Acute appendicitis in pregnancy
- Andrei Rebarber, MD
Andrei Rebarber, MD
- Clinical Professor, Department of Obstetrics & Gynecology
- Icahn School of Medicine at Mount Sinai
- President, Carnegie Imaging for Women, PLLC
- President, Maternal Fetal Medicine Assoc, PLLC
- Brian P Jacob, MD
Brian P Jacob, MD
- Associate Clinical Professor of Surgery
- Mount Sinai Medical Center
- Section Editors
- Charles J Lockwood, MD, MHCM
Charles J Lockwood, MD, MHCM
- Section Editor — Obstetrics
- Senior Vice President, USF Health
- Dean, Morsani College of Medicine
- Professor, Obstetrics and Gynecology
- University of South Florida
- Deborah Levine, MD
Deborah Levine, MD
- Section Editor — Imaging
- Professor of Radiology
- Director of Ob/Gyn Ultrasound
- Department of Radiology
- Beth Israel Deaconess Medical Center
- Martin Weiser, MD
Martin Weiser, MD
- Section Editor — Colorectal Surgery
- Professor of Surgery
- Weill Cornell Medical College
- Memorial Sloan Kettering Cancer Center
Acute appendicitis is the most common general surgical problem encountered during pregnancy . The diagnosis is particularly challenging during pregnancy because of the relatively high prevalence of abdominal/gastrointestinal discomfort, anatomic changes related to the enlarged uterus, and the physiologic leukocytosis of pregnancy. Appendiceal rupture occurs more frequently in pregnant women, especially in the third trimester, possibly because these challenges and reluctance to operate on pregnant women delay diagnosis and treatment [2,3].
Acute appendicitis is suspected in 1/600 to 1/1000 pregnancies and confirmed in 1/800 to 1/1500 pregnancies [4-7]. In a case control study of 53,000 women undergoing appendectomy, pregnant women were less likely to have appendicitis than age-matched, nonpregnant women . The incidence of appendicitis was slightly higher in the second trimester than in the first and third trimesters or postpartum. In addition, cohort study of over 350,000 pregnancies reported that the rate of acute appendicitis was 35 percent lower during the antepartum period than the time outside of pregnancy. This study reported the lowest rates of appendicitis during the third trimester . For women aged 15 to 34 years, there was no increased risk in postpartum appendicitis compared with the time outside of pregnancy. In contrast, an 84 percent increased risk of postpartum appendicitis was reported for women older than 35 years.
Patient presentation — In the "classic" presentation, the patient describes the onset of abdominal pain as the first symptom. The pain is periumbilical initially and then migrates to the right lower quadrant as the inflammatory process progresses [10-12]. Anorexia, nausea and vomiting, if present, follow the onset of pain. Fever up to 101.0ºF (38.3ºC) and leukocytosis develop later.
However, many patients have a nonclassical presentation, with symptoms such as heartburn, bowel irregularity, flatulence, malaise, or diarrhea. If the appendix is retrocecal, patients often complain of a dull ache in the right lower quadrant rather than localized tenderness. Rectal or vaginal examination in such patients is more likely to elicit pain than abdominal examination. A pelvic appendix can cause tenderness below McBurney's point (described below); these patients often complain of urinary frequency and dysuria or rectal symptoms, such as tenesmus and diarrhea. The spectrum of clinical and laboratory findings associated with acute appendicitis is described in detail separately . (See "Acute appendicitis in adults: Clinical manifestations and differential diagnosis".)
Pregnant women are less likely to have a classic presentation of appendicitis than nonpregnant women, especially in late pregnancy. The most common symptom of appendicitis, ie, right lower quadrant pain, occurs close to McBurney's point in the majority of pregnant women, regardless of the stage of pregnancy [5,14,15]; however, the location of the appendix migrates a few centimeters cephalad with the enlarging uterus, so in the third trimester, pain may localize to the mid or even the upper right side of the abdomen [16-18].
- Tamir IL, Bongard FS, Klein SR. Acute appendicitis in the pregnant patient. Am J Surg 1990; 160:571.
- Bickell NA, Aufses AH Jr, Rojas M, Bodian C. How time affects the risk of rupture in appendicitis. J Am Coll Surg 2006; 202:401.
- Weingold AB. Appendicitis in pregnancy. Clin Obstet Gynecol 1983; 26:801.
- Andersen B, Nielsen TF. Appendicitis in pregnancy: diagnosis, management and complications. Acta Obstet Gynecol Scand 1999; 78:758.
- 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.
- Mazze RI, Källén B. Appendectomy during pregnancy: a Swedish registry study of 778 cases. Obstet Gynecol 1991; 77:835.
