What is the risk of appendectomy in a patient at 18 weeks gestation?

From the Guidelines

Appendicectomy during pregnancy, including at 18 weeks, is generally safe when necessary, and laparoscopic appendectomy is preferable to open appendectomy due to its association with shorter length of hospital stay and lower incidence of surgical site infection. The risk of maternal mortality is very low, though there is a slightly increased risk of preterm labor and fetal loss. According to the 2020 update of the WSES Jerusalem guidelines 1, laparoscopic appendectomy during pregnancy is safe in terms of risk of fetal loss and preterm delivery. The procedure should be performed by experienced surgeons, and the patient should be well-informed and provide consent.

Key Considerations

• The benefits of removing an inflamed appendix far outweigh the risks, as a ruptured appendix carries a much higher risk of maternal and fetal complications, including a significant risk of fetal loss 1.
• Prophylactic antibiotics should be administered before surgery to reduce the risk of surgical site infections.
• General anesthesia is used with careful monitoring of maternal and fetal vital signs.
• Positioning during surgery is important, with a slight left tilt to prevent inferior vena cava compression.
• Postoperatively, tocolytics may be used if signs of preterm labor develop, and fetal monitoring is recommended for viable pregnancies.

Recommendations

• Laparoscopic appendectomy is recommended over open appendectomy in pregnant patients when surgery is indicated 1.
• Simple ligation is preferred to stump inversion, either in open or laparoscopic surgery, as the major morbidity and infectious complications are similar 1.
• The use of drains after appendectomy for perforated appendicitis and abscess/peritonitis should be discouraged, as they are of no benefit in preventing intra-abdominal abscess and lead to longer length of hospitalization 1.

From the Research

Risk of Appendectomy in Pregnancy

The risk of appendectomy in a patient at 18 weeks gestation can be assessed based on available studies.

• The study 2 found that laparoscopic appendectomy is a safe and feasible procedure for the treatment of acute appendicitis in all trimesters of pregnancy, including the second trimester when the patient is at 18 weeks gestation.
• Another study 3 reported that pregnancy complications were found to be considerable, with 4/12 (33%) who underwent appendectomy for appendicitis during the first trimester aborting spontaneously, and second trimester appendectomy for appendicitis was followed by premature delivery in 4/28 (14%).
• A more recent study 4 found that there were no differences between women with or without appendectomy in proportion of preterm delivery, small-for-gestational age, or Cesarean delivery, suggesting that appendectomy during pregnancy may not increase the risk of these complications.

Factors Affecting Appendectomy Risk

Several factors can affect the risk of appendectomy in pregnancy, including:

• Gestational age: The study 4 found that women with gestational age > 20 weeks more frequently had an unaffected appendix compared to those operated ≤ 20 gestational weeks.
• Surgical method: Laparoscopic surgery was used in 97% of non-pregnant control group, 92% of appendectomies ≤ 20 weeks gestation, and in 27% >20 weeks 4.
• Time to surgery: Pregnant women had priority for surgery < 6 h compared to < 24 h among non-pregnant women, resulting in a shorter time-to-surgery among pregnant women 4.

Management and Outcomes

The management and outcomes of appendectomy in pregnancy can vary depending on several factors, including:

• Appendicitis diagnosis: The study 5 found that the diagnosis of acute appendicitis is made in approximately 90% of patients presenting with classic symptoms.
• Surgical management: Appendectomy remains the most common treatment for acute appendicitis, but treatment with antibiotics rather than surgery is appropriate in selected patients with uncomplicated appendicitis 5.
• Pregnancy outcomes: The study 6 found that delay in management increases the risk of appendiceal perforation and pregnancy loss, highlighting the importance of prompt diagnosis and treatment.