What is the recommended treatment for appendicitis in pregnant patients?

Treatment of Appendicitis in Pregnant Patients

Laparoscopic appendectomy should be preferred over open appendectomy in pregnant patients with appendicitis when surgery is indicated, as it is technically safe and feasible during pregnancy where laparoscopic expertise is available. 1

Diagnostic Approach

• Pregnant women account for approximately 1 in 20 women of childbearing age presenting with appendicitis, most commonly manifesting in early to mid-pregnancy 1
• Imaging plays a crucial role in diagnosis, with a recommended approach of:
  • Initial ultrasound as first-line imaging modality 1
  • If ultrasound is inconclusive, MRI is preferred as second-line imaging to avoid ionizing radiation 1
  • CT should be limited to cases where MRI is unavailable or inconclusive 1

Surgical Management

Timing of Surgery

• Appendectomy for acute appendicitis should be performed within 24 hours of admission to minimize complications 1
• Delaying surgery beyond 24 hours is associated with increased risk of adverse outcomes 1

Surgical Approach

• Laparoscopic appendectomy offers several advantages over open appendectomy in pregnant patients:
  • Shorter length of hospital stay 1, 2, 3
  • Lower incidence of surgical site infections 1, 2
  • Lower rate of negative appendectomies 2
  • No significant difference in fetal loss or preterm delivery compared to open surgery 1, 4

Technical Considerations

• For intraoperative management during laparoscopic appendectomy:
  • Suction alone is recommended for complicated appendicitis with intra-abdominal collections, as irrigation provides no additional benefit 1
  • Monopolar electrocoagulation and bipolar energy are suggested as cost-effective techniques for mesentery dissection 1
  • Endoloops/suture ligation or polymeric clips are recommended for stump closure 1

Special Considerations in Pregnancy

• Pregnant women are more likely to present with complicated (perforated or gangrenous) appendicitis, with higher risk of fetal loss in cases of perforation 1
• Laparoscopic appendectomy can be safely performed in all trimesters of pregnancy 5, 3
• Close maternal and fetal monitoring is essential during and after the operation 5
• Prophylactic antibiotic treatment is recommended in all cases when appendicitis is suspected during pregnancy 6

Potential Complications

• Pregnancy complications after appendectomy may include:
  • First trimester: risk of spontaneous abortion (reported up to 33% in some studies) 6
  • Second trimester: risk of premature delivery (reported up to 14% in some studies) 6
  • Third trimester: fewer pregnancy complications compared to earlier trimesters 6

Follow-up Care

• Outpatient laparoscopic appendectomy may be considered for uncomplicated appendicitis, provided that an ambulatory setting with well-defined protocols is available 1
• Careful monitoring of pregnancy is essential following appendectomy to detect any potential complications early 5, 3