DOI: 10.1111/1471-0528.

12736 General obstetrics

www.bjog.org

Management and outcomes of acute

appendicitis in pregnancy—population-based
study of over 7000 cases
N Abbasi,a V Patenaude,b HA Abenhaima,b
a
Department of Obstetrics and Gynaecology, Jewish General Hospital, Montreal, QC, Canada b Centre for Clinical Epidemiology and
Community Studies, Jewish General Hospital, Montreal, QC, Canada
Correspondence: HA Abenhaim, Department of Obstetrics & Gynaecology, Jewish General Hospital, 5790 Cote-Des-Neiges Road, Pav H, Room
325, Montreal, QC, Canada H3S 1Y9. Email haim.abenhaim@gmail.com

Accepted 28 January 2014. Published Online 28 March 2014.

Objective To compare outcomes and management practices
among pregnant and nonpregnant women with acute appendicitis.
Design Population-based matched cohort study.
Setting United States of America.
Sample A total of 7114 women with appendicitis among
7 037 386 births.
Methods Logistic regression analyses to calculate the odds ratio
(OR) and corresponding 95% confidence intervals (95% CIs) for
variables and outcomes of interest.
Main outcome measures Maternal morbidities associated with
appendicitis; management practices for pregnant and age-matched
nonpregnant women with appendicitis.
Results There was an overall incidence of 101.1 cases of
appendicitis per 100 000 births. Appendicitis was diagnosed in
35 570 nonpregnant women during the corresponding time frame.
Peritonitis occurred in 20.3% of pregnant women with
appendicitis, with an adjusted OR of 1.3 (95% CI 1.2–1.4) when
compared with nonpregnant women with appendicitis. In
pregnancy, there was an almost two-fold increase in sepsis and
septic shock, transfusion, pneumonia, bowel obstruction,
postoperative infection and length of stay >3 days. Whereas 5.8%
of appendicitis cases among pregnant women were managed
conservatively, they were associated with a considerably increased
risk of shock, peritonitis and venous thromboembolism as
compared to surgically managed cases.
Conclusions Compared with nonpregnant women, pregnant
women with acute appendicitis have higher rates of adverse
outcomes. Conservative management should be avoided given the
serious risk of adverse outcomes in pregnancy.
Keywords Appendicitis, maternal outcomes, peritonitis,
postoperative complications, pregnancy.

Please cite this paper as: Abbasi N, Patenaude V, Abenhaim HA. Management and outcomes of acute appendicitis in pregnancy—population-based study of
over 7000 cases. BJOG 2014;121:1509–1514.

regarding maternal outcomes, we sought to evaluate

Introduction
Appendicitis is the most common surgical complication of
pregnancy1 and accounts for 25% of nonobstetric opera-
tions.2 The incidence of appendicitis in pregnancy is similar
to that of the nonpregnant population, ranging between 1 in
1400 and 1 in 1500 births.3–5 Ninety percent of pregnant
women are <30 years of age,4 correlating with the peak inci-
dence of appendicitis in the general population.6 Despite
reduction in maternal mortality in recent decades, maternal
complications remain high once perforation has occurred.3,7
Recognising the deleterious effects of acute appendicitis
on maternal and fetal wellbeing, and the limited research
maternal morbidities associated with appendicitis, and to
evaluate the impact of peritonitis. Our secondary objective
was to compare management practices for pregnant and
age-matched nonpregnant women with appendicitis.
Methods
Data obtained from the Health Care Cost and Utilization
Project, Nationwide Inpatient Sample (HCUP-NIS) were
used to carry out a population-based matched cohort study,
with a ratio of one case to five controls. The HCUP-NIS
contains data on US hospital inpatient stays from 2003 to

ª 2014 Royal College of Obstetricians and Gynaecologists 1509

 Abbasi et al.

