Appendicitis in Pregnancy

Gad Aptilon Duque; Saran Lotfollahzadeh

Appendicitis in Pregnancy

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Continuing Education Activity

Acute appendicitis is the most common nonobstetric surgical disease of pregnancy. The typical anatomic and physiologic changes of pregnancy can make the diagnosis of acute appendicitis challenging. If the diagnosis of acute appendicitis is not made in a timely fashion, the risk to the gravida and the fetus is significant and includes sepsis, preterm labor resulting in preterm birth, and fetal loss. However, a timely appendectomy can reduce these risks and is generally very well-tolerated, regardless of gestational age. This activity reviews the incidence, pathophysiology, evaluation, complications, and management of acute appendicitis in pregnant patients and highlights the role of the interprofessional team in diagnosing and treating patients with this condition.

Objectives:

Correlate the physiologic changes of pregnancy and the pathophysiology of acute appendicitis with the varied presentations of this disease process in pregnant patients.
Effectively counsel patients about the risks and benefits of appendectomy as a treatment for acute appendicitis during pregnancy.
Identify and effectively manage the complications of acute appendicitis and appendectomy in pregnant patients.
Develop and efficiently implement interprofessional strategies to improve outcomes for pregnant patients with acute appendicitis.

Introduction

Acute appendicitis is a clinical diagnosis confirmed by histopathological findings characterized by inflammation of the vermiform appendix. Clinically, acute appendicitis usually presents acutely within 24 hours. However, the presenting symptoms can be more indolent if appendiceal perforation results in the formation of a contained abscess.[1][2][3][4] The clinical course of acute appendicitis can be highly variable, and the diagnosis may be challenging, particularly in pregnant patients.

Acute appendicitis is the leading cause of nonobstetric surgical disease in pregnant patients. Diagnosing and treating appendicitis promptly during pregnancy is essential to avoid potentially life-threatening complications for both the gravida and the fetus.[5] However, diagnosing acute appendicitis during pregnancy can be challenging since the stereotypical signs and symptoms may not be apparent or easily confused with the typical symptoms of pregnancy. Furthermore, the gravid uterus can displace the appendix and complicate the clinical picture. Standard biochemical and laboratory indicators commonly used in the diagnosis of acute appendicitis may be less reliable during pregnancy.[6]

The general pathogenic, diagnostic, and therapeutic principles of acute appendicitis during pregnancy follow the same pattern as in nonpregnant patients, with specific modifications to accommodate the physiology of normal pregnancy and the growing fetus.

Etiology

Acute appendicitis is most commonly caused by mechanical obstruction of the appendiceal lumen, usually due to the presence of an appendicolith. However, luminal obstruction can also be due to appendiceal tumors, intestinal parasites, or hypertrophied lymphatic tissue. Hypertrophied lymphatic tissue is more common in the pediatric population, and adults are more commonly affected by infections, fecaliths, or neoplasms.[7]

The appendix hosts aerobic and anaerobic bacteria, including Escherichia coli and Bacteroides spp. Therefore, the increased bacterial load during appendiceal luminal obstruction can lead to acute inflammation and abscess formation. Recent next-generation sequencing studies have found that patients with complicated perforated appendicitis have significantly higher bacterial phyla load.[8]

The etiologies of acute appendicitis in pregnant patients are similar to those in nonpregnant adults.[9] Specific microorganisms such as Fusobacterium nucleatum, an anaerobic oral commensal and periodontal pathogen, are associated with pregnancy-related complications such as chorioamnionitis, preterm birth, stillbirth, neonatal sepsis, and preeclampsia. However, the evidence for distinct microbiological culprits for acute appendicitis during pregnancy is lacking.[10]

Epidemiology

Acute appendicitis in the general population occurs at a rate of 100 to 223 new cases per 100,000 individuals per year and represents the primary cause of acute abdominal conditions.[11][12] In the United States, approximately 300,000 hospital visits are reported annually for appendicitis-related issues.[13][9] Appendicitis most commonly occurs between the ages of 5 and 45, with a mean age of 28.[9]

The prevalence of acute appendicitis is similar in pregnant and nonpregnant patients, occurring in 1 of 181 to 1700 pregnancies.[14] The incidence is highest in the second trimester.[15][16] Acute appendicitis accounts for two-thirds of nontraumatic surgical emergencies during pregnancy.[5]

Pathophysiology

The pathophysiology of acute appendicitis in pregnancy is the same as that in nonpregnant persons.