- 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.
- Andersson RE, Lambe M. Incidence of appendicitis during pregnancy. Int J Epidemiol 2001; 30:1281.
- Zingone F, Sultan AA, Humes DJ, West J. Risk of acute appendicitis in and around pregnancy: a population-based cohort study from England. Ann Surg 2015; 261:332.
- Lee SL, Walsh AJ, Ho HS. Computed tomography and ultrasonography do not improve and may delay the diagnosis and treatment of acute appendicitis. Arch Surg 2001; 136:556.
- Birnbaum BA, Wilson SR. Appendicitis at the millennium. Radiology 2000; 215:337.
- Chung CH, Ng CP, Lai KK. Delays by patients, emergency physicians, and surgeons in the management of acute appendicitis: retrospective study. Hong Kong Med J 2000; 6:254.
- Richards C, Daya S. Diagnosis of acute appendicitis in pregnancy. Can J Surg 1989; 32:358.
- Hodjati H, Kazerooni T. Location of the appendix in the gravid patient: a re-evaluation of the established concept. Int J Gynaecol Obstet 2003; 81:245.
- Popkin CA, Lopez PP, Cohn SM, et al. The incision of choice for pregnant women with appendicitis is through McBurney's point. Am J Surg 2002; 183:20.
- Oto A, Srinivasan PN, Ernst RD, et al. Revisiting MRI for appendix location during pregnancy. AJR Am J Roentgenol 2006; 186:883.
- Pates JA, Avendanio TC, Zaretsky MV, et al. The appendix in pregnancy: confirming historical observations with a contemporary modality. Obstet Gynecol 2009; 114:805.
- House JB, Bourne CL, Seymour HM, Brewer KL. Location of the appendix in the gravid patient. J Emerg Med 2014; 46:741.
- McBurney, C. Experience with early operative interference in cases of disease of the vermiform appendix. NY Med J 1889; 50:676.
- Cunningham FG, McCubbin JH. Appendicitis complicating pregnancy. Obstet Gynecol 1975; 45:415.
- McGee TM. Acute appendicitis in pregnancy. Aust N Z J Obstet Gynaecol 1989; 29:378.
- Sivanesaratnam V. The acute abdomen and the obstetrician. Baillieres Best Pract Res Clin Obstet Gynaecol 2000; 14:89.
- Mahmoodian S. Appendicitis complicating pregnancy. South Med J 1992; 85:19.
- Coleman C, Thompson JE Jr, Bennion RS, Schmit PJ. White blood cell count is a poor predictor of severity of disease in the diagnosis of appendicitis. Am Surg 1998; 64:983.
- Tehrani HY, Petros JG, Kumar RR, Chu Q. Markers of severe appendicitis. Am Surg 1999; 65:453.
- Thompson MM, Underwood MJ, Dookeran KA, et al. Role of sequential leucocyte counts and C-reactive protein measurements in acute appendicitis. Br J Surg 1992; 79:822.
- Lurie S, Rahamim E, Piper I, et al. Total and differential leukocyte counts percentiles in normal pregnancy. Eur J Obstet Gynecol Reprod Biol 2008; 136:16.
- KUVIN SF, BRECHER G. Differential neutrophil counts in pregnancy. N Engl J Med 1962; 266:877.
- Tundidor Bermúdez AM, Amado Diéguez JA, Montes de Oca Mastrapa JL. [Urological manifestations of acute appendicitis]. Arch Esp Urol 2005; 58:207.
- Puskar D, Bedalov G, Fridrih S, et al. Urinalysis, ultrasound analysis, and renal dynamic scintigraphy in acute appendicitis. Urology 1995; 45:108.
- Sugita K, Kobayashi S, Mutsuga N, et al. Microsurgery for acoustic neurinoma--lateral position and preservation of facial and cochlear nerves. Neurol Med Chir (Tokyo) 1979; 19:637.
- Bailey LE, Finley RK Jr, Miller SF, Jones LM. Acute appendicitis during pregnancy. Am Surg 1986; 52:218.
- Sand M, Bechara FG, Holland-Letz T, et al. Diagnostic value of hyperbilirubinemia as a predictive factor for appendiceal perforation in acute appendicitis. Am J Surg 2009; 198:193.
- Smith MP, Katz DS, Lalani T, et al. ACR Appropriateness Criteria® Right Lower Quadrant Pain--Suspected Appendicitis. Ultrasound Q 2015; 31:85.
- Barloon TJ, Brown BP, Abu-Yousef MM, et al. Sonography of acute appendicitis in pregnancy. Abdom Imaging 1995; 20:149.