2010, inclusively, and approximates 20% of US hospital

Results
admissions. These include admissions to rural and urban,
teaching and nonteaching hospitals. The database includes During the 8-year period of investigation, 7114 pregnant
clinical and resource use information during hospitalisation and 35 570 age-matched nonpregnant women were identi-
for delivery, including demographic information, duration fied with appendicitis. There were a total of 7 037 386
of admission, comorbidities, discharge diagnoses (up to 15 births over the study period, yielding an overall incidence
between 2003 and 2008 and 25 from 2009 and 2010), proce- of 0.1% or 101.1 cases of appendicitis per 100 000 births.
dures categorised according to the International Classifica- Comparison of baseline characteristics (Table 1) demon-
tion of Diseases, 9th Revision, Clinical Modification strated that among pregnant women with appendicitis
(ICD-9-CM), as well as maternal death, if present. there was a significantly higher proportion of Black and
A cohort of women with appendicitis was isolated using Hispanic women compared with the proportion in non-
the following ICD-9-CM codes 540.0, 540.1, 540.9, 541 and pregnant women with appendicitis. Pregnant women with
542. Pregnant women with appendicitis were identified by appendicitis were less likely to be obese and more com-
obtaining patients with pregnancy or delivery codes and an monly had Medicaid type of insurance.
appendicitis-related code. Appendicitis-related death during Rates of peritonitis were 20.3% in pregnant women with
admission was identified when ‘died’ was indicated under appendicitis and 16.1% in nonpregnant women with
disposition of patient in the HCUP-NIS database, com- appendicitis with an adjusted OR of 1.3 (95% CI 1.2–1.4).
bined with any of the appendicitis codes. Non-pregnant Among pregnant women with appendicitis, sepsis and sep-
controls were identified and age-matched at a 5 to 1 ratio. tic shock, as well as transfusion, pneumonia, bowel
Baseline characteristics were identified either as indepen- obstruction, postoperative infection and length of stay
dent variables within the data or using ICD-9-CM codes. >3 days, were increased. Treatment of appendicitis was
These included age, race, income, type of insurance, hospi- considerably different in pregnancy. The rate of laparos-
tal type and obesity (codes 649.1x, 278.00-1, V85.3-4; copy was 50% less, with an adjusted OR of 0.5 (95% CI
defined as Body Mass Index >30). The ICD-9-CM proce-
dure coding for treatment options was as follows: laparo-
scopic appendicectomy (code 47.01) and laparotomy (code Table 1. Baseline characteristics among pregnant and nonpregnant
47.09). Conservative or nonsurgical management was women with appendicitis
defined as any case with a code for appendicitis without
Characteristics Pregnant Nonpregnant
laparotomy or laparoscopy, and may have also included a
(n = 7114) (n = 35 570)
code for drainage of appendiceal abscess (code 47.2). All (%) (%)
outcomes and postoperative complications were identified
using ICD-9-CM codes as follows: sepsis (including codes
Age (years)
for systemic inflammatory response syndrome, sepsis and <25 42.5 42.5
severe sepsis; codes 995.90, 995.91, 995.92), septic shock 25–35 48.5 48.5
(code 785.52), transfusion (procedure code 99.0), venous >35 9.0 9.0
thromboembolism including pulmonary emboli and deep Race
venous thrombosis; codes (415.1, 453.4, 671.3, 671.4, 673.2, White 44.1 49.5
V12.51), pneumonia (codes 480x–482x, 485–487x), bowel Black 7.1 6.5
Hispanic 21.6 16.1
obstruction (560.1, 560.8x, 560.9), postoperative haemor-
Other (Asian, Pacific Islander, 6.3 6.0
rhage or haematoma (codes 998.11, 998.12) and postopera- Native American, other)
tive infection (codes 998.51, 998.59). Length of stay Obesity (body mass index >30) 3.2 5.6
>3 days was an independent variable that was obtained Income
directly from the database. $1 to $38,999 26.0 23.3
Crude and adjusted odds ratios (ORs) and correspond- $39,000 to $47,999 25.7 24.2
ing 95% confidence intervals (CIs) were calculated using $48,000 to $62,999 25.2 24.9
$63,000 or more 21.0 25.4
unconditional logistic regression for Tables 3 and 4 and
Type of insurance
conditional logistic regression for Table 2. All models were Medicaid 41.8 17.9
adjusted for baseline characteristics. We used a two-tailed Medicare 0.7 1.1
analysis and considered P-values <0.05 as statistically signif- Private including health 47.4 613
icant. This study was approved by the Medical Research maintenance organisation
Ethics Department of the Jewish General Hospital. All Other (self-pay, 10.0 19.7
analyses were performed with the statistical software pack- no charge, other, missing)

