© Borgis - Postępy Nauk Medycznych 8/2014, s. 536-541
Karolina Wawiernia, *Barbara Bukowicka, Wiesław Tarnowski
Ostre zapalenie wyrostka robaczkowego w ciąży – przegląd piśmiennictwa i doświadczenia własne
Acute appendicitis in pregnant – review of the literature and our own experience
Department of General, Oncological and Gastrointestinal Surgery, Medical Centre of Postgraduate Education, Professor Witold Orłowski Independent Public Clinical Hospital, Warszawa
Head of Department: prof. Wiesław Tarnowski, MD, PhD
Wstęp. Ostre zapalenie wyrostka robaczkowego (OZWR) u kobiet w ciąży stanowi istotny problem kliniczny. Odmienności fizjologiczne związane z ciążą mogą być przyczyną opóźnienia w rozpoznaniu i prawidłowym leczeniu.
Materiał i metody. W latach 2004-2013 operowano 35 kobiet w ciąży z podejrzeniem OZWR. Śródoperacyjnie potwierdzono zapalenie wyrostka robaczkowego w 29 przypadkach. W pozostałych 6 przypadkach przyczyny dolegliwości były związane z inną patologią wewnątrzbrzuszną.
Wyniki. W grupie 29 pacjentek z OZWR średni wiek wynosił 28,4 roku. OZWR najczęściej występowało w II trymestrze ciąży. We wszystkich przypadkach stwierdzano ból w prawym dolnym kwadrancie brzucha, w 78% nudności i wymioty, wzrost leukocytozy powyżej 11,0 K/uL w 75% przypadkach 89.7% pacjentek było operowanych w pierwszej dobie od chwili przyjęcia do szpitala.
Wnioski. Leczenie chirurgiczne OZWR w ciąży powinno być wykonane w ciągu pierwszych 24 godzin od przyjęcia do szpitala.
Introduction. Acute appendicitis in pregnant women is essential clinical problem. Physiologic differencies of pregnancy can cause problems in diagnosis and proper treatment.
Material and methods. In period 2004-2013 35 pregnant women were operated on with clinical diagnosis of acute appendicitis. The diagnosis was proven at the time of operation in 29 cases. Causes of remain 6 cases were related to other intra-abdominal pathology.
Results. In group of 29 patients with acute appendicitis mean age was 28.4 years. Appendicitis occurred most often in second trimester of pregnancy. In all cases occurred pain in the lower right quadrant of the abdomen, in 78% nausea and vomiting were observed and in 75% leukocytosis was higher than 11.0 K/uL. 89.7% patients were operated on in first 24 hours after admission to the hospital.
Conclusions. Surgical treatment of acute appendicitis in pregnant women should be taken in first 24 hours after admission to the hospital.
Acute appendicitis (appendicitis) is the most common surgical disease in pregnant and is a risk factor for a healthy pregnancy (1). Moreover it causes an important diagnostic problem. The incidence is estimated at between 1 in 1400 to 1 in 1600 pregnancies (2-5). According to the statistics it occurs slightly more often in the second trimester of pregnancy (2-5) and is most common in patients between 20 and 30 years of age (6).
Diagnosis of appendicitis in pregnancy is associated with many difficulties at the stage of history taking and physical examination. Physiological pregnancy as well as complicated one are associated with many symptoms which are common with appendicitis, such as nausea, vomiting or eating disorders.
Other diagnostic difficulty may be caused by the location of pain. Patognomical location of pain in appendicitis in the right lower quadrant of the abdomen in typical cases during the pregnancy may not be present, because of the uterus enlargement and in turn intestine displacement especially after the fifth month of pregnancy (7-9). However, the pain in the right lower quadrant of the abdomen is reported to be a constant symptom of appendicitis (3, 10). Pain located in the lumbar region and laterally may be associated with appendicitis located behind ceacum, but also with urolithiasis or inflammation of the urinary tract. Anatomically, the right side is particularly predisposed to purulent urinary tract infections because the pressure on the right ureter caused by right sided flexure of the uterus and hormone-dependent decrease in motility of the ureters (11). These two phenomena contribute to urine retention and bacteriuria found in the urine analysis (12).
Many patients have no evidence of fever, white blood cell count is also not reliable as in the course of pregnancy it physiologically grows (13).
At the management of a pregnant patient there is a risk associated on one hand with too late diagnosis with the possibility of perforation, on the other hand with appendectomy in the absence of appendicitis (so-called “negative appendectomy”) (13). In the past, principle aggressive approach and fast qualification for surgery were practiced because it was thought that the risk of negative appendectomy is much smaller for the mother and fetus than restraining from the intervention. Thus, in the current literature, the index of negative appendectomies is as high as 50% (8, 9). A careful analysis of the problem shows that 30% of negative appendectomies ended with miscarriage or preterm birth (14).
However, appendicitis in pregnancy – also treated surgically – carries the risk of perinatal complications. Perinatal complications are observed at a level from 10 to 20% of patients. Fortunately mortality in the present time is at a very low level (11, 12, 15-31).