- Lim HK, Bae SH, Seo GS. Diagnosis of acute appendicitis in pregnant women: value of sonography. AJR Am J Roentgenol 1992; 159:539.
- Pedrosa I, Lafornara M, Pandharipande PV, et al. Pregnant patients suspected of having acute appendicitis: effect of MR imaging on negative laparotomy rate and appendiceal perforation rate. Radiology 2009; 250:749.
- Wallace CA, Petrov MS, Soybel DI, et al. Influence of imaging on the negative appendectomy rate in pregnancy. J Gastrointest Surg 2008; 12:46.
- Shetty MK, Garrett NM, Carpenter WS, et al. Abdominal computed tomography during pregnancy for suspected appendicitis: a 5-year experience at a maternity hospital. Semin Ultrasound CT MR 2010; 31:8.
- 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.
- Pedrosa I, Levine D, Eyvazzadeh AD, et al. MR imaging evaluation of acute appendicitis in pregnancy. Radiology 2006; 238:891.
- Cobben LP, Groot I, Haans L, et al. MRI for clinically suspected appendicitis during pregnancy. AJR Am J Roentgenol 2004; 183:671.
- Israel GM, Malguria N, McCarthy S, et al. MRI vs. ultrasound for suspected appendicitis during pregnancy. J Magn Reson Imaging 2008; 28:428.
- Lehnert BE, Gross JA, Linnau KF, Moshiri M. Utility of ultrasound for evaluating the appendix during the second and third trimester of pregnancy. Emerg Radiol 2012; 19:293.
- Williams R, Shaw J. Ultrasound scanning in the diagnosis of acute appendicitis in pregnancy. Emerg Med J 2007; 24:359.
- Kastenberg ZJ, Hurley MP, Luan A, et al. Cost-effectiveness of preoperative imaging for appendicitis after indeterminate ultrasonography in the second or third trimester of pregnancy. Obstet Gynecol 2013; 122:821.
- Theilen LH, Mellnick VM, Longman RE, et al. Utility of magnetic resonance imaging for suspected appendicitis in pregnant women. Am J Obstet Gynecol 2015; 212:345.e1.
- Kanal E, Barkovich AJ, Bell C, et al. ACR guidance document for safe MR practices: 2007. AJR Am J Roentgenol 2007; 188:1447.
- Duke E, Kalb B, Arif-Tiwari H, et al. A Systematic Review and Meta-Analysis of Diagnostic Performance of MRI for Evaluation of Acute Appendicitis. AJR Am J Roentgenol 2016; 206:508.
- Burke LM, Bashir MR, Miller FH, et al. Magnetic resonance imaging of acute appendicitis in pregnancy: a 5-year multiinstitutional study. Am J Obstet Gynecol 2015; 213:693.e1.
- Ames Castro M, Shipp TD, Castro EE, et al. The use of helical computed tomography in pregnancy for the diagnosis of acute appendicitis. Am J Obstet Gynecol 2001; 184:954.
- Long SS, Long C, Lai H, Macura KJ. Imaging strategies for right lower quadrant pain in pregnancy. AJR Am J Roentgenol 2011; 196:4.
- Hurwitz LM, Yoshizumi T, Reiman RE, et al. Radiation dose to the fetus from body MDCT during early gestation. AJR Am J Roentgenol 2006; 186:871.
- Wagner LK, Huda W. When a pregnant woman with suspected appendicitis is referred for a CT scan, what should a radiologist do to minimize potential radiation risks? Pediatr Radiol 2004; 34:589.
- Damilakis J, Perisinakis K, Voloudaki A, Gourtsoyiannis N. Estimation of fetal radiation dose from computed tomography scanning in late pregnancy: depth-dose data from routine examinations. Invest Radiol 2000; 35:527.
- Terasawa T, Blackmore CC, Bent S, Kohlwes RJ. Systematic review: computed tomography and ultrasonography to detect acute appendicitis in adults and adolescents. Ann Intern Med 2004; 141:537.
- Basaran A, Basaran M. Diagnosis of acute appendicitis during pregnancy: a systematic review. Obstet Gynecol Surv 2009; 64:481.
- Young BC, Hamar BD, Levine D, Roqué H. Medical management of ruptured appendicitis in pregnancy. Obstet Gynecol 2009; 114:453.
- Silvestri MT, Pettker CM, Brousseau EC, et al. Morbidity of appendectomy and cholecystectomy in pregnant and nonpregnant women. Obstet Gynecol 2011; 118:1261.
- Babaknia A, Parsa H, Woodruff JD. Appendicitis during pregnancy. Obstet Gynecol 1977; 50:40.