Acute appendicitis is most commonly due to appendiceal luminal obstruction. This obstruction may be caused by lymphoid hyperplasia, parasitic infections, fecaliths, or benign or malignant neoplasms.

Once obstructed, the appendix fills with mucus and becomes distended, increasing intraluminal and intramural pressure. This results in small vessel occlusion, thrombosis, and lymphatic stasis. As lymphatic and vascular compromise advances, the wall of the appendix becomes ischemic and necrotic. Bacterial overgrowth occurs in the obstructed appendix, with aerobic organisms predominating in early appendicitis and mixed aerobes and anaerobes later in the course. Common organisms include Escherichia coli, Peptostreptococcus, Bacteroides, and Pseudomonas. Once significant inflammation and necrosis occur, the appendix is at risk of perforation, leading to a localized abscess and sometimes frank peritonitis.[17][18]

Appendiceal distention is responsible for the initial visceral and vague abdominal pain often described by the affected patient. The pain typically does not localize to the right lower quadrant until the appendiceal tip becomes inflamed and irritates the adjacent parietal peritoneum or perforation occurs, resulting in localized peritonitis. However, due to the lifting and stretching of the anterior abdominal wall by the gravid uterus, the inflamed appendix is less likely to irritate the parietal peritoneum.

Histopathology

The evidence for distinct histopathological findings for acute appendicitis during pregnancy is lacking. Therefore, the generally accepted histopathological findings and categorization of acute appendicitis in nonpregnant patients also apply to pregnant patients.

The significant microscopic findings in acute appendicitis include neutrophilic infiltration of the muscularis propria. The degree and extent of inflammation are directly proportionate to the severity of the infection and duration of the disease. As acute appendicitis progresses, appendiceal fat and surrounding tissues become involved.[19][9]

Appendicitis has been classified into three main categories based on histopathological findings.

Suppurative or phlegmonous appendicitis: This category of appendicitis is characterized by neutrophils infiltrating the appendiceal mucosa, submucosa, and muscularis propria. The inflammation extends throughout the entire appendiceal wall and can cause extensive ulceration. Intramural microabscesses accompanied by vascular thrombosis may also be observed. The appendix may appear grossly normal in suppurative appendicitis. However, poorly demarcated serosa, dilation, surface vessel congestion, or fibrinopurulent serosal exudate may be seen. Increased appendiceal diameter is an uncertain finding.[9]
Gangrenous and perforated appendicitis: The main characteristic of this category of appendicitis is wall necrosis. If left untreated, perforation will occur. In cases of perforation, transmural inflammation with areas of necrosis and extensive mucosal ulceration can be observed. The inflammation is also anticipated to extend to the surrounding area, specifically the mesoappendix. Grossly, the appendix wall appears friable and may display shades of purple, green, or black.[20]
Periappendicitis: Periappendicitis is inflammation of the serosa and subserosa; the inflammatory infiltrate does not extend into the muscularis propria. Mucosal erosions may be present and suggest inflammation and tissue damage. The gross appearance of periappendicitis varies from normal to congested serosa, accompanied by exudative infiltration.[21][9][20]

Appendicitis may be uncomplicated or complicated. Complicated appendicitis may occur with or without appendiceal perforation. Complicated nonperforated appendicitis includes the distinct histopathological categories of severe phlegmonous and gangrenous nonperforated appendicitis. The histopathological findings dictate the final diagnosis.

History and Physical

Acute appendicitis usually presents with generalized or periumbilical abdominal pain that eventually migrates to the right lower quadrant. While the time course of symptoms is variable, 75% of patients with acute appendicitis present within 24 hours of the onset of symptoms. However, acute appendicitis in the pregnant patient may present with milder, subtler symptoms, and pregnant patients are less likely to present with classic symptoms than age-matched controls, especially in late pregnancy.

