Surgical Management of Appendicitis During Pregnancy

A 35-year-old gravida 2, para 1-0-0-1 mother at 33.1 weeks' gestation presented to the emergency department with a 2-day history of low-grade fever; nonbloody, nonbilious emesis; nonbloody diarrhea; and right lower quadrant pain. She noted sporadic contractions. Physical examination demonstrated right lower quadrant tenderness with rebound and guarding on examination. No fundal tenderness was present. Initial vital signs demonstrated a temperature of 100.3°F (37.9°C), a pulse of 105 beats/min, and a blood pressure of 121/73 mm Hg. Fetal monitoring revealed a reactive nonstress test, with maternal contractions every 4 minutes.The patient's cervix was closed on examination. Laboratory evaluation was significant for leukocytosis, with a white blood cell count of 23,000/µL (23 × 109/L). The differential diagnosis included appendicitis, preterm labor, intra-amniotic infection, and gastroenteritis. General surgery consultation was obtained given the possible diagnosis of appendicitis.Further evaluation of the maternal clinical status included imaging with pelvic ultrasonography, which was normal, with nonvisualization of the appendix. The ovaries were normal. The fetus had active movement and normal amniotic fluid. A pelvic magnetic resonance image (MRI) demonstrated an enlarged appendix measuring 8 mm in diameter with periappendiceal fat infiltration (Fig 1).An urgent consultation was placed with general surgery, who advised expedited surgical management to avoid appendiceal rupture. Multidisciplinary care with maternal-fetal medicine and general surgery occurred with discussion about the surgical approach for the appendectomy. She received a dose of ceftriaxone and metronidazole preoperatively. The patient was counseled regarding the benefits and risks of surgical management compared with medical management with antibiotics alone. The potential risks of medical management alone, including progression and appendiceal rupture, development of preterm labor, and maternal systemic infection, were discussed. The patient agreed to surgical management with intermittent fetal monitoring.A preoperative huddle occurred with the multidisciplinary care team, including general surgery, maternal-fetal medicine, neonatology, anesthesia, and nursing. Preparation regarding maternal surgical positioning, intermittent fetal monitoring by ultrasonography, and general anesthesia occurred. The patient proceeded to the operating room for laparoscopic appendectomy with possible open appendectomy. Preparation was made for the rare possibility of a cesarean delivery.An uncomplicated laparoscopic appendectomy was performed. There was no evidence of appendiceal perforation. Intermittent fetal monitoring was performed by the obstetrician via ultrasonography using a sterile transducer cover. A cesarean delivery kit was available, and the neonatology team was aware of the ongoing procedure. The fetal heart rate remained normal. The patient was extubated and tolerated the procedure well, with no complications. She remained hemodynamically stable postoperatively, and a repeated white blood cell count improved to 16,000/μL (16 × 109/L). Two hours of postoperative fetal monitoring was reassuring (Fig 2). On postoperative day 1, the patient was discharged, still pregnant, to resume scheduled prenatal care.The patient presents in spontaneous labor at 39.3 weeks' gestation. She has an uncomplicated vaginal birth and is discharged on postpartum day 2.The male neonate was delivered at term weighing 3,856 g, with Apgar scores of 8 and 9 at 1 and 5 minutes, respectively. The neonate was admitted to the regular nursery without issue and was discharged with his mother.Appendicitis is the leading cause of nonobstetric surgery in pregnant individuals. Similar to nonpregnant patients, appendicitis in pregnant patients is most commonly caused by obstruction of the appendiceal lumen. Diagnosis can often be delayed or more difficult in pregnancy due to the shifts in anatomy with the gravid uterus, atypical symptoms or symptoms that are mistaken for other pregnancy-related symptoms, and physiologic changes in laboratory values in normal pregnancy, such as leukocytosis. (1)Overall, the goal of managing acute appendicitis in pregnancy centers around the principle of maintaining maternal stability with prompt treatment to optimize maternal and fetal outcomes. Although elective surgery is typically deferred until after pregnancy, acute appendicitis warrants expedited pursuit of surgical management before appendiceal perforation occurs. Ruptured appendicitis increases the risk of maternal sepsis, abscess formation, and pregnancy complications such as preterm labor and stillbirth. Prompt recognition with appropriate evaluation and targeted treatment are essential in avoiding these complications. (1)Imaging is an essential