Appendicitis in pregnancy: how to manage and whether to deliver

Key content

Appendicitis in pregnancy is common.

Whether to deliver a pregnant woman with appendicitis is a contentious issue.

There are many uncertainties with diagnosis of appendicitis in pregnancy.

Management of pregnant women with appendicitis requires a multidisciplinary approach

involving obstetricians, anaesthetists and surgeons.

Learning objectives

To understand the modalities useful in accurate diagnosis of appendicitis in pregnancy.

To learn about the range of clinical presentations and differential diagnoses.

To appreciate the risks involved with different management options, anaesthetic and surgical.

To be able to manage a pregnant woman with suspected appendicitis for the best possible

outcome.

Ethical issues

Operative delivery of a pregnant woman with appendicitis may put her at unnecessary risk. How

should she best be managed for the best possible outcome for her and the fetus?

Keywords: appendicitis / delivery / pregnancy / risk / surgery

Introduction
A pregnant patient presenting with suspected appendicitis presents an interesting clinical

question to both obstetricians and general surgeons (Box 1). It is not clear whether acute

appendicitis is an indication for delivery of a term infant or whether entry into the uterus is best

avoided in the case of intra-abdominal sepsis. Certainly the appendicectomy may be easier to

perform once the uterus is empty but in a young primiparous patient is this sufficient indication

for undertaking caesarean section (CS)? And in cases where the fetus is premature, how should

the patient best be managed? A review was undertaken to clarify management for such cases in

future.

Background

Acute appendicitis is inflammation of the appendix, which in its worst form can lead to rupture.

It is the most common cause of an acute surgical abdomen in pregnancy. Despite this, results

from the Swedish registry study which compared 778 patients undergoing appendicectomy in

pregnancy with non pregnant population based age matched controls found that the pregnant

women were, in fact, less likely to develop appendicitis (odds ratio 78, 95% CI 0.73–0.82).1 In

developed countries acute appendicitis is suspected in 1/ 800 pregnancies and confirmed in 1/800

to 1/1500.2 Its incidence is most common in the second trimester.2

Symptoms and signs

Patients with appendicitis in pregnancy often present in a non classical way (Table 1). In the

classic presentation, central abdominal pain localises to the right iliac fossa – at McBurney’s

point which is 6 cmalong a line from the anterior superior iliac spine toward the umbilicus.3 Pain

is associated with anorexia, nausea and fever up to 39.3°C with raised white cell count.
Underlying inflammation irritates the anterior abdominal wall causing signs of rebound and

guarding; the ‘surgical’ abdomen. Rovsing’s sign of increased pain on withdrawing the

examining hand from the abdomen demonstrates peritoneal irritation. A pregnant patient may

present with heartburn, constipation, diarrhoea, urinary symptoms or just general malaise. Pain

may be felt in McBurney’s point or anywhere on the right side of the abdomen.4 This occurs

because after 12 weeks the enlarged uterus stretches the anterior abdominal wall and omentum

away from the area of inflammation. This prevents the classic signs of rebound tenderness or

guarding.5

Investigations

Investigations can be misleading in pregnancy. Nonpregnant patients with acute appendicitis

usually have a mild leucocytosis, with white cell count over 10x109/L. This is a common finding

in normal pregnancy however, where the leucocyte count may reach 29 x109/L without any

underlying health problem. In pregnancy an elevated white cell count can be attributed to

inflammation if the C reactive protein (CRP) level is also raised. In general however, elevated

CRP is a very non-specific marker for inflammation.6 Imaging is indicated where the diagnosis

is uncertain. The primary goal of imaging is to reduce delays in surgical intervention. The

secondary goal is to reduce the negative appendicectomy rate.7 Ultrasound may identify an

enlarged appendix (a noncompressible, blind-ending tubular structure in the right iliac fossa

exceeding 6 mm diameter), ovarian cyst or cyst accident, fibroid or gallbladder disease.

