What is the management plan for a pregnant patient with confirmed appendicitis?

Management of Appendicitis in Pregnant Patients

For pregnant patients with ultrasound-confirmed appendicitis, prompt surgical consultation and laparoscopic appendectomy is the recommended management approach, as it reduces maternal and fetal morbidity and mortality.

Diagnostic Approach

• For pregnant patients with suspected appendicitis, abdominal ultrasound should be used as the initial imaging modality 1
• If ultrasound results are equivocal or non-diagnostic but clinical suspicion persists, MRI is the preferred next imaging modality to avoid radiation exposure 1
• Short observation periods with repeated ultrasound in pregnant patients with equivocal appendicitis is acceptable and does not appear to increase maternal or fetal adverse outcomes 1

Surgical Management

• Laparoscopic appendectomy is the gold standard treatment for pregnant patients with confirmed appendicitis 2
• Surgery should be performed within 24 hours of admission to minimize complications 1
• Delaying appendectomy beyond 24 hours from admission is associated with increased risk of adverse outcomes 1

Antibiotic Therapy

• All patients with appendicitis should receive appropriate antimicrobial therapy 1
• Recommended regimens include:
  • Amoxicillin/clavulanate
  • Ceftriaxone + metronidazole
  • Cefotaxime + metronidazole 2

Special Considerations in Pregnancy

• Laparoscopic approach is preferred over open appendectomy in pregnant patients when surgery is indicated 2
• Pregnant patients require special attention to:
  1. Positioning during surgery (left lateral tilt to avoid vena cava compression)
  2. Lower insufflation pressures during laparoscopy
  3. Fetal monitoring before and after the procedure
  4. Consultation with obstetrics

Timing Considerations

• Appendicitis in pregnancy is a surgical emergency requiring prompt intervention
• Significant increase in the likelihood of perforated appendicitis occurs after 72 hours of symptoms 1
• Delaying surgery increases risks of maternal morbidity and potential fetal loss

Potential Complications

• Perforation rates are higher in pregnant patients due to anatomical changes and potential diagnostic delays
• Perforation can lead to sepsis in 17-32% of patients with acute appendicitis 3
• Maternal complications include wound infections and intra-abdominal abscesses
• Fetal complications include preterm labor and, in severe cases, fetal loss

Follow-up Care

• Close monitoring for postoperative complications
• Obstetric follow-up to monitor fetal wellbeing
• Wound care and pain management appropriate for pregnancy

The management of appendicitis in pregnancy requires a coordinated approach between emergency medicine, surgery, and obstetrics to ensure optimal outcomes for both mother and fetus.