Appendicitis Pregnancy Elnashar

8/6/2019 Appendicitis Pregnancy Elnashar

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Appendicitis DuringAppendicitis DuringPregnancyPregnancy

Prof.Prof. AboubakrAboubakr [email protected]@hotmail.com


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EpidemiologyAnatomical changes

Pathophysiology

ComplicationsDiagnosis

DD

Surgery

Conclusion


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Epidemiology

Lifetime occurrence of 7%

Peak incidence: 10-30y

The most common cause of acute abdomen in

pregnancy non-obstetric surgical interventionduring pregnancy {Accounts for 25%}

Suspected in: 1 in 1000 pregnant women (Mazze andKlln, 1991)

Confirmed in: 65%


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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 three trimesters.

1st T: 30% 2nd T: 45%

3rd: 25%


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Anatomical changes during pregnancy

I. Position of appendix:

Gravid uterus displacement 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 likely due todiffering extent of cecal fixation.


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Position of Appendix(Baer et al, 1932)

12 W: McBurneys point

24 W: Iliac crest36 W: RUQ


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II. Gravid Uterus:

The uterus enlarges 20 times:1. Stretching of supporting ligaments & muscles.

2. Pressure on intra-abdominal structures & ant abd

wall, prevents irritation of ant abd wall by

inflamed intra-abdominal organs decreasedperception of somatic pain & localization

3. Obstructs & inhibits the movement of the omentum

(policeman of the abdomen): prevents omentum

from localizing infection.


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Appendicitis:

inflammation of thevermiform appendix

caused by an obstruction

attributable to infection,

structure, fecal mass,foreign body, or tumor

Pathophysiology


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Complications

Increased with increasing gestational age.

delay in diagnosis


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1. Abortion: 15%

2. Fetal loss: 1.5-5.1%

3. Preterm labor:

13-22%

3rd T

Perforated appendix & peritonitis1st week after surgery


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4. Perforation

Non Pregnant: 4 -19%

Pregnant:

Highest in 3rd T

1st T: 8%

2

nd

T: 12%3rd T: 20%(Andersson and Lambe, 2001; Ueberrueck and associates ,2004)

Surgery delayed by >24 hrs from presentation: 66%risk of perforation:

Surgery within 24 hrs of presentation with

symptoms: No perforation(Tamir et al, 1999)


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Non-perforated appendix

Fetal mortality: 1.5%

Mat mortality: 0.1% Perforated appendix

Fetal mortality: 5.1%-20%

Maternal mortality: 1% {diffuse peritonitis}

Preterm contractions: {localized peritonitis}83%

(Augustin and Majerovic, 2006).

o Neonatal neurological injury {Sepsis}(Mays et,1995)


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DiagnosisMantrels score

DifficultSymptoms

Signs

Lab

Imaging


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MANTRELSMigratory right iliac fossa pain

Anorexia, Nausea/Vomiting

Tenderness in the right iliac fossa

Rebound pain

Elevated temperature

LeukocytosisShift of leukoc tes to the left of neutro hils

Non

Pregnant


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Pregnant:

More difficult.

1. Nausea, vomiting, anorexia accompany normal

pregnancy.

2. Uterus enlarges: appendix commonly moves

upward and outward: pain& tenderness are"displaced" (Baer et al, 1932).

challenged (Mourad et al, 2000).

3. Peritoneal signs often absent {lifting of abdominal

wall by uterus}May not have typical symptom esp. in latepregnancy

4. Fever in less than majority


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5.Elevated WBC normal in pregnancy

1st 2nd T: 16000 At labor: 20000 30000


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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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2. Anorexia, nausea, vomiting:

Neither sensitive nor specific.

Sensitive predictors of appendicitis in the late

pregnancy (Yan et al, 2009)

3. Fever: 50%

Not sensitive


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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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3. Classic signs

No or little clinical significance in diagnosis (Pastoreet al, 2006)

Rovsing sign:

palpation of the LLQ results in more pain in theRLQ

Dunphy's sign:

increased abdominal pain with coughing


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Psoas sign (retroperitoneal retrocecal appendix)passively extending the thigh of a patient

lying on their side with knees extended


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Obturator sign (pelvic appendix)

pain when there is flexion and internal rotation

of the hip


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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 reliableindication 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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Imaging:

Negative appendectomy rate:-Clinical diagnosis alone: 54%

-Clinical, US & CT: 8%

1st

Line:US

2nd line:

CT

MRI


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US: TA or TV

Graded compression sonography

Non-pregnant: sensitivity 85%specificity 92%

Pregnant:

Difficult {cecal displacement and uterineimposition (Pedrosa et al, 2009).

Easy, safe

Operator dependent


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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: can not rule out diagnosis

80% sensitive: non-perforating appendicitis

28% sensitive: perforated appendicitis


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Scan RLQ w/ increasing pressure

to push bowel loops away

Empty cecum of gas& fluid

Sonographic Criteria

Noncompressible

> 7mm diameter

< 6mm rules out appendicitis

Mural thickening > 3mmPresence of appendiceal fecalith


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CT: Helical CT scan:

Non pregnant 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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Radiation dose: 0.3 rad

Specific views to decrease fetal radiation exposureCumulative dose of 5 rad: safe

Enlarged appendix

No filling with contrast material

Inflammatory changes


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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 andChin, 2006).

Cost

Availability may be prohibitive.