Sensitivity for ultrasound in the diagnosis of appendicitis in pregnancy is 67–100% with

specificity of 83–96%, the variability being due to issues like gestational age, body mass index

and ultrasonographer error.8 Cardiotocography (CT) scanning for appendicitis in pregnancy has
a sensitivity of 86% and specificity of 97%. The disadvantage of CT is the exposure of the

mother and fetus to radiation and its potentially carcinogenic effects. It has not been clear during

studies whether CT for appendicitis is useful after an inconclusive ultrasound study.9 Magnetic

resonance imaging (MRI) is an alternative imaging technique for exclusion of acute appendicitis

in pregnancy when clinical examination and ultrasound are inconclusive. Its appeal is the

avoidance of exposure to radiation. Evaluation of MRI in pregnant women with suspected

appendicitis confers a sensitivity of 91% and a specificity of 98%.10 The American College of

Radiology dictates that MRI should be used in cases where ultrasound is inconclusive for

appendicitis in pregnancy.10

Differential diagnoses

Differential diagnoses for appendicitis in pregnancy include all of those possible in the

nonpregnant plus those pertaining to pregnancy itself.11 Ectopic pregnancy must be excluded in

any woman with a positive pregnancy test complaining of abdominal pain. This can be done by

ultrasound and correlation with blood human chorionic gonadotrophin levels. In a collapsed

patient with positive pregnancy test and abdominal pain, emergency diagnostic laparoscopy

should be done without delaying for results of investigations. The 2011 report from The Centre

for Maternal and Child Enquiries12 discussed cases where patients with ruptured ectopic

pregnancies had presented with gastrointestinal symptoms (likely due to irritation of the gut from

blood) and had been misdiagnosed in emergency departments with devastating consequences.

Threatened miscarriage may present with abdominal pain though gastrointestional symptoms are

rare. Examination of the cervix and correlation with ultrasound can clarify the diagnosis.

Gastroenteritis can cause similar symptoms to appendicitis although often diarrhoea or vomiting
may prevail.13 Close contacts may be affected, or a trigger identified (for example, takeaway

food or recent travel). In appendicitis, nausea and vomiting would usually follow the onset of

abdominal pain. Musculoskeletal pain is extremely common in pregnancy. It usually presents

with gradual onset, with exacerbation on movement and an absence of clinical signs or systemic

upset.14 Oral iron supplements can cause symptoms of gastrointestinal upset but these are

usually mild, can be related to the commencement of iron treatment and stools may be noticeably

darkened. Pyelonephritis may present with the same symptoms as appendicitis but a pyuria

would commonly be seen on urine testing.11 Pregnant women may not manifest the symptoms

of dysuria and urinary frequency commonly seen in nonpregnant patients with pyelonephritis or

urinary tract infection. In late pregnancy, pre-eclampsia or HELLP syndrome (haemolysis,

elevated liver enzymes, low platelets; a severe variant of pre-eclampsia) may present with

abdominal pain and vomiting. Hypertension and proteinuria would usually be seen by the time

abdominal symptoms have developed, although the first changes diagnostic of HELLP may be

seen in liver function tests and the full blood count. Placental abruption or uterine rupture

presents with pain and signs of fetal distress, uterine tenderness, vaginal bleeding or collapse.

These are rare before the final trimester. Chorioamnionitis can be difficult to differentiate from

appendicitis. There may be vague abdominal pain becoming more acute, nausea, vomiting, low

grade fever and diarrhoea. If there is a history of ruptured membranes and/or offensive vaginal

discharge the diagnosis is easier, however occult chorioamnionitis can occur with intact

membranes in the context of listeriosis.13 In postnatal women, ovarian vein thrombophlebitis

can occur.11 This presents with fever, abdominal pain and tenderness in the lower abdomen. The

patient is clinically unwell but gastrointestinal symptoms are unusual. Diagnosis of appendicitis

would be virtually impossible during labour and should be delayed until after delivery.
Management

The treatment for acute appendicitis is surgery.14 The decision to proceed to surgery in a

pregnant woman should be based upon clinical history, examination and imaging results. If the

diagnosis is certain, the decision to perform appendicectomy is easy. Maternal morbidity

following straightforward appendicectomy is low, and equates to that in the non pregnant

population. The difficulty comes when the diagnosis is unclear. Maternal and fetal morbidity

increase dramatically and directly in relation to the severity of the appendicitis. Fetal loss in

simple appendicitis is 1.5%,15 with generalised peritonitis 6%, and if the appendix perforates as

high as 36%.16 Perforation of an infected appendix can cause widespread pus and faecal soiling

of the intra-abdominal cavity. This can cause severe sepsis and a critically ill patient. In addition

to the risk of fetal loss, a perforated appendix increases the risk of preterm delivery17 and future

difficulties with pelvic adhesions and subfertility. Given the significant risks if the appendix

perforates, a lower index of suspicion is used for surgical treatment of appendicitis in the

