This document discusses appendicitis during pregnancy. It covers the epidemiology, anatomical changes, pathophysiology, complications, diagnosis, differential diagnosis, and surgery of appendicitis in pregnant patients. The key points are that appendicitis occurs in about 1 in 1500 pregnancies, symptoms can be more difficult to diagnose due to pregnancy-related changes, ultrasound and CT scan are used for diagnosis but have limitations during late pregnancy, and prompt surgical treatment is indicated to prevent complications of perforation for both the mother and fetus.

1. Appendicitis during pregnancy Prof Aboubakr Elnashar Benha University Hospital, Egypt elnashar53@hotmail.com
Aboubakr Elnashar

2. 1.Epidemiology
2.Anatomical changes
3.Pathophysiology
4.Complications
5.Diagnosis
6.DD
7.Surgery Conclusion
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3. 1. Epidemiology
Lifetime occurrence: 7%
Peak incidence: 10-30y
The most common
cause of ac abdomen in pregnancy
nonobstetric surgical intervention during pregnancy
{25%}
Suspected in: 1 in 1000 pregnant women
(Mazze and Källén, 1991)
Confirmed in: 65%
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4. Incidence:
1 in 1500 pregnancies.
Reduced during pregnancy, especially in 3rd T {Protective effect of pregnancy ?}
(Andersson &Lambe, 2001).
Same (Some studies)
•Equal in all 3 trimesters.
•1st T: 30%
2nd T: 45%
3rd: 25%
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5. 2. Anatomical changes during pregnancy
I. Position of appendix:
Gravid ut  displaced upward & outward
(Baer et al, 1932, Many authors)
No change in location
(Mourad et al, 2000; Hodjati et al ,2003)).
Degree of displacement, if any, is due to different extents of cecal fixation.
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6. Position of Appendix (Baer et al, 1932) 12 w: McBurney’s point 24W: Iliac crest 36W: RUQ
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7. II. Gravid uterus:
The uterus enlarges 20 times:
1. Stretching of supporting ligs & ms.
2. Pressure on intra-abdominal structures & ant abd wall: prevent irritation of ant abd wall by the inflamed intra-abdominal organ decreased perception of somatic pain& localization
3. Obstruct& inhibit the movement of the omentum (policeman” of the abd): prevent omentum “from localizing infection.
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8. Appendicitis:
inflammation of the vermiform appendix
{obstruction attributable to: infection
stricture,
fecal mass,
foreign body, or
tumor}
3. Pathophysiology
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9. 4. Complications
Increased with
increasing ges age
delay in diagnosis
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10. 1. Abortion: 15%
2. Fetal loss: 1.5-5.1%
3. PTL:
• 13-22%
3rd T
Perforated appendix & peritonitis
1st w after surgery
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11. 4. Perforation
Non Preg: 4 -19%
Preg:
Highest in 3rd T
1st T: 8%
2nd T: 12%
3rd T: 20%
(Andersson and Lambe, 2001; Ueberrueck and associates ,2004)
Surgery delayed by >24 h from presentation: 66% risk of perforation:
Surgery within 24 h of presentation: No perforation
(Tamir et al, 1999)
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12. •Non-perforated appendix
•F mortality: 1.5%
•Mat mortality: 0.1%
•Perforated appendix
•F mortality: 5.1%-20%
•Mat mortality: 1% {diffuse peritonitis}
•Preterm contractions {localized peritonitis}: 83%
(Augustin and Majerovic, 2006).
oNeonatal neurological injury {Sepsis}
(Mays et,1995)
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13. 5. Diagnosis
Mantrels score
Difficult
Symptoms
Signs
Lab
Imaging
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14. MANTRELS Migratory RIF pain Anorexia Nausea/Vomiting Tenderness in RIF Rebound pain Elevated temp Leukocytosis Shift of leukocytes to the left of neutrophils
Non Pregnant 3S 3S 2L
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15. Pregnant:
More difficult.
1. Nausea, vomiting, anorexia accompany normal pregnancy.
2. Ut enlarges: appendix commonly moves upward and outward: pain& tenderness are "displaced" (Baer et al, 1932).
3. Peritoneal signs often absent {lifting of abd wall by uterus}
No typical symptom esp. late pregnancy
4. Fever: 50%
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16. 5. Elevated WBC normal in pregnancy
•1st – 2nd T: 16000
•At labor: 20000 – 30000
•<10000: more reassuring
6. Commonly confused with:
Cholecystitis
PTL
Pyelonephritis
Renal colic
Placental abruption
Degenerating fibroid.
