appendicitis during pregnancy
DESCRIPTION
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 : - PowerPoint PPT PresentationTRANSCRIPT
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
Pathogenesis:Pathogenesis:Appendiceal lumen obstruction : lymphoid hyperplasia fecaliths parasites foreign bodies crohn’s disease metastatic cancer carcinoid syndrome
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)
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)
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
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
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
Diagnostic problems:Diagnostic problems:
Symptoms complex – physical changes
anorexia, nausea & vomiting in normal
pregnancyLab – relative leukocytosisImaging techniques
Diagnostic problems:Diagnostic problems:
Differential diagnosis:
pyelonephritis
renal colic
placental abtuptio
uterine myoma degeneration
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)
Helical CT scan:Helical CT scan:
Enlarged appendix, No filling with contrast material, Periappendiceal inflammatory changesNonpregnant patients – 98% sensitivityPregnant - useful, noninvasive & accurate
(Am J Obstet Gynecol 2001 Apr;184(5):954-7
Radiation ?
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)
Treatment:Treatment:
Suspicion
immediate surgical interventionDelay
generalized peritonitisAntimicrobial therapy:
2nd cephalosporin, perioperative, unless gangrene, perforation, phlegmon
Tocolytics:Tocolytics:Concept: calm the uterus from insult of
acute abdomenControversial Ritodrine ineffective
anti-prostaglandin side effects Ritodrine - tachycardia & vomitinganti-prostaglandin – anti-inflammatory &
antipyretic, fetal side effects (Annals of Saudi Med, Vol 18 No 2, 1998)
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)
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)
““The mortality of The mortality of appendicitis complicating appendicitis complicating pregnancy is the mortality pregnancy is the mortality
of delay “of delay “
Babler 1908
Complications:Complications:
Gestational age Complication rate
(Tracey and Fletcher,2000)
Uterine contractions – 80% over 24wPreterm labor:
1. 3rd trimester
2. Perforated appendix & peritonitis
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 malformationNo stillborn infants
Perforated appendicitis:Perforated appendicitis:Incidence:
4 -19% nonpregnant patients
57% pregnant women (Tracey & Fletcher,2000)
Gestational age Perforations Peritonitis
Perforation Perforation –– 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)
Perforation Perforation –– why more ??? why more ???
Position change of appendix
No containment of infection by omentum
Inability of omentum to isolate infection
More generalized peritonitis
Appendicitis during puerperium:Appendicitis during puerperium:
Appendicitis can stimulate labor – after the uterus empties there is diffuse peritonitis