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Pitfalls in Diagnosis of Acute Appendicitis in Pregnancy Increase Risk to Fetus and Mother

Pitfalls in Diagnosis of Acute Appendicitis in Pregnancy Increase Risk to Fetus and Mother

Acute appendicitis is the most common non-obstetrical emergency in pregnancy, occurring in up to 1 in 1,500 pregnancies. Moreover, appendectomy is the most common general surgical procedure performed on pregnant women.

With signs and symptoms that are similar to those of pregnancy itself, appendicitis is difficult to diagnose in pregnant women and to make bad worse, any delay in diagnosis increases the risk of fetal-maternal mortality.
The major predictor of mortality is perforation of the appendix; the risk of perforation
increases over the term of pregnancy.
Surgeons have historically taken an aggressive approach to the treatment of suspected appendicitis in pregnant women in order to reduce the risk and possible consequences of a ruptured appendix.

Why is it difficult to diagnose acute appendicitis during pregnancy?

It's well known that right iliac fossa (RIF) pain, is the most common symptom of acute appendicitis. But as pregnancy develops, the location of pain will be changed in accordance, and this symptom would become less reliable in diagnosing appendicitis.
In addition, GI symptoms of appendicitis such as anorexia, nausea, vomiting, and abdominal discomfortmimic those of early pregnancy, and also the median leukocyte count in pregnancy would be elevated (around 11500/mm3), and that makes the diagnosis even more difficult.

Radiological Imaging:

High-resolution ultrasound with graded compression technique has been used to aid in the diagnosis of appendicitis in pregnancy.
According to sonographic findings, a normal appendix is of 6 mm diameter and is compressible. Ultrasound findings in pregnancy have accuracy similar to the accuracy of sonographic findings in the non-pregnant woman, especially when used in the first and second trimesters. A normal ultrasound, however, does not always rule out appendicitis during pregnancy. There are selected limitations with ultrasound that relate to operator skill level and difficulty in interpretation in women who are obese for example. Currently, computed tomography scan is being used in non-pregnant women with symptoms suggestive of appendicitis and may be warranted in extreme cases in pregnancy. No studies have been published to date on use of computed tomography scanning in pregnant women with appendicitis.


Laparoscopic Appendectomy
Prompt surgery, along with perioperative anti-biotics, is recommended to prevent perforation and to improve the overall outcome for mother and fetus.
Under appropriate conditions, laparoscopic appendectomy can be as safe as open appendectomy.

 Laparoscopic surgery has the advantage of allowing reduced narcotic use and hence less fetal depression, better intraoperative visualization and exposure, less postoperative pain, early return of bowel function, early ambulation, and shorter postoperative stays. Some concerns with laparoscopy have centered on the increased intra-abdominal pressure and the use of carbon dioxide pneumoperitoneum.

A concern was also raised when one study reported that laparoscopic surgery resulted in four fetal deaths (out of seven surgeries). Despite concerns, good outcomes have increasingly been reported. Rates of fetal loss, rates of other complications, and length of procedure were similar for laparoscopic surgery and open appendectomy.

No statistical difference was found between open and laparoscopic appendectomy when compared for gestational duration, Apgar scores, and birth weights. One source demonstrated the feasibility of laparoscopic surgery during all trimesters; others have described it as safe during the first two trimesters and generally contraindicated during the third trimester. The second trimester has been reported the safest for performing laparoscopy.

Other complications
Preterm labour is a complication of appendicitis during pregnancy. One study reported the rate of preterm contractions and preterm labour in third-trimester patients as 83% and 13%, respectively. Reported rates of postoperative preterm labour are between 13% and 16% in third-trimester patients and 25% in second-trimester patients. While one study reported no increased risk of preterm delivery secondary to surgery, another reported an increased risk of delivery during the postoperative week when the appendectomy was performed after 23 weeks gestation. Another study noted an increase in fetal loss during the week following appendectomies performed before 24 weeks gestation.

According to one study, appendectomy during pregnancy was associated with a decrease in mean birth weight and an increase in the number of live-born infants dying within the first week. This study found no increase in stillborn infants or in congenitally malformed infants.

Perforated appendix
While delay in diagnosis is usually thought to result in a perforated appendix, some studies found no association between duration of symptoms and incidence of perforation and no correlation between time to surgery and incidence of perforation. Complications of appendicitis, including perforation, increase by trimester, and a ruptured appendix results in increased fetal morbidity and mortality. The rate of fetal loss in uncomplicated appendicitis ranges from 0 to 1.5% and in ruptured appendicitis from 20% to 35%.Perforation can also result in an increased incidence of wound infection and an increased risk of generalized peritonitis because the omentum cannot isolate the infection.

Preterm labour is common in cases of ruptured appendix during the third trimester. Maternal mortality is extremely unusual; it increases up to 4% with advanced gestation and perforation.


Accurate diagnosis of acute appendicitis in pregnant women is comparable to that of the general population.
There is a higher negative appendectomy rate in the 2nd trimester. Careful history taking and physical examination remains important in diagnosing acute appendicitis in addition to modern imaging tools. Early appendectomy prevents complicated conditions.
There are more obstetric events in pregnant patients of true appendicitis. Due to the limited number of cases, more studies are needed to establish clinical evidence.

اضغط هنا للقراءة باللغة العربية

Prepared by: Dr. Adel M.Al-Haj Saleh

Source :

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