Appendicitis Pregnancy Elnashar

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    Appendicitis DuringAppendicitis DuringPregnancyPregnancy

    Prof.Prof. AboubakrAboubakr [email protected]@hotmail.com

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    EpidemiologyAnatomical changes

    Pathophysiology

    ComplicationsDiagnosis

    DD

    Surgery

    Conclusion

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    Epidemiology

    Lifetime occurrence of 7%

    Peak incidence: 10-30y

    The most common cause of acute abdomen in

    pregnancy non-obstetric surgical interventionduring pregnancy {Accounts for 25%}

    Suspected in: 1 in 1000 pregnant women (Mazze andKlln, 1991)

    Confirmed in: 65%

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    Incidence:

    1 in 1500 pregnancies

    Reduced during pregnancy, especially in 3rd T

    {Protective effect of pregnancy?}(Andersson &Lambe, 2001).

    Same (Some studies)

    Equal in all three trimesters.

    1st T: 30% 2nd T: 45%

    3rd: 25%

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    Anatomical changes during pregnancy

    I. Position of appendix:

    Gravid uterus displacement upward & outward

    (Baer et al, 1932, many authors)No change in location (Mourad et al, 2000; Hodjati et al ,2003)

    Degree of displacement, if any, is likely due todiffering extent of cecal fixation.

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    Position of Appendix(Baer et al, 1932)

    12 W: McBurneys point

    24 W: Iliac crest36 W: RUQ

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    II. Gravid Uterus:

    The uterus enlarges 20 times:1. Stretching of supporting ligaments & muscles.

    2. Pressure on intra-abdominal structures & ant abd

    wall, prevents irritation of ant abd wall by

    inflamed intra-abdominal organs decreasedperception of somatic pain & localization

    3. Obstructs & inhibits the movement of the omentum

    (policeman of the abdomen): prevents omentum

    from localizing infection.

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    Appendicitis:

    inflammation of thevermiform appendix

    caused by an obstruction

    attributable to infection,

    structure, fecal mass,foreign body, or tumor

    Pathophysiology

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    Complications

    Increased with increasing gestational age.

    delay in diagnosis

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    1. Abortion: 15%

    2. Fetal loss: 1.5-5.1%

    3. Preterm labor:

    13-22%

    3rd T

    Perforated appendix & peritonitis1st week after surgery

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    4. Perforation

    Non Pregnant: 4 -19%

    Pregnant:

    Highest in 3rd T

    1st T: 8%

    2

    nd

    T: 12%3rd T: 20%(Andersson and Lambe, 2001; Ueberrueck and associates ,2004)

    Surgery delayed by >24 hrs from presentation: 66%risk of perforation:

    Surgery within 24 hrs of presentation with

    symptoms: No perforation(Tamir et al, 1999)

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    Non-perforated appendix

    Fetal mortality: 1.5%

    Mat mortality: 0.1% Perforated appendix

    Fetal mortality: 5.1%-20%

    Maternal mortality: 1% {diffuse peritonitis}

    Preterm contractions: {localized peritonitis}83%

    (Augustin and Majerovic, 2006).

    o Neonatal neurological injury {Sepsis}(Mays et,1995)

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    DiagnosisMantrels score

    DifficultSymptoms

    Signs

    Lab

    Imaging

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    MANTRELSMigratory right iliac fossa pain

    Anorexia, Nausea/Vomiting

    Tenderness in the right iliac fossa

    Rebound pain

    Elevated temperature

    LeukocytosisShift of leukoc tes to the left of neutro hils

    Non

    Pregnant

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    Pregnant:

    More difficult.

    1. Nausea, vomiting, anorexia accompany normal

    pregnancy.

    2. Uterus enlarges: appendix commonly moves

    upward and outward: pain& tenderness are"displaced" (Baer et al, 1932).

    challenged (Mourad et al, 2000).

    3. Peritoneal signs often absent {lifting of abdominal

    wall by uterus}May not have typical symptom esp. in latepregnancy

    4. Fever in less than majority

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    5.Elevated WBC normal in pregnancy

    1st 2nd T: 16000 At labor: 20000 30000

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    Symptoms

    1. Abdominal pain (almost always)

    Site:

    RLQ: Most reliable sx

    Most common even in 3rd T (Yan et al, 2009)

    1st T: RLQ

    2nd T: At level of umbilicus

    3rd

    T: Diffuse or RUQ

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    2. Anorexia, nausea, vomiting:

    Neither sensitive nor specific.

