INTRODUCTION — Acute appendicitis is the most common general surgical problem encountered during pregnancy . The diagnosis is particularly challenging during pregnancy because of the relatively high prevalence of abdominal/gastrointestinal discomfort, anatomic changes related to the enlarged uterus, and the physiologic leukocytosis of pregnancy. Appendiceal rupture occurs more frequently in pregnant individuals, especially in the third trimester, possibly because of these challenges and reluctance to operate on pregnant people delays diagnosis and treatment [2,3].
This topic will discuss the diagnosis and management of pregnant persons with suspected and confirmed appendicitis. Additional content on appendicitis can be found in related content, including:
In this topic, when discussing study results, we will use the terms "woman/en" or "patient(s)" as they are used in the studies presented. We encourage the reader to consider the specific counseling and treatment needs of transgender and gender diverse individuals.
INCIDENCE — Acute appendicitis is suspected in 1 in 600 to 1 in 1000 pregnancies and confirmed in 1 in 800 to 1 in 1500 pregnancies [4-7]. Appendicitis is less common in pregnant/postpartum than nonpregnant females . The incidence is slightly higher in the second trimester than in the first and third trimesters or postpartum. The second trimester is the most common time of occurrence [8,9].
Patient presentation — In the "classic" presentation, the patient describes the onset of abdominal pain as the first symptom. The pain is periumbilical initially and then migrates to the right lower quadrant as the inflammatory process progresses [10-12]. Anorexia, nausea and vomiting, if present, follow the onset of pain. Fever up to 101.0ºF (38.3ºC) and leukocytosis develop later.
However, many patients have a nonclassical presentation, with symptoms such as heartburn, bowel irregularity, flatulence, malaise, or diarrhea. If the appendix is retrocecal, patients often complain of a dull ache in the right lower quadrant rather than localized tenderness. Rectal or vaginal examination in such patients is more likely to elicit pain than abdominal examination. A pelvic appendix can cause tenderness below McBurney's point (described below); these patients often complain of urinary frequency and dysuria or rectal symptoms, such as tenesmus and diarrhea. The spectrum of clinical and laboratory findings associated with acute appendicitis is described in detail separately . (See "Acute appendicitis in adults: Clinical manifestations and differential diagnosis".)
Pregnant people are less likely to have a classic presentation of appendicitis than nonpregnant people, especially in late pregnancy. The most common symptom of appendicitis (ie, right lower quadrant pain) occurs close to McBurney's point in the majority of pregnant individuals, regardless of the stage of pregnancy [5,14,15]; however, the location of the appendix migrates a few centimeters cephalad with the enlarging uterus, so in the third trimester, pain may localize to the mid or even the upper right side of the abdomen [16-18].
McBurney's point tenderness is described as maximal tenderness at 1.5 to 2 inches from the anterior superior iliac spine (ASIS) on a straight line from the ASIS to the umbilicus . This tenderness may be less prominent during pregnancy because the gravid uterus lifts and stretches the anterior abdominal wall away from the inflamed appendix [20-22]. Since direct contact between the area of inflammation and parietal peritoneum is impeded, there is less rebound tenderness or guarding. The gravid uterus may also inhibit contact between the omentum and the inflamed appendix.
The largest review describing the frequency of the clinical signs and symptoms of appendicitis in pregnancy included 720 cases reported in the literature . The strength of this review is its size, which is 10-fold larger than other series; however, it has several limitations, including nonconsecutive selection of cases and case ascertainment prior to widespread use of current diagnostic imaging procedures. The following summary illustrates the cumulative frequency of signs and symptoms of appendicitis reported in this review. It does not account for differences in frequency according to gestational age and consists of a case mix of 75 percent acute inflammation only and 25 percent perforation.
•Abdominal pain: 96 percent
-Right lower quadrant: 75 percent
-Right upper quadrant: 20 percent
•Nausea: 85 percent
•Vomiting: 70 percent
•Anorexia: 65 percent
•Dysuria: 8 percent
•Right lower quadrant tenderness: 85 percent
•Rebound tenderness: 80 percent
•Abdominal guarding: 50 percent
•Rectal tenderness: 45 percent
•Right upper quadrant tenderness: 20 percent
•Temperature >37.80 Celsius (1000 F): 20 percent
Laboratory — Approximately 80 percent of nonpregnant patients with appendicitis have a preoperative leukocytosis (white cells >10,000 cells/microL) and a left shift in the differential [23-26]. However, mild leukocytosis can be a normal finding in pregnant individuals: the total leukocyte count may be as high as 16,900 cell/microL in the third trimester (table 1), rising as high as 29,000 cells/microL during labor, and a slight left shift may occur [27,28] (see "Maternal adaptations to pregnancy: Hematologic changes", section on 'White blood cells'). In a retrospective review of 66,993 consecutive deliveries including 67 women with a probable diagnosis of acute appendicitis, the mean leukocyte counts in women with proven appendicitis and in those with histologically normal appendices were 16,400 cells/microL and 14,000 cells/microL, respectively .
