What is the optimal management for a 28‑week pregnant patient with uncomplicated acute appendicitis?

Optimal Management of Uncomplicated Acute Appendicitis at 28 Weeks Gestation

Laparoscopic appendectomy should be performed within 24 hours of admission and is the preferred approach for your 28-week pregnant patient with uncomplicated acute appendicitis. 1, 2

Surgical Management: The Preferred Approach

Why Surgery Remains First-Line in Pregnancy

Laparoscopic appendectomy is safe during pregnancy and superior to open surgery, with shorter hospital stays, lower surgical site infection rates, and no increased risk of fetal loss or preterm delivery compared to open approach. 1, 3 At 28 weeks gestation (second trimester), the laparoscopic approach is particularly well-established and should be your default choice. 3

Critical timing consideration: Surgery should not be delayed beyond 24 hours from admission, as delays increase complication rates including perforation risk. 1, 2 The second trimester carries a 14% risk of premature delivery following appendectomy for appendicitis, making prompt intervention essential to minimize inflammatory progression. 4

Technical Surgical Considerations

• Use monopolar or bipolar electrocautery for mesoappendix dissection as the most cost-effective approach 2
• Close the appendiceal stump with endoloops/suture ligation or polymeric clips rather than inversion 2
• Perform aspiration only without peritoneal irrigation if intra-abdominal collections are encountered 1, 2
• Avoid placing abdominal drains routinely after appendectomy 2
• Employ wound ring protectors to decrease surgical site infection risk 2

Perioperative Antibiotic Protocol

Administer broad-spectrum intravenous antibiotics 30-60 minutes before skin incision (e.g., cefazolin 1-2g IV or equivalent). 2 This single preoperative dose is critical for reducing surgical site infections. 2

For uncomplicated appendicitis, postoperative antibiotics are not recommended. 2

Non-Operative Management: A Reasonable Alternative in Select Cases

While surgery is preferred, antibiotic therapy can be discussed as a safe alternative in highly selected cases of uncomplicated appendicitis without appendicolith. 5, 1

Evidence Supporting Conservative Management in Pregnancy

A 2021 retrospective study of 54 pregnant women with uncomplicated appendicitis showed that antibiotic therapy (n=34) resulted in:

• Zero complications versus one wound infection in the surgical group 6
• Recurrence in only 3 patients (1 during pregnancy, 2 postpartum), all successfully treated with appendectomy 6
• No difference in obstetric outcomes including gestational age at delivery, mode of delivery, birth weight, or APGAR scores 6

However, the WSES guidelines note a 15% failure rate and 12% recurrence rate during the same pregnancy in conservatively managed pregnant patients. 5

When to Consider Non-Operative Management

You may offer antibiotic therapy if:

• No appendicolith is present on imaging (appendicoliths predict 40-60% failure rates of conservative management) 5, 7
• Patient strongly wishes to avoid surgery and understands the 15% failure risk and 12% same-pregnancy recurrence risk 5
• Imaging confirms uncomplicated appendicitis without perforation, abscess, or mass effect 7

Antibiotic regimen: Initiate broad-spectrum IV antibiotics (e.g., piperacillin-tazobactam or cephalosporin/fluoroquinolone plus metronidazole), then transition to oral antibiotics based on clinical response, for 3-7 days total. 5, 7

Critical Pitfalls to Avoid

• Do not delay surgery for additional imaging once the diagnosis is established 2
• Do not attempt conservative management if appendicolith is present on ultrasound or MRI, as failure rates exceed 40% 5, 7
• Do not assume "stable" presentation eliminates urgency—the second trimester carries significant premature delivery risk (14%) if appendicitis progresses 4
• Do not use open surgery as first choice—laparoscopic approach is safer and more effective in pregnancy 1, 3
• Do not withhold surgery due to pregnancy concerns—untreated appendicitis poses far greater fetal risk than laparoscopic appendectomy 8, 4

Obstetric Monitoring

Coordinate with obstetrics for:

• Fetal ultrasound including Doppler sonography perioperatively 3
• Cardiotocography monitoring during and after surgery 3
• Prophylactic tocolysis consideration (used in 14/33 patients in one series, though benefit is debated) 8

Algorithm for Decision-Making

1. Confirm uncomplicated appendicitis via ultrasound ± MRI (avoid CT radiation) 9
2. Check for appendicolith on imaging 5
3. If appendicolith present OR patient prefers surgery: Proceed with laparoscopic appendectomy within 24 hours 1, 2, 7
4. If no appendicolith AND patient strongly prefers to avoid surgery: Offer antibiotic therapy with informed consent about 15% failure and 12% recurrence rates 5, 6
5. If conservative management chosen, monitor closely: Convert to surgery immediately if no improvement within 24-48 hours 5