Training conference

 Subject : Acute Appendicitis in pregnancy

 Presenter:3rd year trainee Dr. Abdul Shokoor “Azizi”
 Director :Trainer Dr. Abdul Farid “Haidari”
 Location : Jamhoriat Hospital
 Department : General surgery
 Date :Sunday, 18 , 03, 1393
 Content of conference
 Defination
 Epidemiology and incidence
 Anatomical change of appendix
 Sign and symptoms
 Diagnosis
 Differential diagnosis
 Treatment
 Complication
 Definition:
Appendicitis:
 inflammation of the vermiform appendix caused by an
– obstruction
– structure
– fecal mass
– foreign body
– tumor
 Acute appendicitis in pregnancy
INTRODUCTION
Acute appendicitis is the most common surgical problem or
surgical emergency in pregnancy.
The diagnosis is challenging during preg bcz of the:
– relatively high prevalence of abd/GI discomfort
– anatomic changes - enlarged uterus
– physiologic leukocytosis of pregnancy.
 Continue
 The purpose of this study is
– to investigate the clinical presentation
– management
– outcome in patients who underwent appendectomy during preg.
 Epidemiology and incidence:
 Suggested relation with female sex hormones
 Reduced incidence in pregnancy, esp in the 3rd T (P E of preg?)
 Occurs in approx 1/1500 – 1/2000 pregnancies .
– 1st trimester – 30%
– 2nd trimester – 45%
– 3rd trimester – 25%
 Suspected 35%
 Confirmed in 65%
 Rupture more likely in the 3rd T - due to the delay in diagnosis
and intervention or treatment.
 Anatomical changes during pregnancy
location of the appendix - moves upwards - uterus enlarges
Position of appendix
12 w: McBurney’s point
24W: Iliac crest
36W: RUQ
Gravid uterus: enlarges 20 times:
1. Stretching of supporting ligaments & muscles.
2. Pressure on intra-abd structures & ant abd wall:
prevent irritation  decreased somatic pain & localization

3. Obstruct & inhibit the movement of the omentum

 Symptoms
 Pregnant women are less likely to have a classic presentation of
appendicitis than nonpregnant women.
 Pain – RLQ / Umblicus/ RUQ
1st T: RLQ
2nd T: At level of umbilicus
3rd T: Diffuse or RUQ
 Anorexia
 Nausea
 Vomiting
Not sensitive nor specific.
sensitive predictors of appendicitis in the late pregnancy
 Fever (50% not sensitive) (38.3ºC)
Continou….
Retrocecal appendix - dull ache in the RLQ rather than
localized tenderness.
pelvic appendix:
– urinary frequency and dysuria
– rectal symptoms, such as tenesmus and diarrhea.
 Physical examination
Signs
 All findings are less common in 3rd T
 Localization – gravid uterus lift & stretches
 Appendicular mass – uterus restrict omentum
 Peritoneal sign often absent
 tenderness ̴ 100% (RLQ, Umbilicus/diffused, RUQ)
 Rebound tenderness ̴ 55-75%
 Guarding or rigidity ̴ 50-65%
 Appendicular tenderness
 Low grade fever(50% late pregnancy)
 Diagnosis
Difficult
Symptoms
Signs
Lab
Imaging
Continue…
Pregnant: More difficult.
1. Nausea, vomiting, anorexia - normal pregnancy.
2. Uterus enlarges - appendix moves upward and
outward: pain& tenderness are "displaced“
3. Peritoneal signs often absent - esp late pregnancy
4. Fever in less than majority
5.Elevated WBC normal in pregnancy
6.Commonly is confused with other diseases DD
1. Accuracy of diagnosis
 inversely proportional to ges age.
Correct diagnosis
1st T: 77%
2nd, 3rd T: 57%
 Acceptable negative laparotomy rates
Non Preg: 15%
Pregnant: 35%
2. Perforation
 occurs twice as often in 3rd T as 1st or 2nd
 Delay in surgery > 24 h: ↑perforation: 0% vs 66%
Laboratory
1. WBC: Absolute number: not reliable
1st & 2nd T: 16,000
At labor: 20,000-30,000
2. U/A:
mild pyuria or mild hematuria: 20%
{extraluminal irritation of the ureter, not UTI}.
mild proteinuria
3. CRP
Imaging
Clinical diagnosis alone:54% Negative appendectomy rate
 1st Line:
– US
 2nd line:
– MRI
– CT
MRI
No adverse effects on fetus
Sensitivity: up to 100%
Specificity: 96%

