1. Appendicitis in Pregnancy
Peter O’Leary

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

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

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

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

6. Symptoms Similar to those in non pregnant individuals
Right lower quadrant pain
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
(Int J Gynaecol Obstet Jun;81(3):245-7)
Pain migration
Nausea
Vomiting
Fever
Anorexia

7. Physical examination RLQ tenderness
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)
Rovsing’s sign
Dunphy’s sign
Obturator sign (pelvic appendix)
Psoas sign (retroperitoneal retrocaecal appendix) is less common in pregnant females
Rectal examination tenderness

8. Psoas
sign
Obturator
sign

9. Investigations Confound the diagnosis
WCC 6 to 16 cells/mm3 in the first and second trimester
20 to 30 cells/mm3 during labour
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
Urinanalysis
Mild pyuria
Mild Proteinuria
Microscopic haematuria
An inflamed appendix in close proximity to the bladder or ureter

10. Investigations - Graded Compression Ultrasonography
Gold standard for imaging in preganacy
Tersawa et al – Reported sensitivity of 86% and specificity of 81%
Appendicitis diagnosed if
A non compressible blind ending tube is present in the right lower quadrant
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
Enlarged, non-filling tubular structure
+/- 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 Sensivity 100%, Specificity 93.6%
(Radiology Mar;238(3):891-9)
Gadolinium should not be used
Crosses the placenta

15. Differential Diagnosis
Similar to non pregnant adults
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
Tocolytic agent use is controversial
Not recommended unless complications occur
Transverse incision at McBurney’s point is indicated when the diagnosis is clear
(Am J Surg Jan;183(1):20-2)
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
No increased risk to mother or foetus
No gestational age limit
Advantages
Less wound infections
Decreased foetal depression secondary to analgesia
Shorter hospital stay
Decreased risk of thromboembolic events
Disadvantages
Decreased uterine blood flow
Fetal acidosis
Premature labour
Long term effects on children have not been well studied
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 “
Babler 1908

19. Complications
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
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
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
(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
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

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 84132
2) Appendicitis in pregnancy: diagnosis, management and complications. AUAndersen B; Nielsen TF SOActa Obstet Gynecol Scand 1999 Oct;78(9):758-62
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):1027-9
4) Incidence of appendicitis during pregnancy. AUAndersson RE; Lambe M SOInt J Epidemiol Dec;30(6):1281-5
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
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):245-7
8) 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):1027-9
9) Cunningham, FG, McCubbin, JH. Appendicitis complicating pregnancy. Obstet Gynecol 1975; 45: 415
10) Acute appendicitis in pregnancy. AUMcGee TM SOAust N Z J Obstet Gynaecol Nov;29(4):378-85
11) The acute abdomen and the obstetrician. AUSivanesaratnam V SOBaillieres Best Pract Res Clin Obstet Gynaecol Feb;14(1):89-102
12) Sonography of acute appendicitis in pregnancy. AUBarloon TJ; Brown BP; Abu-Yousef MM; Warnock N; Berbaum KS SOAbdom Imaging Mar-Apr;20(2):149-51
13) Diagnosis of acute appendicitis in pregnant women: value of sonography. AULim HK; Bae SH; Seo GS SOAJR Am J Roentgenol 1992 Sep;159(3):539-42
14) 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):537-46
15) MR imaging evaluation of acute appendicitis in pregnancy. AUPedrosa I; Levine D; Eyvazzadeh AD; Siewert B; Ngo L; Rofsky NM SORadiology Mar;238(3):891-9
16) 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):954-7
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
19) Appendicitis in pregnancy: diagnosis, management and complications. AUAndersen B; Nielsen TF SOActa Obstet Gynecol Scand 1999 Oct;78(9):758-62
20) 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 550-1
21) The acute abdomen in the pregnant patient. Is there a role for laparoscopy? AUGurbuz AT; Peetz ME SOSurg Endosc 1997 Feb;11(2):98-102
22) The laparoscopic management of appendicitis and cholelithiasis during pregnancy. AUAffleck DG; Handrahan DL; Egger MJ; Price RR SOAm J Surg 1999 Dec;178(6):523-9
23) 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):447-50
24) 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