Microscopic hematuria and pyuria may occur when the inflamed appendix is close to the bladder or ureter, but these findings are generally reported in less than 20 percent of patients [20,23,29-32].
Mild elevations in serum bilirubin (total bilirubin >1.0 mg/dL) have been described as a marker for appendiceal perforation (sensitivity 70 percent and specificity 86 percent ).
An elevated c-reactive protein level occurs in appendicitis, but is a nonspecific sign of inflammation.
DIAGNOSIS — Acute appendicitis is a histological diagnosis. The clinical diagnosis should be strongly suspected in pregnant individuals with classic findings: abdominal pain that migrates to the right lower quadrant, right lower quadrant tenderness, nausea/vomiting, fever, and leukocytosis with left shift. (See 'Clinical features' above.)
With a nonclassical presentation, which often happens in pregnancy, imaging is indicated [1,4,32]. The primary goal of imaging is to reduce delays in surgical intervention due to diagnostic uncertainty. A secondary goal is to reduce, but not eliminate, the negative appendectomy rate. In these cases, ultrasound may reveal the probable cause of the patient’s symptoms (eg, ovarian cyst or torsion, degeneration or torsion of a fibroid, nephrolithiasis, cholecystitis).
The diagnosis of acute appendicitis in a laboring patient requires a high index of suspicion, is especially difficult, and may not be possible. Labor can be associated with pain that may be lateralized, fever if chorioamnionitis is present, leukocytosis, and vomiting. Persistence or progression of these symptoms after delivery should prompt physical examination and imaging studies to evaluate for appendicitis.
Imaging — We take a stepped approach to selecting imaging studies for pregnant individuals with suspected appendicitis.
Ultrasonography — The initial modality of choice for diagnostic imaging of the appendix in pregnancy is graded compression ultrasonography . The clinical diagnosis of suspected appendicitis is supported by identification of a noncompressible blind-ended tubular structure in the right lower quadrant with a maximal diameter greater than 6 mm (image 1A-B) [35,36]. The diagnosis should not be excluded if the appendix is not visualized.
Test performance appears to be lower in pregnant people than nonpregnant individuals because the gravid uterus can alter the location of the appendix, can interfere with visualizing the appendix and performing graded compression, particularly in the third trimester, and can lead to inconclusive ultrasound findings [37-39]. Several studies reported nonvisualization of the appendix in a large percentage of pregnant individuals with suspected appendicitis [40-44]. However, in one review of studies of the value of ultrasound in diagnosing appendicitis in pregnancy, sensitivity ranged from 67 to 100 percent and specificity ranged from 83 to 96 percent, compared with the general population in whom sensitivity and specificity were 86 and 96 percent, respectively . We believe that the wide variation in the reported diagnostic performance of graded compression ultrasonography for appendicitis during pregnancy is due to multiple factors such as gestational age, maternal body mass index (BMI), and importantly, the training and experience of the sonologist or radiologist. (See "Diagnostic imaging in pregnant and lactating patients" and "Acute appendicitis in adults: Clinical manifestations and differential diagnosis".)
Magnetic resonance imaging (MRI) — For pregnant persons whose ultrasound examination is inconclusive for appendicitis, magnetic resonance imaging (MRI) is the preferred next test as it avoids the ionizing radiation of computed tomography (CT) and appears to be cost-effective (image 2) [34,46,47]. When MRI is performed during pregnancy, gadolinium is not routinely administered because of fetal safety concerns in the setting of conflicting data [48,49], although use of gadolinium may be considered if essential to maternal evaluation. At least one study has reported an increased risk of a broad set of rheumatologic, inflammatory, or infiltrative skin conditions and for stillbirth or neonatal death for pregnancies exposed to MRI with gadolinium compared with no-MRI pregnancies .
MRI has a high sensitivity and specificity for diagnosing appendicitis during pregnancy. A meta-analysis of 21 studies that included 2282 pregnant individuals who underwent MRI evaluation for suspected acute appendicitis reported a sensitivity of 0.96 (95% CI 0.88-0.99) and specificity of 0.97 (95% CI 0.95-0.98) .
