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Appendicitis in Pregnancy Peter O’Leary. Case 27 year old 27 year old 11 weeks gestation 11 weeks gestation Abdominal pain for 36 hours Abdominal pain.

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Presentation on theme: "Appendicitis in Pregnancy Peter O’Leary. Case 27 year old 27 year old 11 weeks gestation 11 weeks gestation Abdominal pain for 36 hours Abdominal pain."— Presentation transcript:

1 Appendicitis in Pregnancy Peter O’Leary

2 Case 27 year old 27 year old 11 weeks gestation 11 weeks gestation Abdominal pain for 36 hours Abdominal pain for 36 hours –Crampy generalised abdominal pain initially –Moved to the Right Iliac Fossa Nausea Nausea Poor appetite Poor appetiteO/E Tender over McBurneys point Tender over McBurneys point Rovsings +ve Rovsings +ve WCC = 8.9 WCC = 8.9 CRP = 95 CRP = 95 US abdomen - Appendicitis US abdomen - Appendicitis Treatment – Open appendicectomy Treatment – Open appendicectomy

3 Appendicitis in Pregnancy Most common general surgical problem during pregnancy Most common general surgical problem during pregnancy Occurs in approx 1 in 1500 deliveries Occurs in approx 1 in 1500 deliveries –1 st trimester – 30% –2 nd trimester – 45% –3 rd trimester – 25% Rupture more likely in the third trimester, possibly due to the delay in diagnosis and intervention Rupture more likely in the third trimester, possibly due to the delay in diagnosis and intervention

4 Incidence Suggested relation with female sex hormones Suggested relation with female sex hormones Reduced incidence in pregnancy, especially in the third trimester Reduced incidence in pregnancy, especially in the third trimester ? Protective effect of pregnancy ? Protective effect of pregnancy (Int J Epidemiol 2001 Dec;30(6):1281-5) (Int J Epidemiol 2001 Dec;30(6):1281-5)

5 Pathogenesis Appendiceal lumen obstruction Appendiceal lumen obstruction –Lymphoid hyperplasia –Faecaliths –Parasites –Foreign bodies –Crohns disease –Metastatic cancer –Carcinoid syndrome

6 Symptoms Similar to those in non pregnant individuals Similar to those in non pregnant individuals Right lower quadrant pain Right lower quadrant pain Older studies suggest that the location of the appendix moves upwards as the uterus enlarges Older studies suggest that the location of the appendix moves upwards as the uterus enlarges –Umbilicus level in second trimester –Right Upper Quadrant in the third trimester Refuted by subsequent studies which show the most common symptoms of appendicitis ie right lower quadrant pain occur within a few centimetres of McBurneys point Refuted by subsequent studies which show the most common symptoms of appendicitis ie right lower quadrant pain occur within a few centimetres of McBurneys point (Int J Gynaecol Obstet Jun;81(3):245-7) (Int J Gynaecol Obstet Jun;81(3):245-7) Pain migration Pain migration Nausea Nausea Vomiting Vomiting Fever Fever Anorexia Anorexia

7 Physical examination RLQ tenderness RLQ tenderness Rebound and guarding may be less prominent than in non pregnant women Rebound and guarding may be less prominent than in non pregnant women –The gravid uterus lifts and stretches the anterior wall away from the inflamed appendix (Clin Obstet Gynaecol Feb;14(1):89-102) (Clin Obstet Gynaecol Feb;14(1):89-102) Rovsing’s sign Rovsing’s sign Dunphy’s sign Dunphy’s sign Obturator sign (pelvic appendix) Obturator sign (pelvic appendix) Psoas sign (retroperitoneal retrocaecal appendix) is less common in pregnant females Psoas sign (retroperitoneal retrocaecal appendix) is less common in pregnant females Rectal examination tenderness Rectal examination tenderness

8 Obturator sign Psoas sign

9 Investigations Confound the diagnosis Confound the diagnosis WCC 6 to 16 cells/mm3 in the first and second trimester WCC 6 to 16 cells/mm3 in the first and second trimester 20 to 30 cells/mm3 during labour 20 to 30 cells/mm3 during labour Mourad et al Mourad et al –66,993 consecutive pregnancies –67 probable appendicitis –Confirmed appendicitis – mean leucocyte count of 16,400 –Normal appendix – mean leucocyte count of 14,000 CRP CRP Urinanalysis Urinanalysis –Mild pyuria –Mild Proteinuria –Microscopic haematuria An inflamed appendix in close proximity to the bladder or ureter An inflamed appendix in close proximity to the bladder or ureter

