Appendicitis during
pregnancy
Rinat Gabbay April 2002
Appendicitis:
The most common surgical condition of
the abdomen
 Lifetime occurrence of 7%
 Peak incidence 10-30y


The most common nonobstetric surgical
intervention during pregnancy
Pathogenesis:

Appendiceal lumen obstruction :
lymphoid hyperplasia
fecaliths
parasites
foreign bodies
crohn’s disease
metastatic cancer
carcinoid syndrome
Incidence during pregnancy:

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Incidence 0.05%
1:1000 pregnant women - appendectomy
1:1500 proved appendicitis (Mazze & Kallen,1991)
1st trimester – 30% / 22%
2nd trimester – 45% / 27%
3rd trimester – 25% / 50%
(Mourad,2000)
Incidence during pregnancy:

Suggested relation with female sex
hormones – incidence variations during the
menstrual cycle .
 Reduced incidence of appendicitis during
pregnancy, especially in third trimester
 Protective effect of pregnancy ?
(Int J Epidemiol 2001 Dec;30(6):1281-5)
symptoms :
Pain – RLQ / RUQ / Flank
 Anorexia
 Vomiting
 Nausea
 Pain migration
 Fever

Physical examination:
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Tenderness – RLQ
Rebound & Guarding (peritoneal signs)
Rovsing sign
Dunphy’s sign
Psoas sign (retroperitoneal retrocecal appendix)
Obturator sign (pelvic appendix)
Rectal examination tenderness (cul-de-sac)
Low grade fever
Psoas
sign
Obturator
sign
Lab:
CBC – WBC ( 80%  45% )
 CRP
 Urinalysis - mild pyuria
mild proteinuria
mild hematuria

D.D.:
surgical:
gyneco:
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Renal stone
Gastroenteritis
Pancreatitis
Cholecystitis
Mesenteric adenitis
Hernia
Bowel obstruction
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Preterm labor
Placenta abruptio
Chorioamnionitis
Adnexal torsion
Ectopic pregnancy
Pelvic inflammatory
Round lig. pain
Diagnostic problems:

Position of appendix:
normally 70% intraperitoneal
30% pelvic, retroileal, retrocolic
pregnancy – anatomical changes
gravid uterus  displacement upward &
outward  flank pain (3rd trimester) (Baer,1932)
increased separation of peritoneum  decreased
perception of somatic pain and localization
Diagnostic problems:
Symptoms complex – physical changes
anorexia, nausea & vomiting in normal
pregnancy
 Lab – relative leukocytosis
 Imaging techniques

Diagnostic problems:

Differential diagnosis:
pyelonephritis
renal colic
placental abtuptio
uterine myoma degeneration
Imaging:

KUB
 Barium enema
 Graded compression ultrasonography
 Helical CT scan
Graded compression ultrasound:

Normal appendix (<6mm) rules out
appendicitis.
 Nonpregnant – Sensitivity 85%
specificity 92%
 Pregnant – cecal displacement & uterine
imposition makes precise examination
difficult (Williams,21 edition)
Acute appendicitis:
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1.thickened
appendix
2.Caecum
3.Small amount of
pericaecal fluid
4.perippendicular
hyperemia
Helical CT scan:

Enlarged appendix,
 No filling with contrast material,
 Periappendiceal inflammatory changes
 Nonpregnant patients – 98% sensitivity
 Pregnant - useful, noninvasive & accurate
(Am J Obstet Gynecol 2001 Apr;184(5):954-7

Radiation ?
Diagnosis:
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“Pain in RLQ is the most common presenting
syndrome of appendicitis in pregnancy regardless of
gestational age “
(Am J Obstet Gynecol 2001 Jul;185(1):259-60)

“Physical examination is the most reliable tool for
diagnosis”
(Am Surg 2000 Jun;66(6):555-9)
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“Fever and WBC are not clear indicators”
(Am J Obstet Gynecol 2001 Jul;185(1):259-60)
Treatment:
Suspicion 
immediate surgical intervention
 Delay 
generalized peritonitis
 Antimicrobial therapy:
2nd cephalosporin, perioperative, unless
gangrene, perforation, phlegmon
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Tocolytics:

Concept: calm the uterus from insult of
acute abdomen
 Controversial
 Ritodrine
ineffective
anti-prostaglandin
side effects
 Ritodrine - tachycardia & vomiting
 anti-prostaglandin – anti-inflammatory &
antipyretic, fetal side effects
(Annals of Saudi Med, Vol 18 No 2, 1998)
Surgery:

Uncomplicated / complicated surgical
procedure  pregnancy outcome
 Perinatal morbidity in nonobstetrical surgery
in pregnancy tributable to the disease itself
(Mazze and Kallen,1989)
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Laparotomy –
Incision choice in all trimesters –
McBurney’s point (Am J Surg 2002 Jan;183(1):20-2)
laparoscopy:
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Adv:
Less post-op complication
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Disadv:
Co2 pneumoperitoneum:
Dec. uterine blood flow
Fetal acidosis
Premature labor
Safe especially in 1st half of pregnancy (size
of gravid uterus)
Similar perinatal outcomes compared to
laparotomies (Reedy and colleagues,1997)
“The mortality of
appendicitis complicating
pregnancy is the mortality
of delay “
Babler 1908
Complications:

Gestational age 
Complication rate
(Tracey and Fletcher,2000)
Uterine contractions – 80% over 24w
 Preterm labor:
1. 3rd trimester
2. Perforated appendix & peritonitis
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Complications:
Abortion , Fetal loss ~ 15% (1st trimester)
 Decreased birth weight
 Other surgical complication – wound
infection, atelectasis etc.
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No increased infertility – (Viktrup and Hee,1998)
 No congenital malformation
 No stillborn infants
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Perforated appendicitis:
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Incidence:
4 -19% nonpregnant patients
57% pregnant women (Tracey & Fletcher,2000)
Gestational age  Perforations 
Peritonitis
Perforation – why more ???
No direct “cause and effect” relationship between
prolonged duration of symptoms and perforation
 No relationship between time to operative
intervention and perforation

Anatomical explanation
(Am Surg 2000 Jun;66(6):555-9)
Perforation – why more ???
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Position change of appendix
No containment of infection by omentum
Inability of omentum to isolate infection
More generalized peritonitis
White appendix:
Nonpregnant –20%
 Pregnant – 20-50% ( higher in advanced
pregnancy)
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Appendicitis during puerperium:
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Appendicitis can stimulate labor – after the
uterus empties there is diffuse peritonitis
Prognosis:
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Generally good :
Disease found
Surgery complications
The end