age SAS 9.2 (SAS Institute, Cary, NC, USA).

1510 ª 2014 Royal College of Obstetricians and Gynaecologists

 Acute appendicitis and pregnancy

0.5–0.5) and a doubling in laparotomy rate 2.0 (95% CI
1.9–2.1) compared with the nonpregnant population. Con-
servative management was more common in pregnancy
with an adjusted OR of 1.3 (95% CI 1.2–1.5; Table 2).
Clinical course was significantly more severe in women
with peritonitis (Table 3). Sepsis and septic shock were
increased; however, an adjusted OR could not be calculated
for the latter because of the small number of cases. An
almost four-fold increase in transfusion and pneumonia was
noted and postoperative infection and prolonged hospital
stay were eight times higher in women with peritonitis.
When conservative management was compared with
appendicectomy in pregnancy, there were statistically sig-
nificant increases noted in maternal morbidity including
septic shock with an adjusted OR of 6.3 (95% CI 1.9–20.8),
peritonitis with an adjusted OR of 1.6 (95% CI 1.3–2.1)
and more than two-fold increase in venous thromboembo-
lism in the former group (Table 4).

Table 2. Comparison of outcomes and post-operative complications of appendicitis in pregnant and nonpregnant women

Outcomes and Pregnant Nonpregnant Adjusted Adjusted

postoperative (n = 7114) (n = 35 570) OR P-value*
complications (%) (%) (95% CI)*

Outcomes
Sepsis 1.3 0.6 1.9 (1.5–2.6) <0.001
Septic shock 0.2 0.1 1.7 (0.8–3.7) 0.209
Appendicitis with peritonitis 20.3 16.1 1.3 (1.2–1.4) <0.001
Postoperative complications
Transfusion 1.6 0.9 1.7 (1.3–2.1) <0.001
Venous thromboembolism 0.4 0.3 1.6 (1.0–2.5) 0.038
Pneumonia 1.1 0.4 2.5 (1.9–3.4) <0.001
Bowel obstruction 5.3 3.0 1.9 (1.7–2.2) <0.001
Haemorrhage, haematoma 0.2 0.4 0.6 (0.3–1.0) 0.044
Postoperative infection 0.9 0.4 2.0 (1.5–2.7) <0.001
Length of stay >3 days 45.5 26.0 2.3 (2.2–2.4) <0.001
Death 0.0 0.0 – –
Management
Laparotomy 48.1 31.7 2.0 (1.9–2.1) <0.001
Laparoscopy 46.1 64.0 0.5 (0.5–0.5) <0.001
Conservative management 5.8 4.3 1.3 (1.2–1.5) <0.001

*Adjusted for age, race, obesity, income, insurance and hospital type.

