What is the management of appendicitis in pregnant patients?

Management of Appendicitis in Pregnant Patients

Appendicitis in pregnant patients requires prompt diagnosis and surgical intervention, preferably via laparoscopic appendectomy within 24 hours of admission, to minimize maternal and fetal complications.

Diagnosis

Clinical Presentation

• Abdominal pain is the most common symptom (95% of cases) 1
• Uterine contractions and pain migration from periumbilical region to right lower quadrant are significant indicators of appendicitis 2
• Note that normal physiological changes of pregnancy can confound diagnosis:
  • Displacement of appendix by enlarging uterus
  • Leukocytosis, nausea, and vomiting are common in both normal pregnancy and appendicitis

Diagnostic Imaging Algorithm

1. Ultrasound (US) - First-line imaging modality

   • Safe in pregnancy with no radiation exposure 3
   • Diagnostic in approximately 58% of cases 3
   • Limited by body habitus and anatomic changes of pregnancy

2. MRI - Second-line imaging when US is inconclusive

   • High sensitivity (96.8%) and specificity (99.2%) for appendicitis in pregnancy 3
   • No radiation exposure to fetus
   • Combination of US and MRI is the most commonly used approach (41% of cases) 3

3. CT - Reserved for when MRI is unavailable

   • Should be used judiciously due to radiation exposure
   • Low-dose CT with oral contrast can be considered when MRI is not immediately available 3

Laboratory Tests

• Complete blood count and urinalysis
• Note: Leukocytosis alone is not reliable for diagnosis as it occurs in normal pregnancy 2

Management

Timing of Surgery

• Prompt surgical intervention is critical
• Appendectomy should be performed within 24 hours of admission 3
• Delaying surgery beyond 24 hours increases risk of perforation and adverse outcomes 3
• Short in-hospital delay with observation and repeated US in equivocal cases is acceptable and does not increase maternal or fetal risk 3

Surgical Approach

• Laparoscopic appendectomy is preferred over open appendectomy 3
• Benefits of laparoscopy in pregnancy:
  • Shorter hospital stay
  • Lower incidence of surgical site infections
  • Comparable safety in terms of fetal loss and preterm delivery 3, 4
  • Study of 45 pregnant patients showed low rate of preterm delivery and no fetal loss after laparoscopic appendectomy 4

Antibiotic Therapy

• All patients diagnosed with appendicitis should receive antimicrobial therapy 3
• Antibiotics should cover facultative and aerobic gram-negative organisms and anaerobes 3
• For uncomplicated appendicitis: short-course perioperative antibiotics
• For complicated appendicitis: extended course based on clinical response

Complications and Outcomes

Maternal Complications

• Surgical site infections
• Intra-abdominal abscess
• Overall maternal morbidity is low with prompt diagnosis and treatment 5

Fetal Complications

• Premature delivery is the most significant risk:
  • Occurs in approximately 14% of second trimester cases 2
  • Risk present with both perforated appendicitis and negative appendectomy 5
• First trimester appendectomy associated with higher risk of spontaneous abortion (33%) 2
• Third trimester appendectomy has lower pregnancy complication rates 2

Special Considerations

Negative Appendectomy

• Negative appendectomy rates remain high in pregnancy (17-33%) 5, 4, 1
• Even negative appendectomy carries risk of premature delivery 5
• MRI following inconclusive US can help reduce negative appendectomy rates 5

Perforated Appendicitis

• Pregnant women are more likely to present with complicated (perforated or gangrenous) appendicitis 3
• Perforation increases risk of fetal loss 3
• Early diagnosis and treatment are essential to prevent perforation

Conclusion

Early and accurate diagnosis with appropriate imaging followed by prompt laparoscopic appendectomy within 24 hours represents the optimal management strategy for appendicitis in pregnancy, balancing the risks of delayed diagnosis against unnecessary surgical intervention.