component of the diagnostic evaluation for all pregnant patients with suspected acute appendicitis. The American College of Obstetricians and Gynecologists' Committee on Obstetric Practice has recommended that with respect to imaging during pregnancy, ultrasonography and MRI should be the modalities of choice given their lack of ionizing radiation, which can negatively impact the developing fetus. (2) Ultrasonography is a low-risk and readily available imaging modality that can be used as an initial imaging step to evaluate for appendicitis or another pelvic pathology. The appendix may not be imaged due to the gravid uterus or the varied location of the appendix in pregnancy. (2) MRI provides additional benefit compared with ultrasonography given its ability to provide more detailed visualization of soft tissue structures. MRI has lower rates of nonvisualization compared with ultrasonography. Furthermore, there is evidence that MRI can improve diagnostic accuracy by decreasing the rate of negative appendectomies in pregnant patients. (3) Note that the use of gadolinium in contrasted MRI studies during pregnancy has been controversial due to unknown effects on the developing fetus. MRI without gadolinium can reliably assess the appendix. If MRI is not available in a timely manner and diagnostic imaging is indicated, computed tomography (CT) of the pelvis can be considered after discussion of the risks and benefits. (2) The radiation exposure from CT of the pelvis may be associated with a slight increased risk of neonatal malignancy by a factor of 2 above a background risk of 1 in 3,000. A single CT scan of the pelvis using a low-dose radiation protocol is expected to deliver a lower radiation exposure than the stated radiation threshold in pregnancy. (2)Approximately 2% of pregnant individuals require nonobstetric surgery during pregnancy. Typically, procedures described as elective should be delayed until the postpartum period as long as the delay does not cause deleterious effects to the pregnant person's health. Due to the challenges of conducting randomized clinical trials in the pregnant population, data to guide specific recommendations regarding surgery in pregnancy are lacking. A medically necessary surgery should not be delayed regardless of the trimester or denied due to the risk of adversely affecting not only the pregnant individual but also her fetus. Delays in surgical treatment of medically necessary conditions such as appendicitis, cholecystitis or choledocholithiasis can lead to pregnancy complications and deterioration of both the maternal and fetal statuses. Although there may be risk of surgical complications from any procedure, in a pregnant individual, delays resulting in a more advanced medical condition, such as systemic infection, increase the likelihood of pregnancy complications. Given the physiologic changes in pregnancy and unique anatomic differences in the abdomen and pelvis from the gravid uterus, consultation with obstetrics is advised to optimize the surgical setup and procedure (Fig 3).There has not been demonstrated teratogenic risk with the use of any anesthetic agents in pregnancy, and, therefore, standard use of anesthetic agents similar to the nonpregnant population in conjunction with anesthesia personnel is advised. (4) Unique anatomic changes with the gravid uterus warrant tilting the patient slightly, avoiding the direct supine position, which may result in hypotension from vena caval compression. (4) Optimizing mean arterial pressure in a pregnant person during surgery lessens the likelihood of hypoperfusion of the uterus. Similarly, fetal heart rate monitoring may be considered concurrently during a surgery in a viable fetus and used as an additional assessment of optimizing maternal positioning and cardiorespiratory management. (4) The likelihood of need for an unexpected cesarean delivery intraoperatively is low, particularly with an intraoperative hemodynamically stable maternal status. Obstetric personnel with the capability to perform an emergency cesarean delivery are necessary if fetal monitoring is to occur. (4)Appendectomy is the definitive surgical treatment for most cases of appendicitis in both pregnant and nonpregnant patients. (1) There are many important considerations in performing nonobstetric procedures in pregnant patients, including proper maternal positioning, coordinated multidisciplinary care, and monitoring of both maternal and fetal hemodynamics according to gestational age. If managed appropriately, there is relatively low risk for any need to proceed to urgent delivery. This patient presented in the third trimester with acute appendicitis and had an uncomplicated surgery and recovery resulting in a term uncomplicated delivery.

Topic: Appendicitis Diagnosis and Management
Subfield: Emergency Medicine
Field: Medicine
Domain: Health Sciences