after assessment of complaints, examination, and lab: diagnostic imaging necessary as in nonpregnantsThus, virtually all pregnant women will have an imaging study
11Ultrasonography Choice for imaging of appendix in Py: graded compression ultrasonographyAllows visualization of uterus, placenta and ovarieCan exclude other causes of RLQ painApx diagnosed if noncompressible blind- ended tubular structure in RLQ with diameter greater than 6 mm .As a general rule, if a normal appendix is not visualized, appendicitis cannot be excluded
12US overall sensitivity=%86 Specificity=%81 However, gravid uterus can interfere with US, esp in the T3, leading to high negative laparotomy rate when US results inconclusiveIn one small series, appendix could not be visualized with US in 22 of 23 pregnants with suspected apx
13MRI (1) Where available, useful for the next step in diagnostic uncertaintyMRI is an alternative to CT because it avoids exposure to ionizing radiation.Observational data suggest that MRI can accurately diagnose appendicitis during pregnancy
14MRI (2)Excellent modality for excluding apx in Py with characteristic signs and symptoms when inconclusive USGadolinium not routinely administered because of theoretical fetal safety concerns, but may be used if essential .If a prolonged wait before MRI, increasing risk of rupture over time should be considered and undue delays for imaging avoided.
15MRI (3) Sensitivity= %100 Specificity= %93 Positive predictive value = %61Negative predictive value = %100
16CT scan (1) Main findings of apx on CT: RLQ inflammation Enlarged nonfilling tubular structureAppendicolith.
17CT scan (2)Modifications of CT protocol can limit fetal exposure to less than 3 mGy (30 mGy for carcinogenesis in fetus)Standard abdominal CT with oral and IV contrast or a specialized appendiceal CT protocol can also be used, but are associated with higher fetal radiation exposure (20 to 40 mGy)
18Ct scan (3) Overall sensitivity= %94 Specificity= % 95 We suggest CT when clinic and US are inconclusive and MRI is not available
19MANAGEMENT APPROACH AND OUTCOME Decision for laparotomy should be based on clinic, imaging results, and clinical judgmentLab not particularly useful ecxept for R/O of alternate diagnosesDelaying Sx for more than 24 h increases risk of perforation (%14-43 of such patients)
20incisionWhen Dx relatively certain: transverse incision at McBurney's point, or more commonly, over point of maximal tendernessWhen Dx less certain: lower midline vertical incision
21Laparoscopy(1)Several case reports and small case series: laparoscopic appendectomy in Py feasible in all trimesters and with few complicationsOne systematic review: higher rate of fetal loss with laparoscopy than open appendectomy, but data were from retrospective series
22Laparoscopy(2) Decision to proceed to laparoscopy based on: skill and experience of surgeonclinical factors such as size of gravid uterus.
23complications (1)Risk of fetal loss higher in perforated apx (%36 versus %1.5) or when generalized peritonitis or abscess (fetal loss:% 6 versus %2; early delivery: %11 versus %4).Given diagnostic difficulties and significant risk of fetal mortality with perforation, a higher negative laparotomy rate (20 to 35 percent) compared to nonpregnant women has generally been considered to be acceptable.
24complications (2) Maternal morbidity low except in perforated apx Py related complications frequent in T1 and T2Spontaneous abortion %33 percent in T1Premature delivery %14 in T2No pregnancy complications in T3
25Type of delivery C/S rarely indicated at time of appendectomy Risk of dehiscence during labor and vaginal delivery not increased when fascia appropriately reapproximated
26prognosis Good long-term prognosis No increased risk of infertility or other complications
27Patients quite ill and may be septic Perforated appendix Free perforation causes intraperitoneal dissemination of pus and fecal materialPatients quite ill and may be septicIncreased risk of preterm labor and delivery and fetal lossUrgent laparotomy necessary with appendectomy and irrigation and drainage of the peritoneal cavity
28In Nonpregnants with long duration of symptoms (more than five days) When contained perforation: treated with ABs , IV fluids, bowel rest, and close monitoringMany will respond since it has already been "walled-off.“Although there is good evidence to support this approach in nonpregnant individuals, there is only limited evidence in pregnant women.
29Conservative tx of apx in Py Report of 2 patients: ABs (ampi, genta,clinda),IV fluids, and bowel rest: improvement of symptoms over 2-3 dIn one: interval apy 2 m after NVDIn the other: apy at c/s (breech with preterm laborIn both: avoidance of glucocorticoids and tocolytics due to concerns of suppressing manifestations of worsening infection and delaying delivery if intraamniotic infection was also present.Until further experience, these should be followed closely in hospital to monitor for maternal sepsis and preterm labor.
30SUMMARY AND RECOMMENDATIONS Apx: most common general Sx problem in Py, clinic and Dx similar to nonpregnantRLQ pain within a few cm of McBurney's : most common symptomNausea/vomiting: both apx and NL Py. In apx, following pain, in Py usu no pain.US: the best - noncompressible 6mm or more blind ended tubular structure in RLQIf clinic and US inconclusive: MRI, When MRI not available: CTDecision to proceed to Sx based on imaging and clinical judgment.Lab not particularly useful other than R/O other diagnoses.Delaying Sx more than 24 hours increases risk of perforation.When Dx relatively certain:transverse incision over point of maximal tenderness . When less certain: lower midline vertical incision
31references 1- Schwartz Principles of Surgery (book) 2-UptoDate (online)