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Appendicitis in pregnancy

INTRODUCTION

Acute appendicitis is the most common general surgical problem encountered during pregnancy [1]. The incidence ranges from 0.06 to 0.1 percent, or 1 in 1500 deliveries [2-4]. However, pregnant women appear to be less likely to have appendicitis than age-matched, nonpregnant women [5].

CLINICAL MANIFESTATIONS AND DIAGNOSTIC EVALUATION

Overview — The clinical manifestations and diagnostic evaluation of appendicitis in pregnancy are similar to those in nonpregnant individuals and are described in detail separately [6]. (See "Appendicitis in adults: Clinical manifestations and diagnosis".)

Certain points, however, apply to pregnant women:

  • There is a slightly higher rate of appendicitis in the second trimester than in the first and third trimesters or postpartum [5]. An infected appendix appears to be more likely to rupture during pregnancy, especially in the third trimester, possibly because of delay in diagnosis and intervention [7,8].
  • Right lower quadrant pain is the most common symptom of appendicitis and should alert the physician caring for the pregnant patient to strongly consider this diagnosis. Although the location of the appendix migrates a few centimeters cephalad with the enlarging uterus [9,10], the most common symptom of appendicitis, ie, right lower quadrant pain, occurs close to McBurney's point in the vast majority of pregnant women, regardless of the stage of pregnancy [4,11,12].

The differential diagnosis includes the causes of abdominal pain in nonpregnant individuals (table 1), as well as pregnancy-related causes of abdominal pain, such as round ligament syndrome, labor, abruption, ectopic pregnancy, and uterine rupture (see individual topic reviews). The latter three diagnoses, in contrast to appendicitis, are often accompanied by uterine bleeding. In addition, abruption and uterine rupture are commonly associated with fetal heart rate abnormalities. The diagnosis of acute appendicitis in a laboring patient is especially difficult and requires a high index of suspicion. Labor can be associated with pain that may be lateralized, fever if chorioamnionitis is present, leukocytosis, and vomiting.
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