What is the standard treatment for appendicitis in pregnancy?

Standard Treatment for Appendicitis in Pregnancy

Laparoscopic appendectomy is the standard treatment for appendicitis in pregnancy and should be performed without delay beyond 24 hours from admission, regardless of trimester. 1, 2

Diagnostic Approach

Initial Imaging

• Abdominal ultrasound is the first-line imaging modality for pregnant women with suspected appendicitis due to absence of fetal radiation exposure 1, 3
• However, ultrasound has significant limitations in pregnancy, with a median 95% equivocal or indeterminate result rate 1

Subsequent Imaging When Ultrasound is Inconclusive

• MRI should be obtained as the next imaging modality when ultrasound is non-diagnostic but clinical suspicion remains high 1, 3, 4
• MRI is highly sensitive and specific for appendicitis during pregnancy while avoiding radiation exposure 1, 3
• A negative or inconclusive MRI does not exclude appendicitis—surgery should still be considered if clinical suspicion is high 1

Imaging Pitfall

• CT should be avoided when possible due to fetal radiation exposure, though low-dose CT may be considered as a last resort when MRI is unavailable and diagnosis is urgent 3

Surgical Management

Timing

• Surgery should not be delayed beyond 24 hours from admission to avoid complications including perforation 1, 2
• Short in-hospital delays with observation and repeated ultrasound are acceptable in equivocal cases, but definitive surgery should not be postponed once diagnosis is established 1

Surgical Approach

• Laparoscopic appendectomy is preferred over open appendectomy during pregnancy, as it is safe across all trimesters and offers advantages including less pain, lower surgical site infection rates, and shorter hospital stays 1, 2, 5
• Laparoscopic approach can be safely performed in the first, second, and third trimesters with low complication rates (4% major complications) and no increase in fetal loss when performed promptly 5

Critical Timing Considerations

• Both perforated appendicitis AND negative appendectomy carry high risk of premature delivery (approximately 14-33% in first and second trimesters) 4, 6
• This creates a clinical dilemma: delaying surgery risks perforation, but unnecessary surgery also increases pregnancy complications 4
• The balance favors prompt surgical intervention when imaging and clinical assessment suggest appendicitis, as perforation carries worse outcomes 4, 6

Perioperative Management

Analgesia

• Paracetamol (acetaminophen) 500-1000 mg every 6-8 hours (maximum 4 grams/24 hours) is the first-line analgesic due to established safety in pregnancy 2, 3

Antibiotics

• Prophylactic antibiotics are recommended for all pregnant women undergoing laparotomy for suspected appendicitis 6
• Initial intravenous antibiotics with subsequent conversion to oral antibiotics is recommended for perioperative management 1, 3

Pregnancy-Specific Outcomes

Trimester-Specific Risks

• First trimester: 33% spontaneous abortion rate following appendectomy for confirmed appendicitis 6
• Second trimester: 14% premature delivery rate 6
• Third trimester: No significant increase in pregnancy complications observed 6
• These risks apply to both confirmed appendicitis and negative appendectomy, emphasizing the importance of accurate diagnosis 4, 6

Multidisciplinary Approach

• Management should involve a multidisciplinary team including surgery and obstetrics, as both maternal and fetal morbidity are not negligible 7