Acute appendicitis in pregnancy
- William H Barth, Jr, MD
William H Barth, Jr, MD
- Associate Professor
- Harvard Medical School
- Joel E Goldberg, MD, FACS
Joel E Goldberg, MD, FACS
- Assistant Professor of Surgery
- Harvard Medical School
- 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
- Co-Chief of Ultrasound
- Beth Israel Deaconess Medical Center
- Martin Weiser, MD
Martin Weiser, MD
- Section Editor — Colorectal Surgery
- Attending Surgeon
- 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, pregnant women were less likely to have appendicitis than age-matched, nonpregnant women (OR 0.78, 95% CI 0.73-0.82) and the incidence was slightly higher in the second trimester than in the first and third trimesters or postpartum .
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 [9-11]. 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 [5,13,14]; 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 [15-17].
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- 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
- LONG-TERM OUTCOME
- SUMMARY AND RECOMMENDATIONS