1. Appendicitis in pregnancy
Sadaf Alipour
General Surgeon
Assistant Professor
Tehran University of Medical Sciences

2. INTRODUCTION 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. CLINICAL MANIFESTATIONS(1)
 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. CLINICAL MANIFESTATIONS(2)
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. CLINICAL MANIFESTATIONS(3)
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. CLINICAL MANIFESTATIONS (4)
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. Laboratory assessment(1)
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. Laboratory assessment(2)
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. diagnosis 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

10. Imaging
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. Ultrasonography 
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. US 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. MRI (1)
 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. MRI (2)
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. MRI (3) Sensitivity= %100 Specificity= %93
Positive predictive value = %61
Negative predictive value = %100

16. CT scan (1) Main findings of apx on CT: RLQ inflammation
Enlarged nonfilling tubular structure
Appendicolith.

17. CT 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)

18. Ct scan (3) Overall sensitivity= %94 Specificity= % 95
We suggest CT when clinic and US are inconclusive and MRI is not available

19. MANAGEMENT APPROACH AND OUTCOME
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. incision
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. Laparoscopy(1)
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. Laparoscopy(2) Decision to proceed to laparoscopy based on:
skill and experience of surgeon
clinical factors such as size of gravid uterus.

23. complications (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.

24. complications (2) 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. Type of delivery C/S rarely indicated at time of appendectomy
Risk of dehiscence during labor and vaginal delivery not increased when fascia appropriately reapproximated

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

27. Patients quite ill and may be septic
Perforated appendix
 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. In Nonpregnants with long duration of symptoms (more than five days)
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. Conservative tx of apx in Py
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. SUMMARY AND RECOMMENDATIONS
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. references 1- Schwartz Principles of Surgery (book)
2-UptoDate (online)

32. Thank you