The most common presenting symptom of acute appendicitis is abdominal pain. While the anatomical position of the root of the appendix is mostly constant, tail positions can vary, including retrocecal, subcecal, pre-ileal, post-ileal, and pelvic. In acute appendicitis, the initial inflammation stimulates the visceral afferent nerve fibers of T8 through T10, leading to vague midabdominal pain. The pain typically becomes more localized to the right lower quadrant as the inflamed adjacent parietal peritoneum is irritated. Not all patients with acute appendicitis present with migratory abdominal pain.

In classic presentations of acute appendicitis in the general population, abdominal pain may be accompanied by anorexia and nausea with or without vomiting. Fever occurs in 40% of patients and is a later sign.

However, many patients with acute appendicitis present with atypical symptoms, including malaise, heartburn, flatulence, constipation, and diarrhea.[22][17][23][24][25][26] If the tip of the appendix is pelvic, urinary urgency or frequency, dysuria, tenesmus, and diarrhea may be reported.[27][9][22][17][23][24][25][26]

Despite the elevation of the anterior abdominal wall by the gravid uterus, most pregnant patients with acute appendicitis will present with abdominal pain. Regardless of gestational age, this pain is most likely to occur in the right lower quadrant near the McBurney point, located one-third the distance between the anterior superior iliac spine and the umbilicus. However, as the location of the appendix may migrate cephalad with the enlarging uterus, pain may be described in the right flank or even in the right upper quadrant as pregnancy advances.[28][29][30][31][32][26][33][34][35]

The physical examination findings of acute appendicitis in the general population may be subtle, especially early in the disease process; this is also true for pregnant patients. As inflammation progresses, signs of peritoneal inflammation may develop. The most common physical examination findings in acute appendicitis in the pregnant and nonpregnant populations are right lower quadrant abdominal pain, rebound tenderness, and involuntary abdominal guarding. Pain due to retrocecal appendicitis will more likely be elicited with a vaginal or rectal examination, even during pregnancy. Pelvic appendicitis may cause pain below the McBurney point in pregnant and nonpregnant persons.[22][17][23][24][25][26][36]

Evaluation

Several auxiliary scoring systems have been developed to facilitate the prompt diagnosis of acute appendicitis. These scoring systems are mainly based on medical history, physical examination findings, laboratory testing, and imaging measures, including abdominal ultrasonography. The Alvarado score was developed in 1986 and is the most widely used system in current clinical practice. There is evidence to suggest that the Alvarado score is efficacious in pregnant patients.[37]

Laboratory Testing in Acute Appendicitis in Nonpregnant Persons

The total leucocyte count, neutrophil percentage, and C-reactive protein (CRP) concentration are commonly utilized laboratory studies in evaluating patients with suspected acute appendicitis.[38]

A leukocytosis with or without a left shift or bandemia is present in two-thirds of patients with acute appendicitis. A white blood cell (WBC) count of >10,000 cells/mm³ is highly predictive in patients with acute appendicitis. The CRP may be elevated. A combination of normal WBC and CRP results has a high negative predictive value for acute appendicitis.

The WBC and CRP results have a positive predictive value to differentiate between uncomplicated and complicated acute appendicitis.[39] Increasing WBC and CRP values significantly increase the likelihood of complicated appendicitis. A WBC count ≥17,000 cells/mm³ is associated with complicated acute appendicitis.[9]

Microscopic hematuria and pyuria may occur when the inflamed appendix is close to the bladder or ureter. Still, these findings are not specific and are generally reported in less than 20% of patients.[40]

Laboratory Testing in Acute Appendicitis in Pregnant Persons

Leukocytosis as high as 16,900 cells/mm³ may be a normal finding in pregnancy, particularly in the third trimester. The count may rise as high as 29,000 cells/mm³ during labor, with a slight neutrophilic predominance.[41][42][43][44][45][46] Therefore, leukocytosis is an unreliable indicator in the workup of appendicitis in pregnant persons.