Table 3. Comparison of maternal outcomes and postoperative complications in pregnant women with appendicitis, with or without peritonitis

Outcomes and Peritonitis No peritonitis Adjusted Adjusted

postoperative (n = 1443) (n = 5671) OR P-value*
complications (%) (%) (95% CI)*

Outcomes
Sepsis 4.0 0.6 6.7 (4.3–10.2) <0.001
Septic shock 0.6 0.1
Postoperative complications
Transfusion 3.8 1.1 3.6 (2.5–5.2) <0.001
Venous thromboembolism 0.6 0.4 1.4 (0.6–3.2) 0.407
Pneumonia 2.6 0.7 3.9 (2.5–6.1) <0.001
Postoperative haemorrhage/haematoma 0.2 0.2
Postoperative infection 3.1 0.4 8.0 (4.7–13.4) <0.001
Length of stay >3 days 82.4 36.1 8.3 (7.1–9.6) <0.001
Death 0.0 0.0

*Adjusted for age, race, obesity, income and insurance.

ª 2014 Royal College of Obstetricians and Gynaecologists 1511

 Abbasi et al.
Table 4. Comparison of outcomes and postoperative complications in pregnant women with appendicitis, with surgical or conservative
management
Outcomes Conservative
(n = 413)
SIRS, sepsis or severe sepsis 13 (3.1)
Septic shock 4 (1.0)
Peritonitis 119 (28.8)
Venous thromboembolism 4 (1.0)
SIRS, systemic inflammatory response syndrome.
*Adjusted for age, race, obesity, income and insurance.
Discussion
Main findings
Rates of overall morbidity associated with appendicitis and
laparotomy rates were higher among pregnant women.
Women treated conservatively had significantly higher rates
of septic shock, peritonitis and venous thromboembolism.
The risk of developing complications dramatically increased
when appendicitis was complicated by peritonitis.
Strengths and limitations
To evaluate relatively rare events like maternal morbidities
associated with appendicitis, administrative databases are
ideal for providing a large patient sample with sufficient
power to detect such uncommon occurrences. Previously
reported population-based studies consist of between 1000
and 3000 women with appendicitis.2,8–10 To our knowl-
edge, this study contains the largest cohort of cases of
appendicitis in pregnancy, which has allowed us to demon-
strate statistically significant increases in maternal morbid-
ity and accurately depict management practices. The
validity of diagnostic coding used in databases is a critical
element in any database study. Given the limited available
data per subject, case ascertainment was corroborated
through management with ‘appendicectomy’, which
occurred in ~95% of ‘appendicitis’ subjects, as expected.
However, women with appendicitis managed conservatively
could not be corroborated. Nevertheless, this method of
case identification has previously been used with
ICD-9-CM coding for appendicitis and related proce-
dures.8,10–15 Furthermore, in a validation study, Quan
et al.16 compared medical charts and corresponding admin-
istrative discharge data coded with ICD-9-CM codes for
various surgical and medical procedures and concluded
that major procedures like appendicitis were well coded.
Several limitations arise from the use of de-identified
databases. First, little information can be obtained regarding
the clinical presentation and diagnostic modalities used. We
could not determine in which period of gestation the
appendicitis occurred, so were unable to obtain information
1512
Surgical Adjusted OR Adjusted
(n = 6701) (95% CI)* P-value*
80 (1.2) 2.6 (1.4–4.8) 0.002
10 (0.1) 6.3 (1.9–20.8) 0.002
1324 (19.8) 1.6 (1.3–2.1) <0.001
26 (0.4) 2.5 (0.9–7.4) 0.096
regarding incidence per trimester or mode of management
per trimester. Cases of appendicitis in the postpartum
period were also omitted from our study. Moreover, it is
uncertain whether these cases of appendicitis were patholog-
ically confirmed. Complications and mortality were only
evaluated in the same admission, but any events that
occurred after discharge were not included, thus potentially
underestimating the incidence of adverse events. The appen-
dicitis-related deaths were not validated by chart review.
Interpretation
In our study, there were eight deaths among 35 580 non-
pregnant women with appendicitis compared with one
death among 7114 cases of appendicitis in pregnancy,
yielding a case fatality rate of 0.01%. This is consistent with
the low mortality rate associated with appendicitis in mod-
ern times.4,9,10,17 This reduction in mortality from 25% in
the early 1900s18 probably reflects the introduction of effec-
tive antibiotic therapy and improved surgical techniques as
well as improved diagnostic tools. Our study demonstrates
a 20% rate of peritonitis among pregnant women with
appendicitis, which is consistent with other studies.19,20
This increased risk compared with nonpregnant women
may reflect the challenges in diagnosing appendicitis in
pregnancy. This difficulty can in part be explained by the
cephalad displacement of the appendix after the first
trimester, reaching as high as the iliac crest in the third
trimester, as reported by Baer et al.21 Atypical symptoms
may occur as a result, with an increased risk of peritonitis,
because once the appendix is displaced freely outside the
pelvis, perforations cannot be walled off by omentum.4
Although studies have recognised a trend towards
increased maternal morbidity with peritonitis,3,7 our study is
the first to extensively evaluate the specific impact of
peritonitis on postoperative complications. Silvestri et al.9
also found an increase in preoperative systemic infection in
pregnant women with appendicitis, but did not find any
difference in composite 30-day major morbidity or individ-
ual morbidities, including transfusion, infection, thrombosis,
sepsis or septic shock rates except pneumonia. However, we
ª 2014 Royal College of Obstetricians and Gynaecologists