There is no one reliable S or S for diagnosis of appendicitis in pregnancy
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17. Symptoms
1. Abdominal pain (almost always)
• Site:
RLQ: Most reliable sx
Most common even in 3rd T (Yan et al, 2009)
1st T: RLQ
2nd T: At level of umbilicus
3rd T: Diffuse or RUQ
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18. 2. Anorexia, nausea, vomiting:
Not sensitive nor specific.
sensitive predictors of appendicitis in the late pregnancy (Yan et al, 2009)
3. Fever: 50%
not sensitive
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19. Signs
All findings are less common in 3rd T
1. Abdominal tenderness (most common)
Direct RLQ tenderness: ~100%
Rebound tenderness: 55-75%
less common in 3rd T
2. Abdominal rigidity: 50-65%
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20. 3. Classic signs
No or little cl significance in diagnosis (Pastore et al, 2006)
Rovsing sign:
palpation of the LLQ: more pain in the RLQ
Dunphy's sign:
increased abd pain with coughing
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21. Adler Sign:
Appendicitis can be dd from adnexal or uterine pain. If the point of maximal tenderness shifts medially with repositioning on the lt lat side: etiology is adnexal or uterine (vs appendiceal).
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22. Psoas sign (retroperitoneal retrocecal appendix)
Pain on passive extension of the right thigh. Patient lies on left side. Examiner extends patient's right thigh while applying counter resistance to the right hip (asterisk).
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23. Anatomic basis for the psoas sign: inflamed appendix is in a retroperitoneal location in contact with the psoas muscle, which is stretched by this maneuver.
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24. Obturator sign (pelvic appendix)
Pain on passive internal rotation of the flexed thigh. Examiner moves lower leg laterally while applying resistance to the lateral side of the knee (asterisk) resulting in internal rotation of the femur.
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25. Anatomic basis for the obturator sign: inflamed appendix in the pelvis is in contact with the obturator internus muscle, which is stretched by this maneuver.
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26. Laboratory
1. WBC:
2nd &3rd T: 6,000-16,000
Early labor: 20,000-30,000
Absolute number: not reliable
Differential:  levels of band cells can be reliable indication of infection.
2. U/A:
mild pyuria or mild hematuria: 20%
{extraluminal irritation of the ureter, not UTI}.
mild proteinuria
3. CRP (acute-phase protein)
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27. Imaging
Negative appendectomy rate:
-Cl alone: 54%
-Cl, US & CT: 8%
1st Line:
US
2nd line:
CT
MRI
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28. US: TA or TV
Graded compression sonography
Non-pregnant: sensitivity 85%
specificity 92%
Pregnant:
Difficult {cecal displacement & ut imposition (Pedrosa et al, 2009).
Easy, safe
Operator dependent
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29. Accuracy
Accurate in 1st & 2nd T, difficult in 3rd T
confirming the diagnosis in 3rd T: 40% (Yan et al, 2009)
PPV: 100% (provides confirmation of the diagnosis when it is positive).
Normal US: not rule out diagnosis
–80% sensitive: non-perforating appendicitis
–28% sensitive: perforated appendicitis
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30. Scan RLQ with increasing pressure
to push bowel loops away
Empty cecum of gas& fluid
Sonographic Criteria
Noncompressible
> 7mm diameter
<6mm rules out appendicitis
Mural thickening > 3mm
Presence of appendicalith
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31. Aboubakr Elnashar

32. Acute appendicitis
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33. CT: Helical CT scan:
Nonpregnant patients
Sensitivity: 98%
Pregnant:
Sensitivity: >90%
Specificity: >95%
(Torbati et al, 2002; Wallace et al, 2008; Gearhart, 2008; Paulson, 2003; Raman, 2008)
Adv:
Quicker, useful, noninvasive
More sensitive& accurate than US
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34. Radiation dose: 0.3 rad
Specific views to decrease fetal radiation exposure
Cumulative dose of 5 rad: safe
Enlarged appendix
No filling with contrast material
Inflammatory changes
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35. MRI
No adverse effects on fetus (Israel et al, 2008). False-negative: 0% False-positive rate: 30% (Pedrosa et al, 2009) Sensitivity: up to 100% Specificity: 96% (Fielding and Chin, 2006).
Cost Availability may be prohibitive.
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36. Acute perforated appendicitis at 21 w gestation.
