What is the management of appendicitis in pregnancy?

Management of Appendicitis in Pregnancy

Laparoscopic appendectomy within 24 hours of diagnosis is the recommended management for appendicitis in pregnancy, with imaging diagnosis preferably by ultrasound first, followed by MRI if inconclusive. 1

Diagnostic Approach

Initial Imaging

• First-line: Transabdominal ultrasound
  • Safe in all trimesters
  • No radiation exposure to fetus
  • May have limited sensitivity due to anatomical changes of pregnancy 2, 1

Secondary Imaging (if ultrasound inconclusive)

• MRI without contrast - preferred second-line imaging 2, 1
  • High sensitivity and specificity
  • No ionizing radiation
  • Safe in all trimesters of pregnancy
• Low-dose CT with oral contrast - only if MRI unavailable 2
  • Should be avoided especially in first trimester

Surgical Management

Timing of Surgery

• Operate within 24 hours of diagnosis 2, 1
  • Delaying beyond 24 hours increases risk of perforation and adverse outcomes
  • Short in-hospital delay with observation and repeated ultrasound is acceptable for equivocal cases 2

Surgical Approach

• Laparoscopic appendectomy - preferred first-line surgical approach 1

  • Lower overall complication rates compared to open approach
  • Shorter hospital stay
  • Reduced morbidity
  • Safe in all trimesters with appropriate port placement based on gestational age 1

• Open appendectomy - acceptable alternative 1

  • Consider when laparoscopic expertise unavailable
  • May be preferred in late third trimester by some surgeons

Antibiotic Management

Preoperative Antibiotics

• Single preoperative dose of broad-spectrum antibiotics for all patients 1
  • Options include:
    • Amoxicillin/clavulanate
    • Ceftriaxone + metronidazole

Postoperative Antibiotics

• Uncomplicated appendicitis: No postoperative antibiotics needed 1
• Complicated appendicitis (perforation, abscess, peritonitis):
  • Broad-spectrum antibiotics for 3-5 days 1
  • Options include:
    • Meropenem
    • Imipenem/cilastatin
    • Ceftolozane/tazobactam + metronidazole

Special Considerations in Pregnancy

Anatomical Changes

• Appendix location shifts upward and laterally as pregnancy progresses
• Right lower quadrant pain may present higher in abdomen in second and third trimesters 3

Maternal and Fetal Risks

• Perforation increases risk of premature delivery and fetal loss 4, 5
• Negative appendectomy is also associated with increased risk of premature delivery 4
• Delay in diagnosis increases perforation risk (43% perforation rate when symptoms exceed 24 hours) 6

Management of Periappendicular Abscess

• Well-circumscribed abscesses can be treated with percutaneous drainage plus antibiotics 1
• Consider non-operative management with antibiotics and drainage in select cases

Postoperative Care

• Close monitoring for signs of preterm labor
• Multidisciplinary approach involving surgery and obstetrics teams
• Consider tocolytics only if signs of preterm labor develop
• Early ambulation to reduce thromboembolism risk
• Same-day discharge may be considered for uncomplicated cases with adequate pain control and no obstetric concerns 1

Key Pitfalls to Avoid

1. Delayed diagnosis - physiologic changes of pregnancy can mask symptoms of appendicitis
2. Hesitancy to operate - pregnancy is not a reason to delay surgery when appendicitis is suspected 7
3. Overreliance on classic symptoms - pregnant patients may not present with typical appendicitis symptoms
4. Inappropriate imaging - avoid ionizing radiation when possible, especially in first trimester
5. Failure to involve multidisciplinary team - obstetrics should be consulted early

The evidence clearly demonstrates that prompt diagnosis and early surgical intervention within 24 hours are critical to reducing maternal and fetal morbidity in pregnant patients with appendicitis.