believe our clear demonstration of increased maternal mor-
bidity and rates of sepsis with simple appendicitis and peri-
tonitis reinforce the need for early intervention.
Increased maternal morbidity associated with appendici-
tis may not only be explained by the increased rate of peri-
tonitis but also by a two-fold increase in laparotomy noted
in our cohort, which has also been reported by other stud-
ies.9,10 In the general population, laparoscopy is used in
43–58% of women with appendicitis,14,15 and has been
associated with shorter hospital stay,13,15,22 lower rates of
infections,13 fewer gastrointestinal complications13 and
fewer overall complications (including wound infections
and urinary, pulmonary, gastrointestinal and cardiovascular
complications),13,15,22 which may explain the lower rates of
morbidity in our nonpregnant population. Even after
adjustment for socio-economic factors like income, type of
insurance and hospital type, and technical factors like obes-
ity, an open approach was more common in pregnancy.
However, our study could not account for cases converted
from laparoscopy to laparotomy. Gestational age at time of
surgery was not known, as appendicectomies performed
later in pregnancy may preferably be by laparotomy due to
the enlarged uterus.
The high rate of open surgery in our study may also
reflect the ambiguity in terms of preferred approach in
pregnancy. Laparoscopic appendicectomy in pregnancy has
been associated with a higher incidence of preterm delivery
at <37 weeks of gestation and rate of fetal loss, approach-
ing 6% in laparoscopic appendicectomy compared with 3%
in the open approach.23 Using the Nationwide Inpatient
Sample to evaluate outcomes following cholecystectomy in
pregnancy, Kuy et al.24 found increased rates of open pro-
cedures in pregnant women. When compared with laparos-
copy, pregnant women with laparotomies had increased
length of stay, cost, fetal complications (including fetal
loss) and surgical complications (including gastrointestinal,
infectious, wound and pulmonary complications), similar
to our findings. Reedy et al.25 evaluated outcome of surger-
ies for non-obstetric indications during the first and second
trimesters and found increased risk of birthweight <2500 g
and delivery before 37 weeks of gestation, but no difference
for open and laparoscopic approaches.25,26 Ultimately,
choice of treatment approach will depend on the skill and
experience of the surgeon in laparoscopy as well as the size
of the gravid uterus. However, potential increase in fetal
loss with laparoscopy must be balanced with increased
maternal morbidity associated with laparotomy.
In our study, more than 400 pregnant women with appen-
dicitis were treated conservatively, which is higher than what
is reported in the literature. Conservative management of
ruptured appendicitis with phlegmon has been reported by
Young et al.27, where two women were managed conserva-
tively with antibiotics followed by interval appendicectomy
ª 2014 Royal College of Obstetricians and Gynaecologists
Acute appendicitis and pregnancy
later in the pregnancy or postpartum. Vasireddy et al.28
caution against this practice, as two reported maternal
deaths in London followed conservative management. In a
meta-analysis evaluating conservative management of
uncomplicated appendicitis in the general population,
