Acute appendicitis: Pregnancy complicates this diagnosis:

Reasons for Undesirable Pregnancy Outcomes among Women with Appendicitis: The Experience of a Tertiary Center

Background

Although laparoscopic appendectomy increases its popularity today, the answer to the question of whether to perform open or laparoscopic appendectomy during pregnancy is appropriate in many studies, and the choice of surgery depends on the surgeon. Herein, we aimed to evaluate the variables that affect undesirable pregnancy outcomes that occur as a result of appendicitis during pregnancy.

Methods

Seventy-eight pregnant patients with acute appendicitis who underwent laparoscopic or open technique intervention enrolled in this retrospective study. In addition to the demographic structure of the patients, surgical technique, the number of pregnancies, multiple pregnancy status, surgical pathologies, laboratory values, radiological imaging methods, and length of hospital stay were evaluated. The severity of appendicitis was classified according to the pathology results. The patients were divided into two groups according to the outcomes of their pregnancy. Preterm delivery and abortion involved in the study as a single complication section.

Results

The mean age of the pregnant patients was 28.6 ± 5. Of the 78 pregnant women with appendicitis, 47.4% had their first pregnancy, 37.2% had their second pregnancy, and 15.4% had 3 or more pregnancies. The preterm delivery and abortus were 19.5% in the open appendectomy (OA) group and 16.2% in the laparoscopic appendectomy (LA) group. No statistically significant difference was detected in this group in terms of appendicitis pathology triggering preterm delivery or abortion (p 0.075). When white blood count (WBC) and C-reactive protein (CRP) were evaluated by laboratory findings, CRP was found to be statistically significantly higher in patients with preterm birth (p 0.042).

Conclusion

Consequently, acute appendicitis may cause serious intra-abdominal infection and inflammation in addition to the complexity of the diagnosis due to the nature of pregnancy, as well as undesired pregnancy outcomes with the surgical technique, or independently with other variables.

Could laparoscopic appendectomy in pregnant women affect obstetric outcomes? A multicenter study

PURPOSE

The purpose of this study was to compare the perioperative and obstetric outcomes of pregnant women between laparoscopic surgery and open surgery and to evaluate the predictive factors for overall obstetric outcomes.

METHODS

We retrospectively reviewed the medical records of pregnant women who underwent appendectomy between January 2008 and June 2015 at six hospitals affiliated to Hallym University.

RESULTS

Eighty patients were evaluated. Twenty-four underwent laparoscopic appendectomy (LA) and 56 underwent open appendectomy (OA). There were no significant differences in the patients' characteristics and gestational age at surgery between the two groups. Operation time, time to flatus, and time to soft food intake were similar in both groups. The length of stay was shorter in the LA group than in the OA group (5.1 vs 8.1 days, P = 0.044). Gestational age at delivery, birth weight, and delivery type were similar in both groups. There was no significant difference in overall obstetric poor outcome (20.8 vs 14.3 %, P = 0.516), including preterm delivery (8.3 vs 7.1 %, P = 1.000) and fetal loss (12.5 vs 7.1 %, P = 0.350). Multivariable analysis revealed that fever >38 °C (P = 0.022) and maternal age (P = 0.044) were independent predictors for the overall poor outcomes.

CONCLUSIONS

LA was associated with shorter length of stay compared with OA, but perioperative and obstetric outcomes were similar with both procedures. LA can be safely performed in pregnant women in any trimester.

Laparoscopic appendectomy versus open appendectomy in pregnancy: a population-based analysis of maternal outcome

BACKGROUND

Laparoscopic appendectomy (LA) is the standard treatment of acute appendicitis for the general population; however, there is still some doubt regarding its safety for pregnant patients. Therefore, the purpose of this study is to investigate and compare the maternal outcome of pregnant patients with acute appendicitis following either an open appendectomy (OA) or LA from a population-based database.

METHODS

This study is based on the National Health Insurance Research Database. Patients with both ICD-9-CM codes for appendicitis (540.9, 540.0, and 540.1) and pregnancy (V22) in the same admission were considered to have acute appendicitis during pregnancy. These patients were divided into three groups according to the type of treatment: LA, OA, and non-operative treatment. Outcome measures that were compared between the groups included maternal complications such as preterm labor, abortion, and the need of cesarean section. Besides, the differences of medical expenditure and length of hospital stay between the groups were also analyzed.

RESULTS

From 2005 to 2010, a total of 859 pregnant women who had acute appendicitis were identified. They had increased risks for preterm labor, abortion, and increased requirement of cesarean section compared to the control group (i.e., those without acute appendicitis). Among the three groups, the non-operated group has the highest risk of preterm labor. Patients who underwent LA did not have any increased risk of maternal complications compared to the OA group. Furthermore, LA patients had shorter hospital stay than OA.