T2-weighted single-shot fast SE (∞/80) (a) transverse MR images show dilated appendix (arrow) lateral to the cecum (C), with slightly thickened appendix wall. Fluid collection posterior to the appendix is a small periappendiceal abscess (arrowhead) secondary to rupture
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37. Acute perforated appendicitis at 21 w gestation.
T2-weighted single-shot fast SE (∞/80) coronal MR images dilated appendix (arrow) lateral to the cecum (C), with slightly thickened appendix wall. Fluid collection posterior to the appendix is a small periappendiceal abscess (arrowhead) secondary to rupture
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38. 6. Differential Diagnosis
Nonobstetric
Pyelonephritis
Urinary calculi
Cholecystitis
Cholelithiasis
Pancreatitis
Gastroenteritis
Mesenteric Adenitis
Pneumonia
Meckel’s Diverticulum
Peptic Ulcer
Obstetric
PTL
Placental Abruption
Chorioamnionitis
Adnexal Torsion
Ectopic Pregnancy
PID
Round lig pain
Ut rupture
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39. 7. Surgery
Risk
Indication
Preoperative
Anesthesia
Operative Laparotomy Laparoscopy
Postoperative
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40. Risk of operation 1. Abortion during 1st T 2. PTL in 3rd T uncommon: 5-14% Optimal time during 2nd T 3. Wound complications
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41. Indication
When appendicitis is suspected: prompt surgical exploration.
Decision to operate on cl grounds:
1.Accuracy of diagnosis
inversely proportional to ges age. Correct diagnosis 1st T: 77% 2nd, 3rd T: 57% (Mazze and Källén, 1991)
Acceptable negative laparotomy rates Non Preg: 15% Pregnant: 35% (Augustin and Majerovic, 2006).
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42. 2. Risk of the surgical procedure
To mother & child: minimal
compared with
risks of delayed tt & appendix perforation.
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43. 3. Perforation
occurs twice as often in 3rd T as 1st or 2nd
Delay in surgery > 24 h after presentation: marked increase in rate of perforation: 0% vs 66% (Horowitz et al 1995)
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44. Preoperative
keep NPO
IV drip to hydrate
IV antimicrobial therapy: 2nd or 3rd generation cephalosporin Discontinued after surgery unless –Gangrene –Perforation –Periappendiceal phlegmon
Without generalized peritonitis: prognosis is excellent.
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45. Diffuse Peritonitis
(Augustin & Majerovic, 2006).
1. IV Cefuroxime, ampicillin, metronidazole, and oxygen pre-operatively.
2. Immediate CS can be considered, depending on ges age of fetus.
3. Preoperative intubation & ventilation in cases of fetal hypoxia.
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46. Anaestheia
IV Inhaled anesthetics: No teratogenicity Potential teratogens best avoided
Local/Regional anesthetics: NO fetal malformations Risk of hypotension: decrease ut blood flow Minimize: adequate fluids lateral position
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47. Operative
Laparotomy or Laparoscopy?
Depend on
1. Gest age
2. Skill of the surgeon
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48. Laparotomy
1. Tilt table 30° to left
{Decrease pressure to IVC
Facilitate exposure of cecum}
2. Incision
McBurney’s point: <20 ws
Point of maximum tenderness
low midline: diffuse peritonitis, or
doubt about diagnosis
Rt. Paraumbilicus
3. Minimal ut manipulation {decrease risk of PTL}
4. Seldom CS is indicated at the time of appendectomy.
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49. Laparoscopy
During the first half of pregnancy:
similar perinatal outcomes (Reedy etal,1997)
During 2nd half of pregnancy: controversy
experienced surgeons.
(Barnes and colleagues, 2004; Rollins and associates, 2004; Parangi et al, 2007)
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50. Advantages
1. Useful in diagnosis
2. Less post-op complication
3. Earlier mobilization & recovery: fewer DVT
4. Less postoperative narcotic: less fetal depression
5. Shorter hospital stay
Disadvantages
1. Experience limited
2. CO2 pneumoperitoneum:
ut blood flow
Fetal acidosis
PTL
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51. Postoperative
1. Preterm contractions: common but progression to labor is rare:
Observe ut contraction
2. Tocolytics
Recommended by some
S.E:
Ritodrine: tachycardia & vomiting
Anti-prostaglandin: fetal side effects
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52. Conclusion
1.The symptoms of appendicitis mimic symptoms of normal pregnancy, namely, anorexia, n, v & abd discomfort. 2. Prompt diagnosis may improve the prenatal outcome. 3. Delay of surgery: increased risk of perforation: increased risk of abortion or PTL & maternal complications. 4. Early surgical intervention is essential.
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