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Sadaf Alipour General Surgeon Assistant Professor Tehran University of Medical Sciences.

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Presentation on theme: "Sadaf Alipour General Surgeon Assistant Professor Tehran University of Medical Sciences."— Presentation transcript:

1 Sadaf Alipour General Surgeon Assistant Professor Tehran University of Medical Sciences

2  The most common general surgical problem during pregnancy  Incidence % percent, or 1 in 1500 deliveries  However, less in pregnant women than in age-matched nonpregnants  Slightly higher rate in T2 than T1, T3 or postpartum  More likely to rupture, especially in T3, possibly because of delay in Dx and intervention

3  Similar to nonpregnants  RLQ pain: the most common symptom  Should alert the physician caring for the pregnant to strongly consider apx  Pain is close to McBurney's point in most regardless of stage of Py although appendix migrates a few cm cephalad with the enlarging uterus

4  NL:Abdominal discomfort in Py due to enlarging uterus, fetal position or movement, Braxton-Hicks  Severe, sudden, constant pain with other symptoms (nausea, vomiting, vaginal bleeding) or in upper abdomen suggests a disease.  Peritoneal signs (rebound, guarding) never NL in Py  Nausea 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

5  Physiologic changes of Py may affect presentation  Uterus becomes abdominal, enlarging beyond pelvis by 12 weeks  Uterus impedes examination and affect NL location of pelvic and abdominal organs

6  Gravid uterus lifts anterior abdominal wall  Less direct contact between area of inflammation and parietal peritoneum  Less muscle response or guarding  Less peritoneal findings than nonpregnants  The laxity of the abdominal wall may also diminish peritoneal signs.

7  Normal Py in T1 and T2 : WBC = ,000, may rise to 20, ,000 during labor  Leukocytosis may NL in Py but bandemia not NL in Py and suggests infection until proven otherwise  Retrospective 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.

8  Inflamed appendix often close to bladder and ureter  Microscopic hematuria and pyuria in up to one-third of acute appendicitis  Pregnants with pyuria may be treated for UTI and forgo further investigation, delaying Dx of apx

9  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

10  If Dx unclear after assessment of complaints, examination, and lab: diagnostic imaging necessary as in nonpregnants  Thus, virtually all pregnant women will have an imaging study

11  Choice for imaging of appendix in Py: graded compression ultrasonography  Allows visualization of uterus, placenta and ovarie  Can exclude other causes of RLQ pain  Apx 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

12  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 inconclusive  In one small series, appendix could not be visualized with US in 22 of 23 pregnants with suspected apx

13  Where available, useful for the next step in diagnostic uncertainty  MRI is an alternative to CT because it avoids exposure to ionizing radiation.  Observational data suggest that MRI can accurately diagnose appendicitis during pregnancy

14  Excellent modality for excluding apx in Py with characteristic signs and symptoms when inconclusive US  Gadolinium 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.

15  Sensitivity= %100  Specificity= %93  Positive predictive value = %61  Negative predictive value = %100

16  Main findings of apx on CT: RLQ inflammation Enlarged nonfilling tubular structure Appendicolith.

17  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)

18  Overall sensitivity= %94  Specificity= % 95  We suggest CT when clinic and US are inconclusive and MRI is not available

19  Decision for laparotomy should be based on clinic, imaging results, and clinical judgment  Lab not particularly useful ecxept for R/O of alternate diagnoses  Delaying Sx for more than 24 h increases risk of perforation (%14-43 of such patients)

20  When Dx relatively certain: transverse incision at McBurney's point, or more commonly, over point of maximal tenderness  When Dx less certain: lower midline vertical incision

21  Several case reports and small case series: laparoscopic appendectomy in Py feasible in all trimesters and with few complications  One systematic review: higher rate of fetal loss with laparoscopy than open appendectomy, but data were from retrospective series

22 Decision to proceed to laparoscopy based on:  skill and experience of surgeon  clinical factors such as size of gravid uterus.

23  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.

24  Maternal morbidity low except in perforated apx  Py related complications frequent in T1 and T2 Spontaneous abortion %33 percent in T1 Premature delivery %14 in T2 No pregnancy complications in T3

25  C/S rarely indicated at time of appendectomy  Risk of dehiscence during labor and vaginal delivery not increased when fascia appropriately reapproximated

26  Good long-term prognosis  No increased risk of infertility or other complications

27  Free perforation causes intraperitoneal dissemination of pus and fecal material  Patients quite ill and may be septic  Increased risk of preterm labor and delivery and fetal loss  Urgent laparotomy necessary with appendectomy and irrigation and drainage of the peritoneal cavity

28  When contained perforation: treated with ABs, IV fluids, bowel rest, and close monitoring  Many 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.

29  Report of 2 patients: ABs (ampi, genta,clinda),IV fluids, and bowel rest: improvement of symptoms over 2-3 d  In one: interval apy 2 m after NVD  In the other: apy at c/s (breech with preterm labor  In 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.

30  Apx: most common general Sx problem in Py, clinic and Dx similar to nonpregnant  RLQ pain within a few cm of McBurney's : most common symptom  Nausea/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 RLQ  If clinic and US inconclusive: MRI, When MRI not available: CT  Decision 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

31  1- Schwartz Principles of Surgery (book)  2-UptoDate (online)

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