Mild elevations in serum bilirubin have been described as a marker for appendiceal perforation with 70% sensitivity and 86% specificity. However, clinicians should not use this isolated finding as a diagnostic tool.[47] Some studies evaluated the use of the neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio in the diagnostic course of acute appendicitis during pregnancy, and the results were suggestive of increased accuracy in this group of patients.[48]

Imaging Studies

Acute appendicitis is a clinical diagnosis confirmed by histopathological findings. However, imaging modalities are frequently utilized when the clinical diagnosis is uncertain. Commonly used modalities are graded compression ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI). Ultrasound is less sensitive and specific than CT but avoids ionizing radiation in children and pregnant women. MRI may also be useful for pregnant patients with suspected appendicitis and an indeterminate ultrasound.[9] Due to the increased risks of negative appendectomies in pregnancy, imaging is recommended for all pregnant patients with suspected acute appendicitis to improve diagnostic accuracy.

Ultrasonography

Abdominal ultrasonography is a widely used and available primary measure to evaluate patients with acute abdominal pain. A specific compressibility index along with a diameter of less than 5 mm is used to exclude appendicitis. Ultrasonographic findings suggestive of acute appendicitis include an anteroposterior appendiceal diameter of >6 mm, the presence of an appendicolith, and abnormally increased echogenicity of the periappendiceal fat. The major concerns with using abdominal ultrasonography to evaluate the potential diagnosis of acute appendicitis are the innate limitations of ultrasonography in patients with obesity and the operator-dependency to find the suggestive features. Moreover, patients with peritonitis would hardly tolerate the graded compression.[49][9]

In pregnant patients with suspected acute appendicitis, the initial study of choice is ultrasound with graded compression of the right lower quadrant starting at the point of maximal tenderness and scanning between the border of the pelvis, iliac artery, and psoas muscle. The ultrasonographic findings consistent with acute appendicitis are the same in pregnant and nonpregnant persons.[50][51] Ultrasonography is safe in pregnancy and offers information on fetal well-being and obstetrical causes of acute abdominal pain, such as placental abruption. However, ultrasonography is a user-dependent tool, and the gravid uterus will reduce ultrasound sensitivity and specificity for acute appendicitis.[50]

Computed Tomography

An abdominopelvic CT scan has greater than 95% accuracy for diagnosing acute appendicitis.

CT criteria for appendicitis include an enlarged appendix, appendiceal wall thickening, periappendiceal fat stranding, appendiceal wall enhancement, the appearance of inflamed soft tissue at the appendiceal base separating the appendix from the cecum, and the presence of appendicolith.[52][9] In most cases of appendicitis, observing intraluminal air or the contrast media due to luminal distention is uncommon. Non-visualization of the appendix does not rule out appendicitis.

The major concern with obtaining an abdominopelvic CT scan is radiation exposure; however, the average exposure with a typical CT would not exceed 4 mSv, slightly above the background exposure of almost 3 mSv. Modifications of this protocol result in exposure well below the doses known to potentially cause adverse fetal effects. However, the use of abdominopelvic CT in evaluating pregnant patients with suspected acute appendicitis is reserved for circumstances in which ultrasonography is inconclusive and MRI is unavailable.[53][54][55][9][50][56][40][57]

Magnetic Resonance Imaging

Abdominopelvic MRI is highly sensitive and specific for the diagnosis of acute appendicitis. However, due to costs and accessibility, its indications are mainly limited to groups of patients with an embedded risk of radiation exposure, including pregnant women.

MRI demonstrates exceptional sensitivity of 91.8 % and specificity of 97.9% for diagnosing acute appendicitis in clinically symptomatic pregnant individuals. MRI may also be useful for pregnant patients with suspected appendicitis and an indeterminate ultrasound.[58]

MRI protocols may differ significantly; most encompass imaging in three planes using a swiftly acquired sequence featuring T2 weighting, and a subset incorporate T2 fat-suppressed imaging. MRI findings parallel those observed in alternative modalities, encompassing luminal distension and dilation, wall thickening, and periappendiceal free fluid.[58][9]