pregnant patient and delay in definitive management should be avoided. A higher negative

laparotomy rate is considered acceptable. Up to 35% of laparotomies may be negative.18 This

can reduced a little by further preoperative imaging but is affected by relative reluctance to

undertake CT. If surgery does reveal a normal looking appendix it should still be excised. Acute

inflammation of the appendix may be a purely histological diagnosis, removal avoids future

intervention, and the surgery itself is low risk for complications. The technique used for

appendicectomy in a pregnant patient depends on gestation, how sick the individual is and

available surgical expertise. If a perforated appendix is suspected the patient should undergo

immediate laparotomy, appendicectomy and extensive irrigation of the abdomen. If the patient is

critically ill, delivery of the baby (thus emptying the uterus) permits more effective maternal
resuscitation and faster recovery. Maternal welfare should always be the priority and put ahead

of the fetus regardless of gestation. Appendicectomy is best performed in any pregnant patient

through a transverse incision over the point of maximal tenderness. If the diagnosis is not certain,

the general surgical approach would be to make a low midline vertical incision on the abdomen

to allow exposure for surgical treatment of appendicitis or any condition mimicking it.16,17 If

CS was necessary in due course, this same incision could be used but extended. Laparoscopic

appendicectomy is gaining in popularity as a technique. Case reports and small studies suggest

that this is safe and straightforward in all trimesters.17 A systematic retrospective review and

meta-analysis of observational studies demonstrated an increased risk of fetal loss (relative risk

1.91, 95% CI 1.31–2.77) for laparoscopic versus open appendicectomy.19 Antibiotics should not

be used alone in management without surgery as they are not sufficient for definitive

treatment.20 There is minimal evidence for the management of ‘chronic appendicitis’ in

pregnancy.21 This is where the appendix has ruptured but walled itself off thus limiting infection

and no longer requiring operative management. In nonpregnant patients, a ‘walled off’ appendix

may present with a relatively well patient but a prolonged course of symptoms, palpable right

iliac fossa mass, and abcess seen on ultrasound. Treatment consists of antibiotics, intravenous

fluids and monitoring. The patient may recover more quickly with such conservative

management rather than a surgical approach. There are virtually no data about how to manage

this condition when pregnant. If the woman is well enough it seems reasonable to delay

definitive management until after delivery.

Anaesthetic management
Pregnant women undergoing laparoscopy or laparotomy will require anaesthesia. It is crucial that

the surgeon and anaesthetist be aware of pregnancy-related changes in physiology that affect

management of the patient during surgery. General anaesthetic carries a 17-fold higher risk of

complications to the pregnant woman than regional anaesthesia. These include failed intubation

(in 3.3% due to pregnancy induced oedema, short neck, engorged large breasts), aspiration of

gastric contents (Mendelssohn syndrome) and hypoxia.22 Pregnant women desaturate far

quicker than nonpregnant women (3 minutes as opposed to 9 minutes) especially if body mass

index is high. All anaesthetic induction and maintenance agents cross the placenta but effects are

transient and ventilatory support to the neonate is only required until the effects have worn off, if

the neonate is born during general anaesthesia.23 If regional anaesthesia is possible it is therefore

preferred, the only risk being maternal hypotension following local anaestheticinduced

sympathetic blockade. Surgery on a pregnant patient with acute appendicitis should include a left

lateral tilt to avoid aortocaval compression, avoidance of uterine or cervical manipulation or

instrumentation, and limiting intra-abdominal pressure to less than 12 mmHg.24 There is no

evidence for giving tocolytic agents for prophylaxis during surgery. Minimising uterine

manipulation and cervical stimulation should be sufficient. General anaesthesia itself has a

tocolytic effect.25 Fetal heart rate monitoring should be conducted pre and postoperatively once

the fetus is considered viable – 24 weeks of gestation at present. If possible, the fetus could be

monitored throughout surgery, however, this is only useful if there would be intervention in the

case of non reassuring fetal heart rate patterns.25 If adequate maternal oxygenation and uterine

perfusion are maintained the fetus should tolerate surgery and anaesthetic well. During general

anaesthesia, effects of the drugs on the fetal brainstem may cause the fetal heart rate to

demonstrate reduced variability and a lower baseline rate.23 Maternal vasodilation from
decreased sympathetic tone and cardiodepressants in inhalational agents may lower blood

pressure with a resultant drop in uterine perfusion. If cardiotocography (CTG) changes consistent

with fetal compromise are seen, this can usually be reversed by maximising maternal