10 Investigations - Graded Compression Ultrasonography Gold standard for imaging in preganacy Gold standard for imaging in preganacy Tersawa et al – Reported sensitivity of 86% and specificity of 81% Tersawa et al – Reported sensitivity of 86% and specificity of 81% Appendicitis diagnosed if Appendicitis diagnosed if A non compressible blind ending tube is present in the right lower quadrant A non compressible blind ending tube is present in the right lower quadrant Diameter > 6mm Diameter > 6mm

11 Investigations - Graded Compression Ultrasonography

12 Computed Tomography –Sensitivity reported as 94% and specificity as 95% –Features suggestive of appendicitis Right lower quadrant inflammation Right lower quadrant inflammation Enlarged, non-filling tubular structure Enlarged, non-filling tubular structure +/- appendicolith +/- appendicolith –Standard CT protocol v Modified CT protocol –Foetal radiation exposure is approx 300 millirads in the modified protocol –This is well below doses known to cause adverse foetal effects

13 Computed Tomography

14 MRI Avoids Radiation exposure Avoids Radiation exposure Sensivity 100%, Specificity 93.6% Sensivity 100%, Specificity 93.6% (Radiology Mar;238(3):891-9) (Radiology Mar;238(3):891-9) Gadolinium should not be used Gadolinium should not be used –Crosses the placenta

15 Differential Diagnosis Similar to non pregnant adults Similar to non pregnant adults Preganacy related differentials include Preganacy related differentials include –Round Ligament Syndrome –Preterm Labour –Abruption –Ectopic –Uterine rupture –Chorioamnionitis –Adnexel torsion

16 Surgical management Raised clinical suspicion or diagnosis of appendicitis with imaging requires prompt surgical intervention Raised clinical suspicion or diagnosis of appendicitis with imaging requires prompt surgical intervention Tocolytic agent use is controversial Tocolytic agent use is controversial –Not recommended unless complications occur Transverse incision at McBurney’s point is indicated when the diagnosis is clear Transverse incision at McBurney’s point is indicated when the diagnosis is clear (Am J Surg Jan;183(1):20-2) (Am J Surg Jan;183(1):20-2) A lower midline incision is suggested in the literature when the diagnosis is not clear A lower midline incision is suggested in the literature when the diagnosis is not clear –Accommodates unexpected surgical findings –Can accommodate a caesarean section if required

17 “Laparoscopy is safe and effective” Guidelines for diagnosis, treatment and use of laparoscopy for surgical problems during pregnancy – Society of American Gastrointestinal and Endoscopic Surgeons 2007 Can be used in any trimester Can be used in any trimester No increased risk to mother or foetus No increased risk to mother or foetus No gestational age limit No gestational age limit Advantages Advantages –Less wound infections –Decreased foetal depression secondary to analgesia –Shorter hospital stay –Decreased risk of thromboembolic events Disadvantages Disadvantages –Decreased uterine blood flow –Fetal acidosis –Premature labour –Long term effects on children have not been well studied Modification of laparoscopic technique Modification of laparoscopic technique –Slight left lateral positioning of patients during the second half of preganacy –Placement of trocars under direct visualisation –Limit intra abdominal pressure to <12mmHg

18 Complications “ The mortality of appendicitis complicating pregnancy is the mortality of delay “ “ The mortality of appendicitis complicating pregnancy is the mortality of delay “ Babler 1908

19 Complications 25% of pregnant women with appendicitis will develop a perforated appendix 25% of pregnant women with appendicitis will develop a perforated appendix A 66% perforation incidence has been reported when surgery is delayed by more than 24 hours A 66% perforation incidence has been reported when surgery is delayed by more than 24 hours This is compared to a 0% perforation incidence when surgical management is initiated in the first 24 hours This is compared to a 0% perforation incidence when surgical management is initiated in the first 24 hours Perforation is twice as likely to occur in the third trimester compared to the first and second trimester Perforation is twice as likely to occur in the third trimester compared to the first and second trimester The risk of fetal loss is higher when the appendix has ruptured – (36% versus 1.5%) The risk of fetal loss is higher when the appendix has ruptured – (36% versus 1.5%) Maternal morbidity is low when the appendix has ruptured Maternal morbidity is low when the appendix has ruptured ( Am J Surg, (6): p ; discussion 575-6) ( Am J Surg, (6): p ; discussion 575-6)