    Sensitive predictors of appendicitis in the late

    pregnancy (Yan et al, 2009)

    3. Fever: 50%

    Not sensitive

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    Signs

    All findings are less common in 3rd T

    1. Abdominal tenderness (most common)

    Direct RLQ tenderness: ~100%

    Rebound tenderness: 55-75%

    less common in 3rd T

    2. Abdominal rigidity: 50-65%

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    3. Classic signs

    No or little clinical significance in diagnosis (Pastoreet al, 2006)

    Rovsing sign:

    palpation of the LLQ results in more pain in theRLQ

    Dunphy's sign:

    increased abdominal pain with coughing

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    Psoas sign (retroperitoneal retrocecal appendix)passively extending the thigh of a patient

    lying on their side with knees extended

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    Obturator sign (pelvic appendix)

    pain when there is flexion and internal rotation

    of the hip

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    Laboratory

    1. WBC:

    2nd &3rd T: 6,000-16,000

    Early labor: 20,000-30,000

    Absolute number: not reliable

    Differential: levels of band cells can be reliableindication of infection.

    2. U/A:

    mild pyuria or mild hematuria: 20%

    {extraluminal irritation of the ureter, not UTI}.

    mild proteinuria

    3. CRP (acute-phase protein)

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    Imaging:

    Negative appendectomy rate:-Clinical diagnosis alone: 54%

    -Clinical, US & CT: 8%

    1st

    Line:US

    2nd line:

    CT

    MRI

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    US: TA or TV

    Graded compression sonography

    Non-pregnant: sensitivity 85%specificity 92%

    Pregnant:

    Difficult {cecal displacement and uterineimposition (Pedrosa et al, 2009).

    Easy, safe

    Operator dependent

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    Accuracy

    Accurate in 1st & 2nd T, difficult in 3rd T

    confirming the diagnosis in 3rd T: 40% (Yan et al,2009)

    PPV: 100% (provides confirmation of the

    diagnosis when it is positive).

    Normal US: can not rule out diagnosis

    80% sensitive: non-perforating appendicitis

    28% sensitive: perforated appendicitis

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    Scan RLQ w/ increasing pressure

    to push bowel loops away

    Empty cecum of gas& fluid

    Sonographic Criteria

    Noncompressible

    > 7mm diameter

    < 6mm rules out appendicitis

    Mural thickening > 3mmPresence of appendiceal fecalith

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    CT: Helical CT scan:

    Non pregnant patients

    Sensitivity: 98%

    Pregnant:

    Sensitivity: >90%

    Specificity: >95%

    (Torbati et al, 2002; Wallace et al, 2008; Gearhart, 2008; Paulson,

    2003; Raman, 2008)

    Adv:

    Quicker, useful, noninvasive

    More sensitive & accurate than US

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    Radiation dose: 0.3 rad

    Specific views to decrease fetal radiation exposureCumulative dose of 5 rad: safe

    Enlarged appendix

    No filling with contrast material

    Inflammatory changes

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    MRI

    No adverse effects on fetus(Israel et al, 2008).

    False-negative: 0%

    False-positive rate: 30% (Pedrosa et al, 2009)

    Sensitivity: up to 100%Specificity: 96% (Fielding andChin, 2006).

    Cost

    Availability may be prohibitive.

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    Differential DiagnosisDifferential Diagnosis

    Nonobstetric Pyelonephritis

    Urinary calculi

    Cholecystitis

    Cholelithiasis Pancreatitis

    Gastroenteritis

    Mesenteric Adenitis

    Pneumonia

    MeckelsDiverticulum

    Peptic Ulcer

    Obstetric Preterm Labor

    Placental Abruption

    Chorioamnionitis

    Adnexal Torsion Ectopic Pregnancy

    PID

    Round ligament pain

    Uterine rupture

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    SurgeryRisk

    Indication

    PreoperativeAnesthesia

    Operative

    Laparotomy

    LaparoscopyPostoperative

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    Risks ofOperation

    1. Abortion during first trimester

    2. Preterm laborin third trimesterPreterm labor & delivery uncommon: 5-14%

    Optimal time during 2

    nd

    T3. Wound complications

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    Indication

    When appendicitis is suspected: prompt surgical

    exploration.Decision to operate on clinical grounds:

    1. Accuracy of diagnosis

    inversely proportional to gestation age.Correct diagnosis

    1st T: 77%

    2nd, 3rd T: 57% (Mazze and Klln, 1991)

    Acceptable negative laparotomy rates

    Non Pregnant: 15%

    Pregnant: 35%(Augustin and Majerovic, 2006).

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    2. Risk of the surgical procedure:

    to mother & child it is minimal compared to

    risks of delayed treatment & appendix

    perforation.