CONCLUSION

Compared to non-operative treatment, appendectomy is the preferred treatment for pregnant patients who have acute appendicitis. LA can be performed safely in pregnant patients without bringing additional maternal complications compared to OA.

A case of Hickam's dictum: concurrent appendicitis and ectopic pregnancy

BACKGROUND

Both ectopic pregnancy and appendicitis are surgical emergencies that should be considered in female patients who present with right lower-quadrant pain. Deciding on the appropriate imaging modality in the pregnant patient can be difficult. The challenge of diagnosis is compounded when one considers that both pathologies may be present simultaneously.

OBJECTIVES

We present a case demonstrating co-occurrence of ectopic pregnancy and appendicitis and suggest an algorithm for evaluation and management of cases with this presentation.

CASE REPORT

A 25-year-old woman presented to the Emergency Department complaining of 3 days of abdominal pain and a positive urine pregnancy test. After consultation with Obstetrics/Gynecology (OB/GYN) and General Surgery, a nondiagnostic pelvic ultrasound (US), and a magnetic resonance imaging (MRI) study consistent with appendiceal inflammation, the patient was taken to the operating room for a laparoscopic appendectomy. While removing the inflamed appendix, the general surgeon noted the right fallopian tube was enlarged, suggestive of an ectopic pregnancy. OB/GYN was consulted again intraoperatively and noted a right ectopic pregnancy. The surgical intervention was completed with a right salpingectomy.

CONCLUSION

In a pregnant patient with right lower-quadrant pain, the differential diagnosis includes ectopic pregnancy, acute appendicitis, or in rare cases, both.

Appendicitis in pregnancy: an ongoing diagnostic dilemma

INTRODUCTION

Appendicitis in pregnancy (AIP) is the most common nonobstetric cause of an acute abdomen requiring surgical intervention. Diagnostic difficulties arising from gestational symptoms compound the risk of foetal loss after negative appendicectomy and exponentially increase the risk to mother and foetus with delay in genuine cases. In this article, we investigate the symptoms and signs of AIP and attempt to identify consistent clinical features and review the role of imaging in diagnosis.

METHOD

MEDLINE and PubMed were searched for case-control studies recording preoperative symptoms/signs suggestive of AIP, as well as appendiceal pathology. Combined likelihood and odds ratios (OR) were created for clinical features across homogenous papers. Papers examining the use of laparoscopy, ultrasound (US), computerized tomography (CT) and magnetic resonance imaging (MRI) were assessed qualitatively.

RESULTS

Seven papers met the inclusion criteria for the analysis of consistent clinical features (450 patients). The only symptoms or signs significantly associated with a diagnosis of appendicitis were nausea (OR: 2.21, 95%CI: 1.34-3.66), vomiting (OR: 0.82-15.6 range) and peritonism (OR: 1.80, 95%CI: 1.06-3.04). US, CT and MRI have all been used to successfully diagnose AIP. Laparoscopic appendicectomy has been safely undertaken in pregnancy.

CONCLUSION

Appendicitis will continue to challenge the diagnostic acumen of surgeons. Whilst useful, consensus regarding the safety of laparoscopy, CT and MRI in pregnancy is yet to be achieved.

Appendectomy during pregnancy in sickle cell disease patients

BACKGROUND/AIM

Acute appendicitis during pregnancy is the most common problem encountered in general surgery. However, limited data are available regarding acute appendicitis in pregnant sickle cell disease (SCD) patients. We aimed to study was the clinical presentation, management, and outcome in SCD patients who underwent appendectomy for suspected acute appendicitis during pregnancy.

MATERIALS AND METHODS

Between January 1998 and December 2006, 65 pregnant patients with clinically suspected appendicitis underwent surgery at our hospital of whom 11 were SCD patients. Data collected retrospectively included age, gestational stage, clinical signs and symptoms, operative findings, and complications.

RESULTS

Eleven out of 65 (16.9%) were SCD patients. The mean age in the SCD group was 22.5 years while the mean gravida and parity values were 2.0 and 1.1, respectively. The mean HbS, HbF, and HbA2 values were 71.1, 26.2, and 2.6%, respectively. Abdominal pain and vomiting were the most common presenting symptoms regardless of the gestational age. Abdominal and rebound tenderness were the most common physical signs. The mean operative time was 49 min (range: 35-125 min) and the average length of postoperative hospital stay was 4.7 days (2-8 days). There was no maternal death but one patient had spontaneous abortion during the first trimester, two days after the operation. Two patients had premature, postoperative delivery at 30 and 31 weeks of gestation.

CONCLUSION

The clinical manifestations and diagnosis of appendicitis in sickler pregnant patients are similar to those in nonsickler pregnant patients.