CT:
Nonpregnant patients
– Sensitivity: 98%

 Pregnant:
 Sensitivity: >90%
 Specificity: >95%
Radiation dose:
– 0.3 rad
– Cumulative dose of 5 rad: safe
 Differential Diagnosis

Nonobstetric(surgical) Obstetric(gyneco)
 Pyelonephritis  Preterm Labor
 Urinary calculi
 Placental Abruption
 Cholecystitis
 Chorioamnionitis
 Cholelithiasis
 Pancreatitis  Adnexal Torsion
 Gastroenteritis  Round ligament pain
 Mesenteric Adenitis  Uterine rupture
 Pneumonia  Ectopic Pregnancy
 Meckel’s Diverticulum
 Peptic Ulcer
 Hernia
 Bowl obsruction
 Surgery
Indication
Preoperative
Anesthesia
Operative
open surgery
Laparoscopy
Postoperative
 Indication
When appendicitis is suspected: surgical exploration.
Risk of the surgery to mother & child is minimal/ delayed T.
Decision to operate on clinical grounds
clinical suspicion & diagnosis with imaging -prompt surgery.
 Anaestheia
Regional anesthetics:
NO association w/ fetal malformations
Risk of hypotension: decrease uterine blood flow
adequate fluids, lateral position
IV/Inhaled anesthetics:
teratogenicity
Potential teratogens best avoided
 Surgery considerations
 Surgical management
 Tilt table 15-30° to left {Facilitate exposure of cecum}
 ↓ uterine manipulation - ↓ risk of irritability and preterm labor
 External fetal monitoring – esp if perforation
 Lower threshold for surgery- consequences of delay are severe
 Surgical Approach:
 McBurney’s point (gridiron incision ) - choice in all T
 McBurney’s point (linz incision) - diagnosis is clear
 Midline incision - diffuse peritonitis or doubt diagnosis
– Accommodates unexpected surgical findings
– Can accommodate a CS if required
 Laparoscopy
 No increased risk to mother or foetus
 1st T:
similar perinatal outcomes
 2nd & 3rd T:
Controversy most experienced surgeons
Advantages
1. Useful in diagnosis
2. Less post-op complication
3. Earlier mobilization: post-op recovery: fewer
thromboembolic complications
4. Lower post-op narcotic use: less fetal depression
5. Shorter hospital stay
 Disadvantages
 difficult in late 2nd and 3rd T
 Risk of uterine injury w/ trochar.
 ↓ uterine blood flow d/t pneumoperitoneum
 Fetal CO2 absorbtion – fetal acidosis
 Should maintain intraabd pressure <12 mm Hg
 fetal exposure to smoke – CO from cautery or lasers -
evacuated
 uterine irritation from electrocautery
 Postoperative
1.Preterm contractions
– Common – but labor is rare
– Observe uterine contraction
2. Tocolytics(anti contraction)
terbutaline ,Ritodrine, salbutamol(beta2 agonist)
Anti-prostaglandin: fetal side effects
 Complications
 mortality of appendicitis complication-mortality of delay
 25% will perforated appendix
 66% perforation - delayed > 24 h
 0% perforation – first or < 24 h.
 Perforation is twice in 3rd T / 1st & 2nd T.
 risk of fetal loss is higher-appendix ruptured(36% vs
1.5%)
 Increased - increasing ges age and delay in diagnosis
 Complication…
1.Abortion: 15% 1st T
2. Fetal loss: 1.5-5.1%
3. Preterm labor: 13-22% 3rd T
4. Perforation
Non Pregnant : 4 -19%
Pregnant : Highest in 3rd T
1st T: 8%
2nd T: 12%
3rd T: 20%
 Continue…
 Non-perforated appendix:
• Fetal mortality: 3-5%
• Maternal mortality: 0.1%
 Perforated appendix:
• Fetal mortality: 20%-30%
• Maternal mortality: 1-4% {diffuse peritonitis}
• Preterm contraction{localized peritonitis}: 83%
 Reference
 Bailey & love manual of surgery
 SRB’s surgery
 Schewarz surgery
 Current surgery
 Washington manual of surgery
 Sabiston text book of surgery
 Acute abdomine
 www.slideshare.com
 www.docslide.net
 Google Wikipedia
Thanks!