Appendicitis during pregnancy

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Appendicitis Appendicitis during pregnancy during pregnancy Rinat Gabbay April 2002
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Appendicitis during pregnancy. Rinat Gabbay April 2002. Appendicitis:. The most common surgical condition of the abdomen Lifetime occurrence of 7% Peak incidence 10-30y The most common nonobstetric surgical intervention during pregnancy. Pathogenesis:. Appendiceal lumen obstruction : - PowerPoint PPT Presentation

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  • Appendicitis during pregnancyRinat Gabbay April 2002

  • Appendicitis:The most common surgical condition of the abdomenLifetime occurrence of 7%Peak incidence 10-30y

    The most common nonobstetric surgical intervention during pregnancy

  • Pathogenesis:Appendiceal lumen obstruction : lymphoid hyperplasia fecaliths parasites foreign bodies crohns disease metastatic cancer carcinoid syndrome

  • Incidence during pregnancy: Incidence 0.05% 1:1000 pregnant women - appendectomy 1:1500 proved appendicitis (Mazze & Kallen,1991) 1st trimester 30% / 22% 2nd trimester 45% / 27% 3rd trimester 25% / 50% (Mourad,2000)

  • Incidence during pregnancy:Suggested relation with female sex hormones incidence variations during the menstrual cycle .Reduced incidence of appendicitis during pregnancy, especially in third trimesterProtective effect of pregnancy ? (Int J Epidemiol 2001 Dec;30(6):1281-5)

  • symptoms :Pain RLQ / RUQ / FlankAnorexiaVomitingNausea Pain migrationFever

  • Physical examination:Tenderness RLQRebound & Guarding (peritoneal signs)Rovsing signDunphys signPsoas sign (retroperitoneal retrocecal appendix) Obturator sign (pelvic appendix)Rectal examination tenderness (cul-de-sac)Low grade fever

  • PsoassignObturatorsign

  • Lab:CBC WBC ( 80% 45% )CRP Urinalysis - mild pyuria mild proteinuria mild hematuria

  • D.D.:surgical: gyneco:Renal stone GastroenteritisPancreatitisCholecystitisMesenteric adenitisHerniaBowel obstructionPreterm laborPlacenta abruptioChorioamnionitisAdnexal torsion Ectopic pregnancyPelvic inflammatoryRound lig. pain

  • Diagnostic problems:Position of appendix: normally 70% intraperitoneal 30% pelvic, retroileal, retrocolic pregnancy anatomical changes gravid uterus displacement upward & outward flank pain (3rd trimester) (Baer,1932) increased separation of peritoneum decreased perception of somatic pain and localization

  • Diagnostic problems:Symptoms complex physical changes anorexia, nausea & vomiting in normal pregnancyLab relative leukocytosisImaging techniques

  • Diagnostic problems:Differential diagnosis: pyelonephritis renal colic placental abtuptio uterine myoma degeneration

  • Imaging:KUBBarium enemaGraded compression ultrasonographyHelical CT scan

  • Graded compression ultrasound:Normal appendix (
  • Acute appendicitis:

  • 1.thickened appendix2.Caecum3.Small amount of pericaecal fluid4.perippendicular hyperemia

  • Helical CT scan:Enlarged appendix, No filling with contrast material, Periappendiceal inflammatory changesNonpregnant patients 98% sensitivityPregnant - useful, noninvasive & accurate (Am J Obstet Gynecol 2001 Apr;184(5):954-7Radiation ?

  • Diagnosis:Pain in RLQ is the most common presenting syndrome of appendicitis in pregnancy regardless of gestational age (Am J Obstet Gynecol 2001 Jul;185(1):259-60)Physical examination is the most reliable tool for diagnosis (Am Surg 2000 Jun;66(6):555-9)

    Fever and WBC are not clear indicators (Am J Obstet Gynecol 2001 Jul;185(1):259-60)

  • Treatment:Suspicion immediate surgical interventionDelay generalized peritonitisAntimicrobial therapy: 2nd cephalosporin, perioperative, unless gangrene, perforation, phlegmon

  • Tocolytics:Concept: calm the uterus from insult of acute abdomenControversial Ritodrine ineffective anti-prostaglandin side effects Ritodrine - tachycardia & vomitinganti-prostaglandin anti-inflammatory & antipyretic, fetal side effects (Annals of Saudi Med, Vol 18 No 2, 1998)

  • Surgery:Uncomplicated / complicated surgical procedure pregnancy outcomePerinatal morbidity in nonobstetrical surgery in pregnancy tributable to the disease itself (Mazze and Kallen,1989)Laparotomy Incision choice in all trimesters McBurneys point (Am J Surg 2002 Jan;183(1):20-2)

  • laparoscopy:Adv:Less post-op complicationDisadv:Co2 pneumoperitoneum:Dec. uterine blood flowFetal acidosisPremature laborSafe especially in 1st half of pregnancy (size of gravid uterus) Similar perinatal outcomes compared to laparotomies (Reedy and colleagues,1997)

  • The mortality of appendicitis complicating pregnancy is the mortality of delay Babler 1908

  • Complications: Gestational age Complication rate (Tracey and Fletcher,2000)Uterine contractions 80% over 24wPreterm labor: 1. 3rd trimester 2. Perforated appendix & peritonitis

  • Complications:Abortion , Fetal loss ~ 15% (1st trimester)Decreased birth weight Other surgical complication wound infection, atelectasis etc.

    No increased infertility (Viktrup and Hee,1998)No congenital malformationNo stillborn infants

  • Perforated appendicitis:Incidence: 4 -19% nonpregnant patients 57% pregnant women (Tracey & Fletcher,2000)

    Gestational age Perforations Peritonitis

  • Perforation why more ???No direct cause and effect relationship between prolonged duration of symptoms and perforationNo relationship between time to operative intervention and perforation

    Anatomical explanation (Am Surg 2000 Jun;66(6):555-9)

  • Perforation why more ???Position change of appendix

    No containment of infection by omentum

    Inability of omentum to isolate infection More generalized peritonitis

  • White appendix:Nonpregnant 20%Pregnant 20-50% ( higher in advanced pregnancy)

  • Appendicitis during puerperium:

    Appendicitis can stimulate labor after the uterus empties there is diffuse peritonitis

  • Prognosis:Generally good : Disease found Surgery complications

  • The end