Acute Appendicitis in Pregnancy

In I892, Lawson Tait described a case in which four years previously he had successful diagnosed and removed the first acutely inflamed appendix (Shepherd, I956). In the same year Wiggins reported a case of perforated appendix with a three-month foetus in utero in which he advised removal of the appendix, only to have his counsel rejected by the patient's relatives. She died of peritonitis and the pregnancy was found postmortem. Munde, in I894, appears to have reported the first successful American case to be tieated by operation. 13ahler (I908), and later Marbury (1953), both quote Hancock (I848) as having reported a case of perityphlitic abscess drained surgically in the puerperium, but it is doubtful from the history if this was in fact such a case. It seems more probable that he was dealing with a strangulated Richter's hernia. The occurrence of five cases, in the past two years at the Middlesex Hospital, of this complication of pregnancy, has prompted a further study of the condition. A search through the records of the last ii years revealed only three others, making a total of eight cases in the period 19461956 inclusive. It is emphasised that only cases of acute appendicitis, confirmed by the operative findings and the histological report, have been included. One, case No. 7, was treated conservatively whilst pregnant, but was subsequently found at laparotomy to have incontestable evidence of a recent attack of acute appendicitis. Six other patients, in which appendicectomy was performed for symptoms and signs suggesting appendicitis but where chronic disease or evidence of past inflammation only was found, have not been included. These eight cases are related to a total number of deliveries in the same period of 8,6o8 patients, an incidence ofone case in i,078 deliveries. However, as only two cases occurred among patients already booked for delivery at the Middlesex Hospital the true incidence is obviously much lower. Rosner, quoted by Bahler (I908), found 22 cases in 15,000 pregnancies, whereas Van Gordt also cited by Bahler, gave an incidence of three cases in io,ooo pregnancies. More recently Cosgrove (1937) counted i8 cases in 25,000 live births and Smith and Bartlett (I940), found 20 cases in 66,431 live births, an incidence of i in 1,389 and i in 3,322 respectively. Differing criteria as to the diagnosis accounts for much of this variation, and the present series more nearly approaches that of Cosgrove (I937). Others approaching the matter differently, have stated that from 1.9 per cent. to 2 per cent. of all women who have appendicitis are also pregnant (Baer, Reis and Arens, I932, and Johnson, I944). The total number of appendicectomies performed at the Middlesex Hospital during the period under consideration on women between the ages of i6 to 45 years was i,288, of whom 14 were pregnant, and of whom only eight had acute appendicitis and were pregnant as well. This gives a figure of I.I per cent. which is not dissimilar to the aforementioned ones. In the series under review three cases occurred in the last trimester, whilst of the remaining five, two occurred at 26 weeks maturity, and the rest (three cases), between i6 and 2o weeks maturity. The number is, however, small and therefore little can be inferred from these figures. Because of its rarity, few are likely to be seen even during the lifetime of a busy practising obstetrician.