What is the risk of fetal demise in acute appendicitis (inflammation of the appendix)?

From the Guidelines

The risk of fetal demise in acute appendicitis is significantly reduced with prompt surgical intervention, particularly with laparoscopic appendectomy, which is safe and preferable to open surgery during pregnancy. According to the 2020 update of the WSES Jerusalem guidelines 1, laparoscopic appendectomy during pregnancy is associated with a lower risk of fetal loss and preterm delivery, as well as shorter hospital stays and lower incidence of surgical site infections. The guidelines suggest that laparoscopic appendectomy should be preferred to open appendectomy in pregnant patients when surgery is indicated 1.

Key Considerations

• Prompt diagnosis and surgical intervention are crucial to reduce the risk of fetal demise
• Laparoscopic appendectomy is the preferred treatment in all trimesters
• Perioperative antibiotics should be administered to reduce the risk of infection
• Delay in diagnosis is common in pregnancy due to anatomical displacement of the appendix and overlapping symptoms with normal pregnancy

Recommendations

• Pregnant women with suspected appendicitis should undergo immediate evaluation with physical examination and appropriate imaging, preferably ultrasound first, followed by MRI if needed, to minimize radiation exposure
• Laparoscopic appendectomy should be performed by an experienced surgeon, with traditional open surgery considered in late pregnancy if visualization is difficult
• Perioperative antibiotics, such as cefazolin 2g IV or ampicillin-sulbactam 3g IV, should be administered, with extended courses for perforated appendicitis 1

From the Research

Risk of Fetal Demise in Acute Appendicitis

• The risk of fetal demise in acute appendicitis is a significant concern, as appendicitis is the most common extra-uterine surgical emergency requiring immediate surgical intervention during pregnancy 2.
• A study found that 4/12 (33%) of women who underwent appendectomy for appendicitis during the first trimester aborted spontaneously, and second trimester appendectomy for appendicitis was followed by premature delivery in 4/28 (14%) of cases 3.
• Another study reported that premature delivery occurred in 2 out of 6 cases with perforated appendicitis and 2 out of 6 cases following a negative appendectomy, but perinatal mortality did not occur 4.
• A review of 45 cases of suspected appendicitis during pregnancy found that 3 (8.1%) patients delivered prior to 35 weeks' gestation and 18.1% delivered before term (<37 weeks), but there was no fetal loss in the follow-up 5.
• The risk of fetal loss and preterm delivery is higher in cases where appendicitis is diagnosed and treated during the first and second trimesters, rather than the third trimester 3.

Factors Affecting Fetal Demise

• The natural history of acute appendicitis is not changed during pregnancy, but gestational physiological changes can obscure the accurate diagnosis of acute appendicitis, leading to delays in treatment and increased risk of fetal demise 2.
• Perforated appendicitis and negative appendectomy during pregnancy are associated with a high risk of premature delivery, which can increase the risk of fetal demise 4.
• The use of antibiotic treatment as a bridge-to-surgery in remote areas may be a sensible treatment option, but its effectiveness in reducing the risk of fetal demise is not well established 6.

Diagnosis and Treatment

• Clinical presentation and imaging remain vital in deciding whether surgical intervention is indicated, and accurate and prompt diagnosis of acute appendicitis should be strived for to avoid unnecessary exploration and to aim for timely surgical intervention in pregnant women suspected of having appendicitis 4.
• Laparoscopic appendectomy is a valuable option for pregnant patients with suspicion of acute appendicitis, with a low rate of preterm delivery and absence of fetal loss, regardless of trimester 5.