oxygenation, correcting hypovolaemia and hypotension and ensuring a left lateral tilt. Opiate

analgesia can be used safely to control perioperative pain. Non-steroidal anti-inflammatory drugs

should be avoided especially after 32 weeks of gestation as they may cause premature closure of

the ductus arteriosus. Pregnant patients are hypercoagulable due to changes in Vitamin K

dependent clotting factors and reduction in protein S. This reduces the chance of haemorrhage at

delivery time but confers an increased risk of thromboembolic event during surgery. All pregnant

women admitted to hospital for surgery should be provided with thromboembolic stockings

although strong evidence for this recommendation is lacking.26 A decision must be made as to

whether thromboprophylaxis with low molecular weight heparin is required.27 As a general rule,

any pregnant patient who is systemically unwell is likely to require thromboprophylaxis during

their hospital admission. Perioperative antibiotics should include Gram-negative, Gram-positive

and anaerobe cover, such as, cephalosporin plus metronidazole. Antibiotic prophylaxis should be

given if the patient undergoes surgery. Cephalosporins, penicillin, erythromycin, metronidazole,

azithromycin and clindamycin are considered safe in pregnancy. Aminoglycosides can cause

ototoxicity and nephrotoxicity, tetracyclines affect bone growth and stain teeth, trimethoprim,

nitrofurantoin and quinolones should be avoided.20

Effect of surgery on pregnancy

In general, surgery during pregnancy is not known to increase the risk of miscarriage. A

literature review of pregnancy outcomes after surgery reported that 10.5% of patients operated
on in the first trimester went on to miscarry.28,29 This figure is no different from the

background risk (8–16%).30 If the patient is critically ill and surgery is needed urgently it should

be done regardless of gestation.11 Maternal welfare should always be the priority and put ahead

of the fetus regardless of gestation. During the first trimester it is known that events may have an

‘all or nothing effect’. If the pregnancy is not lost entirely it is likely to be unaffected. Potentially

there is some risk of teratogenesis through drugs administered until the early second trimester. It

seems the second trimester is the best time to perform semi elective surgery as organogenesis is

complete and the rate of preterm delivery is 1% rather than 9% in the third trimester.28,29

Fortunately, the long-term prognosis for children born after appendicectomy in pregnancy is

good, with normal development at 17 months of age.31 If there is high risk of preterm delivery

and the gestation is critical – between 24 and 34 weeks, antenatal corticosteroids can be

administered preoperatively.32 These are given as two doses of 11.4 mg betamethasone 24 hours

apart. Maximum benefit to the fetus is seen between 48 hours and 1 week after the second dose,

so ideally surgery should be performed at that time. Steroids should be avoided in the case of

severe maternal sepsis however, including appendicitis, as they may impair the action of the

maternal immune system.32 Ongoing appendicitis and maternal sepsis may cause uterine

irritation and preterm labour. As per usual management, preterm labour after 34 weeks of

gestation can be allowed to proceed. Tocolysis for pregnancy prior to this gestation should only

be used if there is no contraindication to prolonging the pregnancy. Fears that an

appendicectomy incision could reopen during labour are unfounded. Presence of a recent

abdominal incision does not preclude pushing in the second stage. Casearean section is rarely

indicated at the time of appendicectomy.19,22,29 Unless the patient is critically ill, emptying the

uterus will not affect recovery from the surgery. Opening the uterus within an abdominal cavity
affected by peritonitis increases the risk of intrauterine infection and adhesions. This can cause

secondary problems with fertility. Unless the patient is over 37 weeks of gestation and expecting

a CS for obstetric indications the recommendation is that it not be done simultaneously.5,17,19

CTG monitoring in the septic patient will often demonstrate fetal tachycardia and reduced

variability. This can make it difficult to be certain of fetal wellbeing. Preoperative intravenous

hydration, antibiotic treatment and pain relief should result in restoration of a normal fetal

heartbeat. In the case of persistent fetal heart rate abnormalities, delivery should be arranged. If

the CTG remains abnormal at the time of planned appendicectomy, Caesarean section can be

undertaken for this obstetric indication. In this situation, risks outweigh benefits.

Conclusion

Appendicitis in pregnancy is common. Fetal and maternal outcomes are directly linked to the

severity of inflammation. Surgical management in pregnancy is the only option for cure at any

gestation. It seems that simultaneous delivery is only indicated in cases of critical fetal or

maternal compromise.