There is no single treatment protocol recommended and followed by all the medical centers. The most important is the conclusion that the delay in diagnosis definitely worsens the prognosis (32). In recent literature reviews (32) complicated appendicitis was significantly more often associated with miscarriage comparing to the appendicitis without perforation (12.1 vs 3.4%, P = 0.0027).
For each acute abdominal pain in pregnancy diagnosis should always lead toward confirmation or exclusion of appendicitis (33). It is important to also remember to exclude potentially fatal pathologies associated with pregnancy such as placenta abruption or uterine rupture (34). Diagnosis should be based on accurate history taking, physical examination, laboratory tests (peripheral blood morphology, urinalysis, liver profile: AST, ALT, also amylase, lipase). These studies are not enough to confirm the diagnosis of appendicitis but they may exclude other acute abdominal diseases (such as: acute pancreatitis, cholestasis of pregnant, urinary tract infection etc.). CRP level is generally above normal, but may remain within the limits (19, 20) – it does not constitute a patognomic parameter for appendicitis (as it does in the case of non-pregnant patients).
Additionally the standard practice is to perform an ultrasound imaging of the abdominal cavity and the fetus. Please note that an ultrasound in such conditions is extremely difficult. Although in some US studies, the sensitivity of abdominal ultrasound in the detection of appendicitis in children and adults was 98% (but usually is at a level of 86%) and a specificity of 81% (35), be aware that this method is very dependent on the person performing the study. In the presence of pregnancy related changes in the anatomical relations in the peritoneal cavity and the uterus itself, it is very difficult to make correct interpretation and appropriate diagnostic evaluation – hence the rate of positive tests is significantly reduced.
In case of a negative ultrasound (even 97% of appendicitis is not visualized) in cases of doubt should be considered an additional tomography (CT) and/or resonance imaging (MRI) of the abdomen (36). MRI (performed without a solution gadolinium) is of sensitivity of 80 to 86% and specificity of 97 to 99% (37). If MRI is not available it is recommended to perform a CT scan of the abdomen and pelvis with the lowest possible dose of radiation – that is less than 5 rad (standard dose of radiation used in the pelvic imaging is 1 to 5 rads, depending on local protocols) (38, 39).
Comparison of the methods for diagnostic imaging in appendicitis (40-43) (tab. 1 and fig. 1).
Table 1. Comparison of the methods for diagnostic imaging in appendicitis: advantages and disadvantages.
|Examination||Advantages||Disadvantages||Sensitivity %||Specifity %|
|Abdominal ultrasound||– no exposition for the radiation|
– no need of contrast
– high availability
– low cost
|– the result depends on the person performing the examination|
– often unclear results
|MRI||– no exposition for the radiation|
– comparing to the ultrasound the result is not so dependent from the person performing the examination
– requires radiologist expearienced with interpretation of MRI
– less available
|CT ||– comparing to the ultrasound the result is not so dependent from the person performing the examination|
– high availability
|– exposition of the fetus for the radiation (small dose from 1 to 4 rad)||92||99|
Fig. 1. Comparison of the methods for diagnostic imaging in appendicitis according to the trimester of the pregnancy.
Complications of appendicitis in pregnancy:
1. typical for appendicitis:
– perforation of the appendix,
– abscess/periappendical infiltration,
– acute peritonitis,
– wound infection,
– systemic septic complications,
2. associated with pregnancy:
– premature contractions,
– premature birth,
– low birth weight of the baby,
– intrauterine fetal death (44).
Algorithm for the management of pregnant patients with suspected appendicitis (13) (fig. 2).
Fig. 2. Algorithm for the management of pregnant patients with suspected appendicitis.
Acute appendicitis in pregnancy is an important issue. The more advanced the age of pregnancy, the more difficult is the diagnosis (12, 15) – as a result of the previously mentioned anatomical changes associated with the growing uterus. In a study of Freeland et al. on appendicitis diagnosis in pregnant (13), 15 to 20% of the patients with negative appendectomy had been diagnosed with another cause of discomfort (e.g. ovarian cyst, twisted fallopian tube, peritoneal lymphadenitis, salpingitis).
Operation – qualification, selection of access, perioperative management
In the case of suspected appendicitis qualification for surgery should take place within the first 24 hours of observation in order to avoid the risk of perforation or other severe complications (2, 5, 45).
At the time of diagnosis and qualification for the operation, the surgeon is facing with a dilemma: classical surgery or laparoscopic access. The choice of method of operation is the result of many factors and depends on the gestational age, the severity of appendicitis, the patient’s weight, previous abdominal surgery and the operator’s preference included. In the first trimester of pregnancy classical operation with access via laparotomy, performing McBurney incision in a typical location, which can be extended if necessary, usually ensures an adequate access for appendicitis. In the second and third trimester of pregnancy, it is recommended to open peritoneal cavity a little higher and more towards the right flank. Such access allows surgeon to visualize the pathology of appendix, which at this stage is usually raised together with the ceacum by the pregnant uterus (34). When the symptoms of diffuse peritonitis are present, some authors demonstrate the need for median incision which allows quick access to the entire peritoneal cavity (34).
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