Varadhan et al.29 demonstrated a risk reduction of compli-
cations by 31% with antibiotic therapy, with no significant
differences for treatment efficacy, length of hospitalisation or
risk of developing complicated appendicitis. Andersson and
Petzold30 reviewed nonsurgical treatment of appendicitis
with abscess or phlegmon in the general population as well
and found a failure rate of only 7.2% as well as a three-fold
increase in morbidity with immediate surgery.30 They sug-
gest that conservative management is a safe option. Although
conservative management may have a therapeutic role in the
general population, our study is the first to objectively dem-
onstrate the adverse consequences associated with conserva-
tive management in pregnancy with statistically significant
rises in maternal morbidities, most notably septic shock, so
questioning the safety of non-surgical management of
appendicitis during pregnancy.
Conclusion
Despite improvement in maternal mortality rates, peritoni-
tis and ensuing complications remain high in pregnancy.
Although, effective antibiotics and advances in imaging and
surgical techniques have contributed to better outcomes,
this may further improve if the threshold to operate in
pregnant women with suspicious symptoms is reduced. We
believe that delay in intervention is the fundamental con-
tributor to poor outcomes in pregnancy, and we continue
to advocate early recognition and rapid surgical manage-
ment to limit the detrimental impact of appendicitis on
both mother and fetus.
Disclosure of interests
The authors report no conflict of interest.
Contribution to authorship
NA and HA contributed to the conception and design of
the study. In addition they interpreted the data and drafted
the article. VP was involved in the acquisition and analysis
of the data. NA, HA and VP all contributed to the revision
and final approval of the version to be published.
Details of ethics approval
This study was submitted to the Research Ethics Department
of the Jewish General Hospital, however “as the NIS data-
base used for this study is public and the data is anonymous
accessible this project falls under articles 2.2 and 2.4 of the
Tri-Counsel Policy Statement (2010) and therefore does not
require REB review”.
1513
 Abbasi et al.
Funding
Funding was obtained from our institution. &
References
1 Cunningham FG, McCubbin JH. Appendicitis complicating
pregnancy. Obstet Gynecol 1975;45:415–20.
2 Mazze RI, Kallen B. Appendectomy during pregnancy: a Swedish
registry study of 778 cases. Obstet Gynecol 1991;77:835–40.
3 Tamir IL, Bongard FS, Klein SR. Acute appendicitis in the pregnant
patient. Am J Surg 1990;160:571–6.
4 Babaknia A, Parsa H, Woodruff JD. Appendicitis during pregnancy.
Obstet Gynecol 1977;50:40–4.
5 Mourad J, Elliott JP, Erickson L, Lisboa L. Appendicitis in pregnancy:
new information that contradicts long-held clinical beliefs. Am J
Obstet Gynecol 2000;182:1027–9.
6 Addiss DG, Shaffer N, Fowler BS, Tauxe RV. The epidemiology of
appendicitis and appendectomy in the United States. Am J
Epidemiol 1990;132:910–25.
7 Yilmaz HG, Akgun Y, Bac B, Celik Y. Acute appendicitis in
pregnancy—risk factors associated with principal outcomes: a case
control study. Int J Surg 2007;5:192–7.
8 Wei P-L, Keller JJ, Liang H-H, Lin H-C. Acute appendicitis and
adverse pregnancy outcomes: a nationwide population-based study.
