Appendicitis in Pregnancy Peter O’Leary

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

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

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)

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

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. 2003 Jun;81(3):245-7) Pain migration Nausea Vomiting Fever Anorexia

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. 2000 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

Psoas sign Obturator sign

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

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

Investigations - Graded Compression Ultrasonography

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

Computed Tomography

MRI Avoids Radiation exposure Sensivity 100%, Specificity 93.6% (Radiology. 2006 Mar;238(3):891-9) Gadolinium should not be used Crosses the placenta

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

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. 2002 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

“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

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

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, 1990. 160(6): p. 571-5; discussion 575-6)

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

References 1) Gastrointestinal surgical conditions during pregnancy. AUSharp HT SOClin Obstet Gynecol 1994 Jun;37(2):306-15.  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. 2001 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. 2006 Mar;202(3):401-6. 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. 2003 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. 1989 Nov;29(4):378-85 11) The acute abdomen and the obstetrician. AUSivanesaratnam V SOBaillieres Best Pract Res Clin Obstet Gynaecol. 2000 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. 1995 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. 2006 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. 2004 Jul;34(7):589-90. 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. 2005 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. 2002 Jan;183(1):20-2.

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