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Appendicitis during pregnancy

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Appendicitis during pregnancy Rinat Gabbay April 2002 Appendicitis: The most common surgical condition of the abdomen Lifetime occurrence of 7% Peak incidence 10-30y ... – PowerPoint PPT presentation

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Title: Appendicitis during pregnancy


1
Appendicitis during pregnancy
  • Rinat Gabbay April 2002

2
Appendicitis
  • The most common surgical condition of the abdomen
  • Lifetime occurrence of 7
  • Peak incidence 10-30y
  • The most common nonobstetric surgical
    intervention during pregnancy

3
Pathogenesis
  • Appendiceal lumen obstruction
  • lymphoid hyperplasia
  • fecaliths
  • parasites
  • foreign bodies
  • crohns disease
  • metastatic cancer
  • carcinoid syndrome

4
Incidence during pregnancy
  • Incidence 0.05
  • 11000 pregnant women - appendectomy
  • 11500 proved appendicitis (Mazze
    Kallen,1991)
  • 1st trimester 30 / 22
  • 2nd trimester 45 / 27
  • 3rd trimester 25 / 50
  • (Mourad,2000)

5
Incidence during pregnancy
  • Suggested relation with female sex hormones
    incidence variations during the menstrual cycle .
  • Reduced incidence of appendicitis during
    pregnancy, especially in third trimester
  • Protective effect of pregnancy ?
  • (Int J Epidemiol 2001 Dec30(6)1281-5)

6
symptoms
  • Pain RLQ / RUQ / Flank
  • Anorexia
  • Vomiting
  • Nausea
  • Pain migration
  • Fever

7
Physical examination
  • Tenderness RLQ
  • Rebound Guarding (peritoneal signs)
  • Rovsing sign
  • Dunphys sign
  • Psoas sign (retroperitoneal retrocecal appendix)
  • Obturator sign (pelvic appendix)
  • Rectal examination tenderness (cul-de-sac)
  • Low grade fever

8
Psoas sign
Obturator sign
9
Lab
  • CBC WBC ( 80 ? 45 )
  • CRP
  • Urinalysis - mild pyuria
  • mild proteinuria
  • mild hematuria

10
D.D. surgical gyneco
  • Renal stone
  • Gastroenteritis
  • Pancreatitis
  • Cholecystitis
  • Mesenteric adenitis
  • Hernia
  • Bowel obstruction
  • Preterm labor
  • Placenta abruptio
  • Chorioamnionitis
  • Adnexal torsion
  • Ectopic pregnancy
  • Pelvic inflammatory
  • Round lig. pain

11
Diagnostic problems
  • Position of appendix
  • normally 70 intraperitoneal
  • 30 pelvic, retroileal,
    retrocolic
  • pregnancy anatomical changes
  • gravid uterus ? displacement upward
  • outward ? flank pain (3rd trimester)
    (Baer,1932)
  • increased separation of peritoneum ? decreased
    perception of somatic pain and localization

12
Diagnostic problems
  • Symptoms complex physical changes
  • anorexia, nausea vomiting in normal
  • pregnancy
  • Lab relative leukocytosis
  • Imaging techniques

13
Diagnostic problems
  • Differential diagnosis
  • pyelonephritis
  • renal colic
  • placental abtuptio
  • uterine myoma degeneration

14
Imaging
  • KUB
  • Barium enema
  • Graded compression ultrasonography
  • Helical CT scan

15
Graded compression ultrasound
  • Normal appendix (lt6mm) rules out appendicitis.
  • Nonpregnant Sensitivity 85
  • specificity 92
  • Pregnant cecal displacement uterine
    imposition makes precise examination difficult
    (Williams,21 edition)

16
Acute appendicitis
17
  • 1.thickened
  • appendix
  • 2.Caecum
  • 3.Small amount of
  • pericaecal fluid
  • 4.perippendicular
  • hyperemia

18
Helical CT scan
  • Enlarged appendix,
  • No filling with contrast material,
  • Periappendiceal inflammatory changes
  • Nonpregnant patients 98 sensitivity
  • Pregnant - useful, noninvasive accurate
  • (Am J Obstet Gynecol 2001
    Apr184(5)954-7
  • Radiation ?

19
Diagnosis
  • Pain in RLQ is the most common presenting
    syndrome of appendicitis in pregnancy regardless
    of gestational age
  • (Am J
    Obstet Gynecol 2001 Jul185(1)259-60)
  • Physical examination is the most reliable tool
    for diagnosis (Am Surg
    2000 Jun66(6)555-9)
  • Fever and WBC are not clear indicators
  • (Am J Obstet
    Gynecol 2001 Jul185(1)259-60)

20
Treatment
  • Suspicion ?
  • immediate surgical intervention
  • Delay ?
  • generalized peritonitis
  • Antimicrobial therapy
    2nd cephalosporin, perioperative, unless
    gangrene, perforation, phlegmon

21
Tocolytics
  • Concept calm the uterus from insult of acute
    abdomen
  • Controversial
  • Ritodrine ineffective
  • anti-prostaglandin side effects
  • Ritodrine - tachycardia vomiting
  • anti-prostaglandin anti-inflammatory
    antipyretic, fetal side effects
  • (Annals of Saudi Med,
    Vol 18 No 2, 1998)

22
Surgery
  • Uncomplicated / complicated surgical procedure ?
    pregnancy outcome
  • Perinatal morbidity in nonobstetrical surgery in
    pregnancy tributable to the disease itself

  • (Mazze and Kallen,1989)
  • Laparotomy
  • Incision choice in all trimesters
    McBurneys point (Am J Surg 2002
    Jan183(1)20-2)

23
laparoscopy
  • Adv
  • Less post-op complication
  • Disadv
  • Co2 pneumoperitoneum
  • Dec. uterine blood flow
  • Fetal acidosis
  • Premature labor
  • Safe especially in 1st half of pregnancy (size of
    gravid uterus)
  • Similar perinatal outcomes compared to
    laparotomies (Reedy and colleagues,1997)

24
The mortality of appendicitis complicating
pregnancy is the mortality of delay

  • Babler 1908

25
Complications
  • Gestational age ? Complication rate
  • (Tracey
    and Fletcher,2000)
  • Uterine contractions 80 over 24w
  • Preterm labor
  • 1. 3rd trimester
  • 2. Perforated appendix peritonitis

26
Complications
  • Abortion , Fetal loss 15 (1st trimester)
  • Decreased birth weight
  • Other surgical complication wound infection,
    atelectasis etc.
  • No increased infertility (Viktrup and Hee,1998)
  • No congenital malformation
  • No stillborn infants

27
Perforated appendicitis
  • Incidence
  • 4 -19 nonpregnant patients
  • 57 pregnant women (Tracey
    Fletcher,2000)
  • Gestational age ? Perforations ?
  • Peritonitis

28
Perforation why more ???
  • No direct cause and effect relationship between
    prolonged duration of symptoms and perforation
  • No relationship between time to operative
    intervention and perforation
  • Anatomical explanation
  • (Am
    Surg 2000 Jun66(6)555-9)

29
Perforation why more ???
  • Position change of appendix
  • No containment of infection by omentum
  • Inability of omentum to isolate infection
  • More generalized peritonitis

30
White appendix
  • Nonpregnant 20
  • Pregnant 20-50 ( higher in advanced pregnancy)

31
Appendicitis during puerperium
  • Appendicitis can stimulate labor after the
    uterus empties there is diffuse peritonitis

32
Prognosis
  • Generally good
  • Disease found
  • Surgery complications

33
The end
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