- McGory ML, Zingmond DS, Tillou A, et al. Negative appendectomy in pregnant women is associated with a substantial risk of fetal loss. J Am Coll Surg 2007; 205:534.
- Ito K, Ito H, Whang EE, Tavakkolizadeh A. Appendectomy in pregnancy: evaluation of the risks of a negative appendectomy. Am J Surg 2012; 203:145.
- Vasireddy A, Atkinson S, Shennan A, Bewley S. Management of appendicitis. Surgical management remains best option during pregnancy. BMJ 2012; 344:29.
- Curet MJ, Allen D, Josloff RK, et al. Laparoscopy during pregnancy. Arch Surg 1996; 131:546.
- Gurbuz AT, Peetz ME. The acute abdomen in the pregnant patient. Is there a role for laparoscopy? Surg Endosc 1997; 11:98.
- Affleck DG, Handrahan DL, Egger MJ, Price RR. The laparoscopic management of appendicitis and cholelithiasis during pregnancy. Am J Surg 1999; 178:523.
- Wu JM, Chen KH, Lin HF, et al. Laparoscopic appendectomy in pregnancy. J Laparoendosc Adv Surg Tech A 2005; 15:447.
- Donkervoort SC, Boerma D. Suspicion of acute appendicitis in the third trimester of pregnancy: pros and cons of a laparoscopic procedure. JSLS 2011; 15:379.
- Holzer T, Pellegrinelli G, Morel P, Toso C. Appendectomy during the third trimester of pregnancy in a 27-year old patient: case report of a "near miss" complication. Patient Saf Surg 2011; 5:11.
- Machado NO, Grant CS. Laparoscopic appendicectomy in all trimesters of pregnancy. JSLS 2009; 13:384.
- Lemieux P, Rheaume P, Levesque I, et al. Laparoscopic appendectomy in pregnant patients: a review of 45 cases. Surg Endosc 2009; 23:1701.
- Sadot E, Telem DA, Arora M, et al. Laparoscopy: a safe approach to appendicitis during pregnancy. Surg Endosc 2010; 24:383.
- Hannan MJ, Hoque MM, Begum LN. Laparoscopic appendectomy in pregnant women: experience in Chittagong, Bangladesh. World J Surg 2012; 36:767.
- Kirshtein B, Perry ZH, Avinoach E, et al. Safety of laparoscopic appendectomy during pregnancy. World J Surg 2009; 33:475.
- Jeong JS, Ryu DH, Yun HY, et al. Laparoscopic appendectomy is a safe and beneficial procedure in pregnant women. Surg Laparosc Endosc Percutan Tech 2011; 21:24.
- Al-Fozan H, Tulandi T. Safety and risks of laparoscopy in pregnancy. Curr Opin Obstet Gynecol 2002; 14:375.
- Guidelines Committee of the Society of American Gastrointestinal and Endoscopic Surgeons, Yumi H. Guidelines for diagnosis, treatment, and use of laparoscopy for surgical problems during pregnancy: this statement was reviewed and approved by the Board of Governors of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), September 2007. It was prepared by the SAGES Guidelines Committee. Surg Endosc 2008; 22:849.
- Walsh CA, Tang T, Walsh SR. Laparoscopic versus open appendicectomy in pregnancy: a systematic review. Int J Surg 2008; 6:339.
- Wilasrusmee C, Sukrat B, McEvoy M, et al. Systematic review and meta-analysis of safety of laparoscopic versus open appendicectomy for suspected appendicitis in pregnancy. Br J Surg 2012; 99:1470.
- Walker HG, Al Samaraee A, Mills SJ, Kalbassi MR. Laparoscopic appendicectomy in pregnancy: a systematic review of the published evidence. Int J Surg 2014; 12:1235.
- Sachs A, Guglielminotti J, Miller R, et al. Risk Factors and Risk Stratification for Adverse Obstetrical Outcomes After Appendectomy or Cholecystectomy During Pregnancy. JAMA Surg 2017.
- Choi JJ, Mustafa R, Lynn ET, Divino CM. Appendectomy during pregnancy: follow-up of progeny. J Am Coll Surg 2011; 213:627.
- CLINICAL FEATURES
- Patient presentation
- - Ultrasonography
- - Magnetic resonance imaging
- - Computed tomography
- DIFFERENTIAL DIAGNOSIS
- MANAGEMENT AND SHORT-TERM OUTCOME
- Perforated appendix
- - Free perforation
- - Walled-off perforation
- SURGICAL APPROACH
- Open appendectomy
- Laparoscopic appendectomy
- LONG-TERM OUTCOME
- SUMMARY AND RECOMMENDATIONS