Appendicitis is the most common non-obstetric surgical condition during pregnancy. While its overall incidence is low at 0.05%, delays in diagnosis and treatment can lead to higher rates of perforation compared to non-pregnant patients. A suspected diagnosis of appendicitis during pregnancy requires immediate surgical evaluation given the risks of generalized peritonitis if appendicitis is left untreated. Laparoscopic appendectomy can be performed safely in selected pregnant patients, especially in the first half of pregnancy, with outcomes similar to open appendectomy. Prompt surgical treatment generally results in good maternal and fetal prognosis.

1. Appendicitis duringAppendicitis during
pregnancypregnancy

2. Appendicitis: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

3. Pathogenesis:Pathogenesis:
Appendiceal lumen obstruction :
lymphoid hyperplasia
fecaliths
parasites
foreign bodies
crohn’s disease
metastatic cancer
carcinoid syndrome

4. Incidence during pregnancy:Incidence during pregnancy:
 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)

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6. Incidence during pregnancy: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)

7. symptoms :symptoms :
Pain – RLQ / RUQ / Flank
Anorexia
Vomiting
Nausea
Pain migration
Fever

8. Physical examination:Physical examination:
 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

9. Psoas
sign
Obturator
sign

10. Lab:Lab:
CBC – WBC ( 80%  45% )
CRP
Urinalysis - mild pyuria
mild proteinuria
mild hematuria

11. D.D.:D.D.:
surgicalsurgical:: gynecogyneco::
 Renal stone
 Gastroenteritis
 Pancreatitis
 Cholecystitis
 Mesenteric adenitis
 Hernia
 Bowel obstruction
 Preterm labor
 Placenta abruptio
 Chorioamnionitis
 Adnexal torsion
 Ectopic pregnancy
 Pelvic inflammatory
 Round lig. pain

12. Diagnostic problems: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

13. Diagnostic problems:Diagnostic problems:
Symptoms complex – physical changes
anorexia, nausea & vomiting in normal
pregnancy
Lab – relative leukocytosis
Imaging techniques

14. Diagnostic problems:Diagnostic problems:
Differential diagnosis:
pyelonephritis
renal colic
placental abtuptio
uterine myoma degeneration

15. Imaging:Imaging:
KUB
Barium enema
Graded compression ultrasonography
Helical CT scan

16. Graded compression ultrasound: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)

17. Acute appendicitis:Acute appendicitis:

18. 
 1.thickened
appendix
 2.Caecum
 3.Small amount of
pericaecal fluid
 4.perippendicular
hyperemia

19. Helical CT scan: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 ?

20. Diagnosis:Diagnosis:
 “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)
 “Fever and WBC are not clear indicators”
(Am J Obstet Gynecol 2001 Jul;185(1):259-60)

21. Treatment:Treatment:
Suspicion 
immediate surgical intervention
Delay 
generalized peritonitis
Antimicrobial therapy: 2nd
cephalosporin, perioperative, unless gangrene,
perforation, phlegmon

22. Tocolytics: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)

23. Surgery:Surgery:
Uncomplicated / complicated surgical
procedure  pregnancy outcome
Perinatal morbidity in nonobstetrical surgery
in pregnancy tributable to the disease itself
(Mazze and Kallen,1989)
Laparotomy –
Incision choice in all trimesters –
McBurney’s point (Am J Surg 2002 Jan;183(1):20-2)

24. laparoscopy:laparoscopy:
 Adv:
Less post-op complication
 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)

25. ““The mortality ofThe mortality of
appendicitis complicatingappendicitis complicating
pregnancy is the mortalitypregnancy is the mortality
of delay “of delay “
Babler 1908

26. Complications:Complications:
 Gestational age  Complication rate
(Tracey and Fletcher,2000)
Uterine contractions – 80% over 24w
Preterm labor:
1. 3rd
trimester
2. Perforated appendix & peritonitis

27. Complications:Complications:
Abortion , Fetal loss ~ 15% (1st
trimester)
Decreased birth weight
Other surgical complication – wound
infection, atelectasis etc.
No increased infertility – (Viktrup and Hee,1998)
No congenital malformation
No stillborn infants

28. Perforated appendicitis:Perforated appendicitis:
Incidence:
4 -19% nonpregnant patients
57% pregnant women (Tracey & Fletcher,2000)
 Gestational age  Perforations 
Peritonitis

29. PerforationPerforation –– why more ???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)

30. PerforationPerforation –– why more ???why more ???
Position change of appendix
No containment of infection by omentum
Inability of omentum to isolate infection
More generalized peritonitis

31. White appendix:White appendix:
Nonpregnant –20%
Pregnant – 20-50% ( higher in advanced
pregnancy)

32. Appendicitis during puerperium:Appendicitis during puerperium:
Appendicitis can stimulate labor – after the
uterus empties there is diffuse peritonitis

33. Prognosis:Prognosis:
Generally good :
Disease found
Surgery complications

34. The endThe end