20 Complications More recently it has been suggested that there is no direct “cause and effect” relationship between prolonged symptoms and perforation More recently it has been suggested that there is no direct “cause and effect” relationship between prolonged symptoms and perforation An anatomical explanation is offered instead – –Gravid uterus results in the omentum being unable to isolate infection Am Surg 2000 Jun;66(6):555-9 Am Surg 2000 Jun;66(6):555-9

21 References 1) Gastrointestinal surgical conditions during pregnancy. AUSharp HT SOClin Obstet Gynecol 1994 Jun;37(2): ADDepartment of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City ) Gastrointestinal surgical conditions during pregnancy. AUSharp HT SOClin Obstet Gynecol 1994 Jun;37(2): ADDepartment of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City ) Appendicitis in pregnancy: diagnosis, management and complications. AUAndersen B; Nielsen TF SOActa Obstet Gynecol Scand 1999 Oct;78(9): ) Appendicitis in pregnancy: diagnosis, management and complications. AUAndersen B; Nielsen TF SOActa Obstet Gynecol Scand 1999 Oct;78(9): ) Appendicitis in pregnancy: new information that contradicts long-held clinical beliefs. AUMourad J; Elliott JP; Erickson L; Lisboa L SOAm J Obstet Gynecol 2000 May;182(5): ) Appendicitis in pregnancy: new information that contradicts long-held clinical beliefs. AUMourad J; Elliott JP; Erickson L; Lisboa L SOAm J Obstet Gynecol 2000 May;182(5): ) Incidence of appendicitis during pregnancy. AUAndersson RE; Lambe M SOInt J Epidemiol Dec;30(6): ) Incidence of appendicitis during pregnancy. AUAndersson RE; Lambe M SOInt J Epidemiol Dec;30(6): ) How time affects the risk of rupture in appendicitis. AUBickell NA; Aufses AH Jr; Rojas M; Bodian C SOJ Am Coll Surg Mar;202(3): Epub 2006 Jan 18 5) How time affects the risk of rupture in appendicitis. AUBickell NA; Aufses AH Jr; Rojas M; Bodian C SOJ Am Coll Surg Mar;202(3): Epub 2006 Jan 18 6) Weingold, AB. Appendicitis in pregnancy. Clin Obstet Gynecol 1983; 26:801 6) Weingold, AB. Appendicitis in pregnancy. Clin Obstet Gynecol 1983; 26:801 7) Location of the appendix in the gravid patient: a re-evaluation of the established concept. AUHodjati H; Kazerooni T SOInt J Gynaecol Obstet Jun;81(3): ) Location of the appendix in the gravid patient: a re-evaluation of the established concept. AUHodjati H; Kazerooni T SOInt J Gynaecol Obstet Jun;81(3): ) Appendicitis in pregnancy: new information that contradicts long-held clinical beliefs. AUMourad J; Elliott JP; Erickson L; Lisboa L SOAm J Obstet Gynecol 2000 May;182(5): ) Appendicitis in pregnancy: new information that contradicts long-held clinical beliefs. AUMourad J; Elliott JP; Erickson L; Lisboa L SOAm J Obstet Gynecol 2000 May;182(5): ) Cunningham, FG, McCubbin, JH. Appendicitis complicating pregnancy. Obstet Gynecol 1975; 45: 415 9) Cunningham, FG, McCubbin, JH. Appendicitis complicating pregnancy. Obstet Gynecol 1975; 45: ) Acute appendicitis in pregnancy. AUMcGee TM SOAust N Z J Obstet Gynaecol Nov;29(4): ) Acute appendicitis in pregnancy. AUMcGee TM SOAust N Z J Obstet Gynaecol Nov;29(4): ) The acute abdomen and the obstetrician. AUSivanesaratnam V SOBaillieres Best Pract Res Clin Obstet Gynaecol Feb;14(1): ) The acute abdomen and the obstetrician. AUSivanesaratnam V SOBaillieres Best Pract Res Clin Obstet Gynaecol Feb;14(1): ) Sonography of acute appendicitis in pregnancy. AUBarloon TJ; Brown BP; Abu-Yousef MM; Warnock N; Berbaum KS SOAbdom Imaging Mar- Apr;20(2): ) Sonography of acute appendicitis in pregnancy. AUBarloon TJ; Brown BP; Abu-Yousef MM; Warnock N; Berbaum KS SOAbdom Imaging Mar- Apr;20(2): ) Diagnosis of acute appendicitis in pregnant women: value of sonography. AULim HK; Bae