J Gastrointest Surg 2012;16:1204–11.
9 Silvestri MT, Pettker CM, Brousseau EC, Dick MA, Ciarleglio MM,
Erekson EA. Morbidity of appendectomy and cholecystectomy in
pregnant and nonpregnant women. Obstet Gynecol
2011;118:1261–70.
10 McGory ML, Zingmond DS, Tillou A, Hiatt JR, Ko CY, Cryer HM.
Negative appendectomy in pregnant women is associated with a
substantial risk of fetal loss. J Am Coll Surg 2007;205:534–40.
11 Andersson RE, Lambe M. Incidence of appendicitis during
pregnancy. Int J Epidemiol 2001;30:1281–5.
12 Blomqvist P, Ljung H, Nyren O, Ekbom A. Appendectomy in Sweden
1989–1993 assessed by the Inpatient Registry. J Clin Epidemiol
1998;51:859–65.
13 Guller U, Hervey S, Purves H, Muhlbaier LH, Peterson ED, Eubanks S,
et al. Laparoscopic versus open appendectomy: outcomes comparison
based on a large administrative database. Ann Surg 2004;239:43.
14 Sporn E, Petroski GF, Mancini GJ, Astudillo JA, Miedema BW,
Thaler K. Laparoscopic appendectomy: is it worth the cost? Trend
analysis in the US from 2000 to 2005. J Am Coll Surg
2009;208:179–85.
1514
15 Nguyen NT, Zainabadi K, Mavandadi S, Paya M, Stevens CM, Root J,
et al. Trends in utilization and outcomes of laparoscopic versus open
appendectomy. Am J Surg 2004;188:813–20.
16 Quan H, Parsons GA, Ghali WA. Validity of procedure codes in
International Classification of Diseases, 9th revision, clinical
modification administrative data. Med Care 2004;42:801–9.
17 Sharp HT. Gastrointestinal surgical conditions during pregnancy. Clin
Obstet Gynecol 1994;37:306–15.
18 Babler EA. Perforative appendicitis complicating pregnancy. with
report of a successful case. JAMA 1908;51:1310–14.
19 Weingold AB. Appendicitis in pregnancy. Clin Obstet Gynecol
1983;26:801–9.
20 McGee TM. Acute appendicitis in pregnancy. Aust N Z J Obstet
Gynaecol 1989;29:378–85.
21 Baer JL, Reis RA, Arens RA. Appendicitis in pregnancy. JAMA
1932;98:1359–64.
22 Brügger L, Rosella L, Candinas D, Güller U. Improving outcomes
after laparoscopic appendectomy: a population-based, 12-year trend
analysis of 7446 patients. Ann Surg 2011;253:309–13.
23 Walsh CA, Tang T, Walsh SR. Laparoscopic versus open
appendicectomy in pregnancy: a systematic review. Int J Surg
2008;6:339–44.
24 Kuy S, Roman SA, Desai R, Sosa JA. Outcomes following
cholecystectomy in pregnant and nonpregnant women. Surgery
2009;146:358–66.
25 Reedy MB, Kallen B, Kuehl TJ. Laparoscopy during pregnancy: a
study of five fetal outcome parameters with use of the Swedish
Health Registry. Am J Obstet Gynecol 1997;177:673–9.
26 Cohen-Kerem R, Railton C, Oren D, Lishner M, Koren G. Pregnancy
outcome following non-obstetric surgical intervention. Am J Surg
2005;190:467–73.
27 Young BC, Hamar BD, Levine D, Roque H. Medical management of
ruptured appendicitis in pregnancy. Obstet Gynecol 2009;114:
453–6.
28 Vasireddy A, Atkinson S, Shennan A, Bewley S. Surgical
management of appendicitis remains best option during pregnancy.
BMJ 2012;344:e3575.
29 Varadhan KK, Neal KR, Lobo DN. Safety and efficacy of antibiotics
compared with appendicectomy for treatment of uncomplicated
acute appendicitis: meta-analysis of randomised controlled trials.
BMJ 2012;344:e2156.
30 Andersson RE, Petzold MG. Nonsurgical treatment of appendiceal
abscess or phlegmon: a systematic review and meta-analysis. Ann
Surg 2007;246:741–8.
ª 2014 Royal College of Obstetricians and Gynaecologists