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Differential DiagnosisDifferential Diagnosis

Nonobstetric Pyelonephritis

Urinary calculi

Cholecystitis

Cholelithiasis Pancreatitis

Gastroenteritis

Mesenteric Adenitis

Pneumonia

MeckelsDiverticulum

Peptic Ulcer

Obstetric Preterm Labor

Placental Abruption

Chorioamnionitis

Adnexal Torsion Ectopic Pregnancy

PID

Round ligament pain

Uterine rupture


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SurgeryRisk

Indication

PreoperativeAnesthesia

Operative

Laparotomy

LaparoscopyPostoperative


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Risks ofOperation

1. Abortion during first trimester

2. Preterm laborin third trimesterPreterm labor & delivery uncommon: 5-14%

Optimal time during 2

nd

T3. Wound complications


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Indication

When appendicitis is suspected: prompt surgical

exploration.Decision to operate on clinical grounds:

1. Accuracy of diagnosis

inversely proportional to gestation age.Correct diagnosis

1st T: 77%

2nd, 3rd T: 57% (Mazze and Klln, 1991)

Acceptable negative laparotomy rates

Non Pregnant: 15%

Pregnant: 35%(Augustin and Majerovic, 2006).


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2. Risk of the surgical procedure:

to mother & child it is minimal compared to

risks of delayed treatment & appendix

perforation.


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3. Perforation

occurs twice as often in 3rd T as 1st or 2ndDelay in surgery > 24 h after presentation:marked increase in rate of perforation: 0% vs.66%

(Horowitz et al 1995)


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Preoperativekeep NPOIV drip is used 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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Diffuse Peritonitis(Augustin & Majerovic, 2006).

1. IV Cefuroxime, ampicillin, metronidazole, andoxygen pre-operatively.

2. Immediate C-section can be considered,

depending on gestational age of fetus.

3. Preoperative intubation & ventilation in cases of

fetal hypoxia.


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Anesthesia

IV Inhaled anesthetics:Not associated w/ teratogenicity

Potential teratogens best avoided

Local/Regional anesthetics:NO association w/ fetal malformations

Risk of hypotension: decrease uterine blood flow

Minimize: adequate fluids, lateral position


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Operative

Laparotomy or Laparoscopy

Depends on

1. Gestational age

2. Skill of the surgeon


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Laparotomy

1. Tilt table 30 to left

{Decrease pressure to IVC

Facilitate exposure of cecum}

2. IncisionMcBurneys point:


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Laparoscopy

During the 1

st

half of pregnancy:similar perinatal outcomes (Reedy etal,1997)

During 2nd half of pregnancy: controversy

most experienced surgeons. (Barnes and colleagues, 2004;Rollins and associates, 2004; Parangi et al, 2007)


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Advantages

1. Useful in diagnosis

2. Less post-op complication

3. Earlier mobilization & recovery: fewer thromboembolic

complications

4. Lower postoperative narcotic use: less fetal depression

5. Shorter hospital stay

Disadvantages

1. Experience limited

2. Co2 pneumoperitoneum:

uterine blood flow

Fetal acidosis

Premature labor


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Postoperative

1. Preterm contractions are common but

progression to labor is rare.

Observe uterine contraction

2. Tocolytics

Recommended by someS.E:

Ritodrine: tachycardia & vomiting

Anti-prostaglandin: fetal side effects


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Conclusion

1. The symptoms of appendicitis mimic symptoms of

normal pregnancy, namely, anorexia, nausea,

vomiting & abdominal discomfort.

2. Delay of surgery correlates to more advanced

disease with an increased risk of perforation. This, in

turn, contributes to an increased risk of further

complications including abortion or premature labor &

higher maternal complication rates.

3. Prompt diagnosis may improve the perinatal

outcome.

4. Early surgical intervention is essential.


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References

1. Mazze RI, Kallen B. Appendectomy during pregnancy: a Swedish registry study

of 778 cases. Obstet Gynecol 1991;77:835-40.

2. Andersson RE, Lambe M. Incidence of appendicitis during pregnancy. Int J

Epidemiol 2001;30:1281.

3. Baer JL, Reis RA, Arens RA. Appendicitis in pregnancy with changes in position

and axis of normal appendix in pregnancy. JAMA 1932;98:1359..

4. Mourad J, Elliott J, Erickson L, Lisboa L. Appendicitis in pregnancy: new

information that contradicts long-held clinical beliefs. Am J Obstet Gynecol

2000;182:1027-9.

5. Tamir IL. Acute appendicitis in the pregnant patient. Am J Surg1990;160:571-6.6. Lyass S, Pikarsky A, Eisenberg VH, Elchalal U, Schenker JG, Reissman P. Is

laparoscopic appendectomy safe in pregnant women? Surg Endosc. 2001;15:377-

9.

7. WallaceC, Petrov M, Soybel D, Ferzoco S, Ashley S. Influence of imaging on

the negative appendectomy rate in pregnancy. Surg 2008;12: 46-50.

8. Horowitz MD, Gomez GA, Santiesteban R, Burkett G. Acute appendicitis duringpregnancy. Diagnosis and management. Arch Surg 1985;120:13627.

9. Rollins M, Chan K, Price R Laparoscopy for appendicitis and cholelithiasis

during pregnancy: a new standard of care. Surg Endosc. 2004; 18: 237-41.

10. Yan T, Tat L Risk factors of postoperative infections in adults with complicated

appendicitis. Surg Laparosc Endosc Percutan Tech. 2009; 19: 244-8.

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Appendicitis Pregnancy Elnashar