SH; Seo GS SOAJR Am J Roentgenol 1992 Sep;159(3): ) Diagnosis of acute appendicitis in pregnant women: value of sonography. AULim HK; Bae SH; Seo GS SOAJR Am J Roentgenol 1992 Sep;159(3): ) Systematic review: computed tomography and ultrasonography to detect acute appendicitis in adults and adolescents. AUTerasawa T; Blackmore CC; Bent S; Kohlwes RJ SOAnn Intern Med 2004 Oct 5;141(7): ) Systematic review: computed tomography and ultrasonography to detect acute appendicitis in adults and adolescents. AUTerasawa T; Blackmore CC; Bent S; Kohlwes RJ SOAnn Intern Med 2004 Oct 5;141(7): ) MR imaging evaluation of acute appendicitis in pregnancy. AUPedrosa I; Levine D; Eyvazzadeh AD; Siewert B; Ngo L; Rofsky NM SORadiology Mar;238(3): ) MR imaging evaluation of acute appendicitis in pregnancy. AUPedrosa I; Levine D; Eyvazzadeh AD; Siewert B; Ngo L; Rofsky NM SORadiology Mar;238(3): ) The use of helical computed tomography in pregnancy for the diagnosis of acute appendicitis. AUAmes Castro M; Shipp TD; Castro EE; Ouzounian J; Rao P SOAm J Obstet Gynecol 2001 Apr;184(5): ) The use of helical computed tomography in pregnancy for the diagnosis of acute appendicitis. AUAmes Castro M; Shipp TD; Castro EE; Ouzounian J; Rao P SOAm J Obstet Gynecol 2001 Apr;184(5): ) When a pregnant woman with suspected appendicitis is referred for a CT scan, what should a radiologist do to minimize potential radiation risks? AUWagner LK; Huda W SOPediatr Radiol Jul;34(7): Epub 2004 May 26 17) When a pregnant woman with suspected appendicitis is referred for a CT scan, what should a radiologist do to minimize potential radiation risks? AUWagner LK; Huda W SOPediatr Radiol Jul;34(7): Epub 2004 May 26 18) Babaknia, A, Parsa, H, Woodruff, JD. Appendicitis during pregnancy. Obstet Gynecol 1977; 50:40 18) Babaknia, A, Parsa, H, Woodruff, JD. Appendicitis during pregnancy. Obstet Gynecol 1977; 50:40 19) Appendicitis in pregnancy: diagnosis, management and complications. AUAndersen B; Nielsen TF SOActa Obstet Gynecol Scand 1999 Oct;78(9): ) Appendicitis in pregnancy: diagnosis, management and complications. AUAndersen B; Nielsen TF SOActa Obstet Gynecol Scand 1999 Oct;78(9): ) Laparoscopy during pregnancy. AUCuret MJ; Allen D; Josloff RK; Pitcher DE; Curet LB; Miscall BG; Zucker KA SOArch Surg 1996 May;131(5):546-50; discussion ) Laparoscopy during pregnancy. AUCuret MJ; Allen D; Josloff RK; Pitcher DE; Curet LB; Miscall BG; Zucker KA SOArch Surg 1996 May;131(5):546-50; discussion ) The acute abdomen in the pregnant patient. Is there a role for laparoscopy? AUGurbuz AT; Peetz ME SOSurg Endosc 1997 Feb;11(2): ) The acute abdomen in the pregnant patient. Is there a role for laparoscopy? AUGurbuz AT; Peetz ME SOSurg Endosc 1997 Feb;11(2): ) The laparoscopic management of appendicitis and cholelithiasis during pregnancy. AUAffleck DG; Handrahan DL; Egger MJ; Price RR SOAm J Surg 1999 Dec;178(6): ) The laparoscopic management of appendicitis and cholelithiasis during pregnancy. AUAffleck DG; Handrahan DL; Egger MJ; Price RR SOAm J Surg 1999 Dec;178(6): ) Laparoscopic appendectomy in pregnancy. AUWu JM; Chen KH; Lin HF; Tseng LM; Tseng SH; Huang SH SOJ Laparoendosc Adv Surg Tech A Oct;15(5): ) Laparoscopic appendectomy in pregnancy. AUWu JM; Chen KH; Lin HF; Tseng LM; Tseng SH; Huang SH SOJ Laparoendosc Adv Surg Tech A Oct;15(5): ) The incision of choice for pregnant women with appendicitis is through McBurney's point. AUPopkin CA; Lopez PP; Cohn SM; Brown M; Lynn M SOAm J Surg Jan;183(1): ) The incision of choice for pregnant women with appendicitis is through McBurney's point. AUPopkin CA; Lopez PP; Cohn SM; Brown M; Lynn M SOAm J Surg Jan;183(1):20-2.

22 Thank You


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