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    3. Perforation

    occurs twice as often in 3rd T as 1st or 2ndDelay in surgery > 24 h after presentation:marked increase in rate of perforation: 0% vs.66%

    (Horowitz et al 1995)

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    Preoperativekeep NPOIV drip is used to hydrate

    IV antimicrobial therapy:2nd or 3rd generation cephalosporin

    Discontinued after surgery unless

    Gangrene

    Perforation

    Periappendiceal phlegmon

    Without generalized peritonitis: prognosis is

    excellent.

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    Diffuse Peritonitis(Augustin & Majerovic, 2006).

    1. IV Cefuroxime, ampicillin, metronidazole, andoxygen pre-operatively.

    2. Immediate C-section can be considered,

    depending on gestational age of fetus.

    3. Preoperative intubation & ventilation in cases of

    fetal hypoxia.

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    Anesthesia

    IV Inhaled anesthetics:Not associated w/ teratogenicity

    Potential teratogens best avoided

    Local/Regional anesthetics:NO association w/ fetal malformations

    Risk of hypotension: decrease uterine blood flow

    Minimize: adequate fluids, lateral position

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    Operative

    Laparotomy or Laparoscopy

    Depends on

    1. Gestational age

    2. Skill of the surgeon

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    Laparotomy

    1. Tilt table 30 to left

    {Decrease pressure to IVC

    Facilitate exposure of cecum}

    2. IncisionMcBurneys point:

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    Laparoscopy

    During the 1

    st

    half of pregnancy:similar perinatal outcomes (Reedy etal,1997)

    During 2nd half of pregnancy: controversy

    most experienced surgeons. (Barnes and colleagues, 2004;Rollins and associates, 2004; Parangi et al, 2007)

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    Advantages

    1. Useful in diagnosis

    2. Less post-op complication

    3. Earlier mobilization & recovery: fewer thromboembolic

    complications

    4. Lower postoperative narcotic use: less fetal depression

    5. Shorter hospital stay

    Disadvantages

    1. Experience limited

    2. Co2 pneumoperitoneum:

    uterine blood flow

    Fetal acidosis

    Premature labor

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    Postoperative

    1. Preterm contractions are common but

    progression to labor is rare.

    Observe uterine contraction

    2. Tocolytics

    Recommended by someS.E:

    Ritodrine: tachycardia & vomiting

    Anti-prostaglandin: fetal side effects

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    Conclusion

    1. The symptoms of appendicitis mimic symptoms of

    normal pregnancy, namely, anorexia, nausea,

    vomiting & abdominal discomfort.

    2. Delay of surgery correlates to more advanced

    disease with an increased risk of perforation. This, in

    turn, contributes to an increased risk of further

    complications including abortion or premature labor &

    higher maternal complication rates.

    3. Prompt diagnosis may improve the perinatal

    outcome.

    4. Early surgical intervention is essential.

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    References

    1. Mazze RI, Kallen B. Appendectomy during pregnancy: a Swedish registry study

    of 778 cases. Obstet Gynecol 1991;77:835-40.

    2. Andersson RE, Lambe M. Incidence of appendicitis during pregnancy. Int J

    Epidemiol 2001;30:1281.

    3. Baer JL, Reis RA, Arens RA. Appendicitis in pregnancy with changes in position

    and axis of normal appendix in pregnancy. JAMA 1932;98:1359..

    4. Mourad J, Elliott J, Erickson L, Lisboa L. Appendicitis in pregnancy: new

    information that contradicts long-held clinical beliefs. Am J Obstet Gynecol

    2000;182:1027-9.

    5. Tamir IL. Acute appendicitis in the pregnant patient. Am J Surg1990;160:571-6.6. Lyass S, Pikarsky A, Eisenberg VH, Elchalal U, Schenker JG, Reissman P. Is

    laparoscopic appendectomy safe in pregnant women? Surg Endosc. 2001;15:377-

    9.

    7. WallaceC, Petrov M, Soybel D, Ferzoco S, Ashley S. Influence of imaging on

    the negative appendectomy rate in pregnancy. Surg 2008;12: 46-50.

    8. Horowitz MD, Gomez GA, Santiesteban R, Burkett G. Acute appendicitis duringpregnancy. Diagnosis and management. Arch Surg 1985;120:13627.

    9. Rollins M, Chan K, Price R Laparoscopy for appendicitis and cholelithiasis

    during pregnancy: a new standard of care. Surg Endosc. 2004; 18: 237-41.

    10. Yan T, Tat L Risk factors of postoperative infections in adults with complicated

    appendicitis. Surg Laparosc Endosc Percutan Tech. 2009; 19: 244-8.