Pregnant Patient Returns!
Answer: D
Appendicitis in the pregnant patient
Appendicitis in the pregnant patient
- Most common cause of acute abdomen in the pregnant patient
- Most common non-obstetric cause of surgical emergency in pregnancy
- Overall incidence of appendicitis is not changed during pregnancy but the severity might be increased; incidence: 1/1500 pregnancies
- Delay in diagnosis remains the leading cause of morbidity in this disease process. Early diagnosis is important because of increased rate of fetal loss and maternal mortality.
- The incidence of perforation is 25%, and if surgery is delayed more than 24hrs, the incidence of perforation increases to 66%
- Ruptured appendicitis is associated with a 30% chance of fetal loss in the 1st and 2nd trimester, and as high as 70% in the 3rd trimester, compared to 3-5% risk without rupture
- Maternal mortality is 4% with ruptured appendicitis.
- Almost always, abdominal pain is present
- Nausea is almost always present; vomiting in 2/3 patients
- Anorexia is less common that non-pregnant patients – only in 1/3-2/3 patients
- Location of appendix:
- 1st trimester: appendix will be at McBurney’s point
- 2nd trimester: appendix is displaced upward and laterally, usually periumbilical or just right of this area
- 3rd trimester: near the gallbladder or diffuse
- Postpartum day 10: appendix returns to its normal position
- Direct abdominal tenderness is observed most commonly
- Rebound tenderness is present in 55-75% of patients
- Abdominal muscle rigidity is observed in 50-65% patients
- Psoas irritation is less common than non-pregnant patients
- Rectal tenderness is usually present, especially in the 1st trimester
- Fever and tachycardia are variable – not sensitive signs.
- Leukocytosis is difficult to interpret, since WBC is often high as 15,000 in pregnancy. Severe disease can occur with normal WBC. Granulocytosis (left shift) suggests an infectious etiology.
- Urinalysis: sterile pyuria is observed in 10-20% of patients with appendicitis
- Graded compression ultrasound is 1st choice (very operator dependent, sensitivities range from 50-100%, specificities 33-92%, negative predictive values – 64-88% for sonographic diagnosis of appy in general adult population). Retrocecal or elevated appendix may be difficult to find sonographically, and a ruptured appendix may be hard to find on ultrasound (sensitivity is 28.5% versus 80.5% in a nonperforating appendicitis) Therefore, a negative US examination does not exclude the possibility of appendicitis, and if there remains a high clinical suspicion, additional imaging should be considered. It is not useful if >35 weeks, as the graded compression technique is not able to visualize the appendix clearly.
- 2nd line is MRI without contrast – especially in the 2nd and 3rd trimester, in which US is difficult. Both T1W and T2 sequences are performed. Imaging sequences: axial, sagittal, coronal T2 weighted single-shot fast spin echo (SSFSE), axial T1-weighted dual gradient-echo, axial true fast imaging with steady-state precession (FISP), and axial STIR.
- 3rd line is CT – can be performed in the 2nd and 3rd trimester if MR imaging is unavailable or there is lack of expertise.
- Laparoscopy