The largest single study of pregnant persons suspected of having acute appendicitis (over 700 patients) reported 61 individuals had surgically confirmed disease out of 66 patients with suggestive MRI findings (ie, appendiceal dilation, appendicolith, free fluid, and fat stranding) . Based on this detection rate, the study reported the following pooled data for MRI assessment of appendicitis in pregnant individuals:
●Positive predictive value 92.4 percent (95% CI 83.2-97.5)
●Negative predictive value 99.7 percent (95% CI 98.9-99.9)
●Sensitivity 96.8 percent (95% CI 89-99.6)
●Specificity 99.2 percent (95% CI 98.2-99.8)
●Accuracy 99 percent (95% CI 98.0-99.6)
Of the five individuals with false-positive MRI studies, pathologic evaluation identified one ovarian torsion, one appendicolith with mild lymphoid hyperplasia, one fibrous obliteration of the appendiceal lumen without changes of acute appendicitis, and two normal appendices.
Compared with ultrasound, additional benefits of MRI include potential identification of peri-appendiceal findings when the appendix is not visualized and recognition of other causes of abdominal pain. In the study of over 700 women above, of 207 women whose appendix was not visible on MRI, three were surgically diagnosed with appendicitis; two women had positive secondary MRI findings (ie, right lower quadrant fluid and pericecal stranding) for appendicitis and one woman had a negative MRI . Of 643 pregnant women whose MRI studies were negative for appendicitis, 72 women had alternate MRI findings that could have accounted for their acute pain.
In reviewing the MRI images, the T1 bright appendix sign can be a useful finding for excluding appendicitis, in addition to the routinely used findings of enlarged appendix size, periappendiceal fat stranding, and high signal intensity on diffusion-weighted images. The T1 bright appendix sign, which is typically seen in normal pregnancy, is defined as a high intensity signal filling more than half length of the appendix on T1-weighted imaging (image 3). In a retrospective study of 125 pregnant women with suspected appendicitis, the T1 bright appendix was identified in 51 percent of women without appendicitis, but only in 4.5 percent of women with appendicitis . The overall sensitivity, specificity, positive predictive value, and negative predictive value were 44.9, 95.5, 97.6, and 30 percent, respectively. Thus, visualization of a bright appendix is helpful in excluding appendicitis, but a negative finding is not diagnostic for the disease.
If there is a prolonged wait time for MRI evaluation, the risk of potential appendiceal rupture is balanced against the potential benefits of the study, such as identifying a different cause of pain or avoiding surgery. If MRI if not readily available, then CT scan can be performed if the diagnosis is unclear. If either imaging modality is not available quickly or if the patient declines CT because of the radiation exposure, surgery should not be delayed in pregnant persons with findings suggestive of appendicitis despite inconclusive ultrasound results.
Computed tomography (CT) — We perform CT when clinical findings and ultrasound examination are inconclusive and MRI is not available, given the proven diagnostic value of CT in nonpregnant individuals: overall sensitivity 94 percent (95% CI 91-95), specificity 95 percent (95% CI 93-96), positive likelihood ratio 13.3 (95% CI 9.9-17.9), and negative likelihood ratio 0.09 (95% CI 0.07-0.12) .
CT is generally widely available. The main findings of appendicitis on CT are right lower quadrant inflammation, an enlarged nonfilling tubular structure, and/or an appendicolith (image 4). The initial experience with helical CT for the diagnosis of appendicitis in pregnancy appears promising, but data are limited to small case series . Modifications to the CT protocol can limit estimated fetal radiation exposure to less than 3 mGy, well below doses known to potentially cause adverse fetal effects (30 mGy for risk of carcinogenesis, 50 mGy for deterministic effects [55,56]), and do not limit diagnostic performance [54,57]. Standard abdominal CT scanning with an oral contrast preparation and intravenous contrast or a specialized appendiceal CT scanning protocol can also be used, but are associated with higher fetal radiation exposure (20 to 40 mGy [56,58]). The relative advantages and disadvantages of the two protocols and what constitutes a positive study are described separately. (See "Acute appendicitis in adults: Clinical manifestations and differential diagnosis", section on 'Imaging examinations'.)
Data from studies in pregnant persons are more limited. A meta-analysis of three retrospective studies in pregnant people reported the sensitivity and specificity of CT in cases of normal/uncertain ultrasonography were: sensitivity 85.7 percent (95% CI 63.7-96) and specificity 97.4 percent (95% CI 86.2-99.9) . These studies included 2 to 49 patients with appendicitis. In one of the studies, the negative laparotomy rates among patients who underwent (1) clinical examination alone, (2) clinical evaluation and ultrasound examination, and (3) clinical evaluation and ultrasound examination followed by CT were 54 percent (7 of 13), 36 percent (20 of 55), and 8 percent (1 of 13), respectively . The ultrasound studies were interpreted as either diagnostic of appendicitis or as normal/inconclusive, thus the authors did not determine whether CT was useful after a normal versus an inconclusive ultrasound study.
DIFFERENTIAL DIAGNOSIS — The differential diagnosis of suspected acute appendicitis includes disorders typically considered in nonpregnant individuals. (See "Acute appendicitis in adults: Clinical manifestations and differential diagnosis", section on 'Differential diagnosis'.)
