What is the management of acute appendicitis in a 20-week pregnant woman?

Management of Acute Appendicitis in a 20-Week Pregnant Woman

Laparoscopic appendectomy should be performed within 24 hours of admission for a pregnant woman at 20 weeks gestation with acute appendicitis, as this approach is safe and effective with minimal risk to maternal and fetal outcomes. 1, 2

Diagnostic Approach

• Point-of-care ultrasound (POCUS) should be used as the first-line imaging method for suspected appendicitis in pregnant patients due to its safety and reasonable diagnostic accuracy 1, 2
• If ultrasound findings are inconclusive or negative but clinical suspicion remains high, MRI is recommended as the next imaging step rather than CT to avoid radiation exposure 3, 4
• A brief period of observation with repeated ultrasound is acceptable in equivocal cases and does not significantly increase maternal or fetal risks 1, 2

Surgical Management

Timing of Surgery

• Appendectomy 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 including higher rates of perforation and complications 1, 2
• For uncomplicated appendicitis, surgery can be scheduled for the next available operating list within the 24-hour window 1

Surgical Approach

• Laparoscopic appendectomy is the preferred surgical approach during pregnancy, including at 20 weeks gestation 1, 2
• Benefits of laparoscopic approach include:
  • Shorter hospital stay compared to open appendectomy 2, 5
  • Lower incidence of surgical site infections 2
  • Less postoperative pain 1
• Technical considerations for laparoscopic approach in pregnancy:
  • Port placement should be adjusted according to uterine size at 20 weeks 2
  • For complicated appendicitis with intra-abdominal collections, perform aspiration without peritoneal irrigation 2

Non-Operative Management Considerations

• Non-operative management with antibiotics may be considered in highly selected cases of uncomplicated appendicitis without appendicolith 1, 2
• However, surgical management remains the standard of care for pregnant patients due to:
  • Difficulty in monitoring disease progression during pregnancy 6, 7
  • Higher stakes of treatment failure in pregnant patients 7, 8
  • Risk of premature delivery associated with both perforated appendicitis and negative appendectomy 4, 7

Perioperative Care

• Analgesia: Acetaminophen (paracetamol) is the first-line analgesic at a dose of 500-1000mg every 6-8 hours, not exceeding 4g/24h 3
• Antibiotic therapy:
  • For uncomplicated appendicitis: Single preoperative dose 2
  • For complicated appendicitis: Initial IV antibiotics with subsequent conversion to oral antibiotics based on clinical response 1, 2
• Fetal monitoring should be implemented before and after surgery in coordination with obstetric services 5, 8

Potential Complications and Outcomes

• Maternal complications are generally low with prompt surgical intervention 6, 5
• Fetal risks include:
  • Premature delivery, particularly with perforated appendicitis 4, 7
  • Fetal loss, which is more common in first trimester cases but can occur at 20 weeks 7, 8
• Negative appendectomy during pregnancy is also associated with adverse pregnancy outcomes and should be minimized through accurate diagnosis 4, 7