What are the next steps in managing appendicitis in pregnancy?

From the Guidelines

If you suspect appendicitis during pregnancy, seek immediate medical attention at an emergency department, as delayed diagnosis can lead to serious complications for both mother and baby. Appendicitis is the most common non-obstetric surgical emergency during pregnancy. Symptoms include right lower quadrant pain (which may be displaced upward as pregnancy progresses), nausea, vomiting, fever, and loss of appetite. Diagnosis typically involves clinical examination, blood tests to check for elevated white blood cell count, and imaging—ultrasound is usually the first choice during pregnancy, though MRI may be used if ultrasound is inconclusive, as recommended by the 2024 clinical practice guideline update by the Infectious Diseases Society of America 1. CT scans are generally avoided due to radiation exposure.

Key Considerations

• Surgical removal of the appendix (appendectomy) is the standard treatment, which can be performed laparoscopically in early pregnancy or via open surgery in later pregnancy, with laparoscopic appendectomy being the preferred approach over open appendectomy for both uncomplicated and complicated acute appendicitis, where laparoscopic equipment and expertise are available 1.
• Antibiotics will be administered before and after surgery, typically including broad-spectrum coverage such as cefazolin or a combination of ampicillin, gentamicin, and metronidazole.
• Surgery is safe during all trimesters and is necessary to prevent perforation, which carries higher risks of preterm labor and fetal loss.
• Non-operative management with antibiotics may be considered in selected cases, but the success of this approach requires careful patient selection and exclusion of patients with gangrenous appendicitis, abscesses, and diffuse peritonitis, as noted in the 2020 update of the WSES Jerusalem guidelines 1.

Imaging and Diagnosis

• Ultrasound is the preferred initial imaging modality for suspected appendicitis in pregnant patients, with MRI being used if ultrasound is inconclusive, as recommended by the 2024 clinical practice guideline update by the Infectious Diseases Society of America 1.
• CT scans are generally avoided due to radiation exposure, but may be considered in certain cases where the benefits outweigh the risks.

Timing of Appendectomy

• Short, in-hospital surgical delay up to 24 h is safe in uncomplicated acute appendicitis and does not increase complications and/or perforation rate in adults, as noted in the 2020 update of the WSES Jerusalem guidelines 1.
• Delaying appendectomy for uncomplicated acute appendicitis for up to 24 h after admission does not appear to be a risk factor for complicated appendicitis, postoperative surgical site infection, or morbidity.

Special Considerations in Pregnancy

• Pregnant women with appendicitis are at higher risk of perforation and fetal loss, making prompt diagnosis and treatment crucial.
• The presence of an appendicolith has been identified as an independent prognostic risk factor for treatment failure in non-operative management of uncomplicated acute appendicitis, as noted in the 2020 update of the WSES Jerusalem guidelines 1.

From the Research

Next Steps in Managing Appendicitis in Pregnancy

The management of appendicitis in pregnancy involves several key steps to ensure the best possible outcomes for both the mother and the fetus.

• Accurate and Prompt Diagnosis: Accurate and prompt diagnosis of acute appendicitis is crucial to avoid unnecessary exploration and to aim for timely surgical intervention in pregnant women suspected of having appendicitis 2.
• Clinical Presentation and Imaging: Clinical presentation and imaging remain vital in deciding whether surgical intervention is indicated. An MRI may be considered following an inconclusive or negative abdominal ultrasound to improve diagnostic accuracy and reduce the rate of negative appendectomies 2, 3.
• Surgical Intervention: Laparoscopic appendectomy is a valuable option for pregnant patients with suspected acute appendicitis, with a low rate of preterm delivery and no fetal loss reported in a large series of cases 4.
• Prophylactic Antibiotic Treatment: Prophylactic antibiotic treatment is recommended in all laparotomies during pregnancy when appendicitis is suspected to reduce the risk of infection and promote a safe outcome for both the mother and the fetus 5.
• Multidisciplinary Approach: Appendicitis in pregnancy is often managed jointly by both the surgical and obstetric teams, highlighting the need for a close working relationship between various specialties to achieve the best outcome for mother and fetus 3.

Considerations for Pregnancy Trimesters

The management of appendicitis in pregnancy may vary depending on the trimester.

• First Trimester: Appendectomy during the first trimester may be associated with a higher risk of spontaneous abortion 5.
• Second Trimester: Appendectomy during the second trimester may be associated with a higher risk of premature delivery 5.
• Third Trimester: Appendectomy during the third trimester may not be associated with an increased risk of pregnancy complications 5.

Diagnostic Challenges

The diagnosis of appendicitis in pregnancy can be challenging due to the physiological changes of pregnancy and the need to balance the risks of delay in diagnosis with the risks of unnecessary surgical intervention.

• Normal Physiological Changes: Normal physiological changes of pregnancy can pose diagnostic and therapeutic difficulties to the clinician, including changes in abdominal pain and laboratory findings 3.
• Differential Diagnoses: A range of differential diagnoses should be considered in pregnant women with suspected appendicitis, including other causes of acute abdominal pain 3.