Routine use of MRI in pregnant patients reduces the negative appendectomy rate by almost 50% and does not increase the perforation rate. MRI has performed relatively well in a few limited retrospective studies ranging from 97 to 100% sensitivity.[59][60] When available, the liberal use of MRI in pregnant patients suspected to have acute appendicitis is recommended for these reasons. When MRI is unavailable or available only on a limited basis, the decision about any delay in appendectomy to obtain an MRI study requires all available clinical and imaging information, as the potential consequences of both negative appendectomy and appendiceal perforation are severe.[50]

Treatment / Management

Surgical Treatment of Acute Appendicitis Without Perforation

Usually, the curative treatment of acute appendicitis is appendectomy. Perioperative antibiotic treatment should cover Gram-negative and Gram-positive bacteria (usually with second-generation cephalosporin) and anaerobes (clindamycin or metronidazole). Delaying surgical intervention for more than 24 hours after symptoms appear increases the perforation risk.[61][62][63]

The two mainstream approaches for appendectomy are laparoscopic and open techniques. No randomized trials have been performed to suggest that one technique is better than another; therefore, the choice of technique should be based on the clinical status and preferences of the patient, the gestational age and the size of the gravid uterus, and the surgeon's experience level. However, current guidelines state that laparoscopic appendectomy is the standard of care in pregnant patients as it is safe, allows easier identification of the variable location of the appendix, and offers an opportunity to evaluate the abdomen for any associated pathologic processes.[64]

Despite this, multiple systematic reviews comparing laparoscopic appendectomy and open appendectomy have indicated a slightly higher potential for fetal loss among pregnant patients undergoing laparoscopic surgery.[65][66] However, laparoscopic appendectomy for acute appendicitis significantly decreases the time spent in surgery and the duration of hospitalization. Additionally, both the open and laparoscopic appendectomy groups showed comparable obstetric outcomes. These findings strongly support the effectiveness of the laparoscopic approach in treating acute appendicitis during pregnancy.[14]

Some of the recommended modifications for the laparoscopic technique include a slight left-lateral positioning of patients after 20 weeks estimated gestational age, the use of an open-access approach for initial trocar placement to avoid injury to the gravid uterus, limiting intraabdominal insufflation pressure to less than 12 mmHg, and adjustment of port position for fundal height.[67][68]

When performing an open appendectomy in a pregnant patient, a transverse incision is made at the point of maximal tenderness and not necessarily at the McBurney point.[29][30] When the diagnosis is less certain, a lower midline vertical incision may be a possible option since it allows exposure of the abdomen to diagnose and treat other surgical conditions that mimic appendicitis.

Nonsurgical management of acute appendicitis using antibiotic therapy has been associated with a higher likelihood of negative outcomes in pregnant individuals. Therefore, appendectomy remains the established and preferred treatment for acute appendicitis during pregnancy.[69][70]

Treatment of Complicated Acute Appendicitis with Perforation

If an appendiceal perforation is present, the management will depend on the nature of the perforation. A free perforation that causes the dissemination of pus and fecal material into the peritoneal cavity will likely result in a very ill and potentially septic patient with an increased risk of preterm labor, delivery, and fetal loss. These patients require urgent laparotomy for appendectomy with irrigation and drainage of the peritoneal cavity.[71][72]

Nonpregnant patients with long-standing symptoms of more than five days suggestive of a contained perforation are usually managed with antibiotics, intravenous fluids, and bowel rest. Immediate surgery in this group of patients correlates with increased morbidity due to adhesions and inflammation and unavoidable injury to the adjacent structures. There may be the development of serious postoperative complications, such as abscesses or enterocutaneous fistulae, requiring reoperation for more extensive resections and the need for colostomies.

The evidence regarding the management of a contained appendiceal perforation in pregnant patients is sparse.[73] It is advisable to proceed cautiously and monitor these patients in the hospital to avoid sepsis, preterm labor, or fetal loss. Information regarding interventional drainage of appendiceal abscesses in pregnant patients is not available.

Differential Diagnosis

The differential diagnosis of suspected acute appendicitis during pregnancy includes disorders typically considered in nonpregnant individuals. Therefore the clinician should consider cecal diverticulitis, Meckel diverticulitis, acute ileitis, inflammatory bowel disease, renal colic, and urinary tract infections. Gynecological conditions in the differential diagnosis include tubo-ovarian abscess, pelvic inflammatory disease, ruptured ovarian cyst, and adnexal torsion.

Perhaps more importantly, pregnancy-related causes of lower abdominal pain, fever, leukocytosis, nausea and vomiting, and changes in bowel function need to be considered, such as placental abruption, uterine rupture, preeclampsia, and HELLP (hemolysis, elevated liver function tests, low platelets) syndrome. During early pregnancy, ectopic pregnancy requires exclusion. Round ligament syndrome as a cause of right lower quadrant pain during periods of rapid uterine growth must be considered.

Surgical Oncology

Appendiceal malignancies are rare, with 1.2 cases per 100,000 in the United States. The average age at presentation is 50 to 55 years; however, appendiceal neoplasms can occur during the reproductive years. Approximately 30% of appendiceal malignancies present acutely. The most common appendiceal malignancies are gastroenteropancreatic neuroendocrine tumors (GEP-NETs), goblet cell carcinoma, colonic-type adenocarcinoma, and mucinous neoplasms.[74]

Gastroenteropancreatic Neuroendocrine Tumors (GEP-NETs)

(GEP-NETs) are the most common histopathological subtypes of appendiceal malignancies. They rarely metastasize to the liver or lymph nodes; in patients with suspicious GEP-NETs, further evaluation of the liver and the ileocolic lymph node basin is essential. The primary tumor size dictates the surgical evaluation.

Goblet Cell Carcinoma

Goblet cell carcinomas are ubiquitous in appendiceal malignancies, sharing the diagnostic features of both appendiceal adenocarcinoma and neuroendocrine tumors. A comprehensive peritoneal evaluation with further peritoneal cancer index score documentation should be undertaken.[75]

Lymphoma

Non-Hodgkin lymphomas (NHL), and its subtypes, including mucosa-associated lymphoid tissue (MALT) lymphomas, might initially present with acute appendicitis. The surgical management of this extremely uncommon appendiceal malignancy is limited to a simple appendectomy. However, a comprehensive systemic evaluation should be included to exclude any potential metastatic site.[76]

Adenocarcinoma

Adenocarcinoma of the appendix, a rare appendiceal neoplasm with three histopathological subtypes, most commonly presents with acute appendicitis. The standard treatment is performing a right hemicolectomy, irrespective of the tumor size and or the involvement of the lymph node basin.[77]

Mucocele and Mucinous Neoplasm

Appendiceal mucocele, which might result from a benign or malignant spectrum of mucosal hyperplasia and various cystic formations, might present with acute appendicitis. Several pre-operative radiological features, including a well-encapsulated cystic structure in the right lower quadrant, suggest an appendiceal mucocele; however, a definitive diagnosis requires intraoperative evaluation and histopathological reports.

The preferred surgical management is an appendectomy with extraordinary cautionary measures to prevent capsular rupture. A comprehensive peritoneal evaluation with further peritoneal cancer index score documentation should be undertaken. Patient selection for the laparoscopic approach in managing appendiceal mucocele is critical and is limited to those with radiologic features suggestive of a homogenous cyst.[78]

Prognosis

Appendectomy is a relatively safe surgical procedure. In a global observational study of the general population, the overall mortality rate for appendicitis was 0.28%.[79] The following factors are associated with increased mortality rates in appendicitis in the general population: age greater than 80 years, immunosuppression, severe cardiovascular disease or the presence of other comorbidities, previous episodes of suspected appendicitis, and prior antimicrobial therapy. If acute appendicitis is diagnosed and definitively treated early in the disease, recovery is expected within 24 to 48 hours. However, patients with advanced abscesses, peritonitis, or sepsis may have a more prolonged and complicated course, possibly requiring additional surgery.

The long-term prognosis for pregnant patients undergoing appendectomy is generally good. Preexisting morbidities, not the surgery itself, are the greater risk factors for postoperative adverse obstetric events.[80][81] Maternal morbidity and mortality following appendectomy are low and comparable to nonpregnant patients.[82]

Complications

The complications of appendectomy in pregnancy include risks to the pregnancy, fetus, and gravida. Bleeding, postoperative infection, intraperitoneal abscess formation, injury to surrounding tissues, pain, and scarring are all known risks of appendectomy. However, untreated appendicitis carries a significant risk of appendiceal perforation. Free perforations can disseminate purulent and feculent material into the peritoneal cavity, increasing the risk of preterm labor, preterm delivery, and fetal loss.

The risk of fetal loss during uncomplicated appendectomies is 2%; however, in the presence of generalized peritonitis and peritoneal abscess, the fetal loss may increase to 6%.[72] In the presence of free appendiceal perforation, the risk of fetal loss may rise to 36%.[71] The incidence of preterm labor due to appendectomy is 4% and rises to 11% in cases of complicated appendicitis. The association between negative appendectomy to preterm labor and fetal loss is 10% and 4%, respectively.[72]

Promptly diagnosing and managing acute appendicitis in pregnancy significantly reduces the morbidity and mortality rates for both gravida and fetus.

Consultations

Any suspected case of acute appendicitis in pregnancy requires an obstetrical consultation to rule out obstetric and gynecological causes of pain as well as to establish the well-being of the fetus before, during, and after anesthesia.

Deterrence and Patient Education

Acute appendicitis is a common disease process during the reproductive years and is the most common nonobstetric surgical diagnosis during pregnancy.

The risks of appendectomy during pregnancy are low for both the gravida and fetus. However, appendiceal perforation, particularly free perforation, carries significant morbidity and mortality for both the gravida and the fetus. The risk of appendiceal rupture is variable but is about 2% at 36 hours after the onset of symptoms and increases by approximately 5% every 12 hours after that.

Pregnant patients should be counseled to seek medical care if they develop persistent abdominal pain during their pregnancy, particularly if the pain is accompanied by anorexia, nausea, vomiting, or fever.

Enhancing Healthcare Team Outcomes

Acute appendicitis during pregnancy poses a diagnostic conundrum. These patients may exhibit nonspecific signs and symptoms such as vomiting, nausea, and leukocytosis. The cause of acute abdominal pain may be due to various diagnoses, including gynecological, obstetrical, gastrointestinal, urological, metabolic, and vascular etiologies. While the physical examination may reveal a surgical abdomen, the underlying etiology may be challenging to discern.

When caring for pregnant patients with acute appendicitis, a collaborative and coordinated approach involving physicians or advanced practice providers, nurses, pharmacists, and other healthcare professionals is crucial to ensure patient-centered care, improve outcomes and enhance safety for both the gravida and the fetus, and optimize team performance.

Physicians and advanced practice providers should possess knowledge and expertise of the unique anatomical and physiological changes during pregnancy that can affect the diagnosis and management of acute appendicitis. The timely diagnosis and treatment of acute appendicitis in pregnancy are crucial to minimizing risk to the gravida and fetus. An obstetrical care provider and a general surgeon must collaborate to develop a tailored treatment plan that incorporates the stage of pregnancy, the severity of appendicitis, and the potential impact on maternal and fetal well-being. In cases where evidence is not definitive or minimal, expert opinion from the specialist may be utilized to recommend the type of imaging or treatment.[64] [Level 1]

The anesthesia team must be consulted to determine the best technical anesthetic approach for whatever intervention is chosen, accounting for the stage of pregnancy and patient preferences.

The clinical nursing staff plays a vital role in conducting thorough assessments in the perioperative period, monitoring vital signs, and evaluating fetal well-being, including during the surgical procedure. The clinical nursing staff also educates patients about self-care, pain management, and postoperative recovery. The clinical pharmacy staff also plays a significant role in managing acute appendicitis in pregnancy by assisting the interprofessional team with developing a medication regimen compatible with pregnancy.

By leveraging their skills, adopting a patient-centered approach, promoting interprofessional communication, and coordinating care effectively, healthcare professionals can enhance patient outcomes, safety, and satisfaction when caring for pregnant patients with acute appendicitis. Continuous education, evidence-based practice, and a focus on delivering holistic and individualized care contribute to a successful team approach. [Level 5]

Details

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