In addition, pregnancy-related causes of lower abdominal pain, fever, leukocytosis, nausea/vomiting, and changes in bowel function, need to be considered:
●The possibility of ectopic pregnancy should be excluded in any person with a positive pregnancy test and right lower quadrant pain. (See "Ectopic pregnancy: Clinical manifestations and diagnosis".)
●Indigestion, bowel irregularity, nausea/vomiting, and malaise are common symptoms of both appendicitis and normal early pregnancy. In appendicitis, nausea and vomiting, if they occur, follow the onset of pain, whereas nausea and vomiting of pregnancy are not associated with pain. (See "Clinical manifestations and diagnosis of early pregnancy".)
●Round ligament syndrome is a common cause of mild right lower quadrant pain in early pregnancy, but is not associated with other symptoms and is not progressive. (See "Clinical manifestations and diagnosis of early pregnancy".)
●Pyelonephritis is more common in pregnant people than in nonpregnant people. If pregnant individuals with right-sided pain, fever, leukocytosis, and pyuria are treated for pyelonephritis without further investigation, the actual diagnosis of appendicitis may be delayed.
●In the second half of pregnancy, preeclampsia and HELLP (Hemolysis, Elevated Liver function tests, Low Platelets) syndrome can be associated with nausea/vomiting and abdominal pain, but in contrast to appendicitis, the pain is usually in the right upper quadrant or epigastrium, hypertension is usually present, and fever and leukocytosis are atypical. (See "Preeclampsia: Clinical features and diagnosis" and "HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets)".)
●Abruptio placenta and uterine rupture are associated with lower abdominal pain, which may be midline or lateral. Unlike appendicitis, both diagnoses are often associated with vaginal bleeding, fetal heart rate abnormalities, and uterine tenderness. (See "Acute placental abruption: Pathophysiology, clinical features, diagnosis, and consequences" and "Uterine rupture: After previous cesarean birth".)
●In postpartum patients, ovarian vein thrombophlebitis (OVT) should be considered. These patients usually present within one week after delivery and appear clinically ill; symptoms may include fever and abdominal pain and tenderness localized to the right if the right ovarian vein is affected. Nausea, ileus, and other gastrointestinal symptoms may occur but are usually mild, which may be helpful in distinguishing right-sided OVT from appendicitis. (See "Septic pelvic thrombophlebitis".)
MANAGEMENT AND SHORT-TERM OUTCOME
Appendectomy — The conventional treatment of acute appendicitis in pregnancy is appendectomy, which is curative. Perioperative antibiotic treatment should provide Gram-negative and Gram-positive coverage (eg, a second-generation cephalosporin) and coverage for anaerobes (eg, clindamycin or metronidazole). Management with antibiotic therapy alone is not advised because it is associated with both short-term and long-term failure and limited safety data are available for pregnant patients [60-66]. (See "Management of acute appendicitis in adults", section on 'Nonoperative management'.)
Prompt diagnosis and surgical intervention are indicated, as delaying surgical intervention for more than 24 hours after symptom onset increases the risk of perforation [2,40], which occurs in 14 to 43 percent of such patients. Maternal morbidity following appendectomy is comparable to that in nonpregnant women and low , except in patients in whom the appendix has perforated. Importantly, the risk of fetal loss is increased when the appendix perforates (fetal loss 36 versus 1.5 percent without perforation ) or when there is generalized peritonitis or a peritoneal abscess (fetal loss 6 versus 2 percent; early delivery 11 versus 4 percent ).
Given the difficulties in the clinical diagnosis of appendicitis and the significant risk of fetal mortality if the appendix perforates, a higher negative laparotomy rate (20 to 35 percent) compared with nonpregnant persons is generally considered acceptable. Aggressive use of radiologic imaging, including ultrasound, magnetic resonance (MR), and computed tomography (CT) scanning, has the potential to reduce the incidence of negative appendectomy. There is some evidence that the higher rate of negative laparotomy during pregnancy is linked, at least in part, to a reluctance to perform preoperative CT in these patients [38,70]. (See 'Imaging' above.)
A normal-appearing appendix at time of surgery should be removed because histological examination may reveal acute inflammation, excision avoids the potential for future evaluation and intervention for suspected appendicitis, and appendectomy is associated with a very low risk of complications.
Perforated appendix — The management of appendiceal perforation depends on the nature of the perforation: free versus walled-off.
Free perforation — A free perforation can cause intraperitoneal dissemination of pus and fecal material. These patients are typically quite ill and may be septic; they are at increased risk of preterm labor and delivery and fetal loss [68,69]. Urgent laparotomy is necessary for appendectomy with irrigation and drainage of the peritoneal cavity.
Walled-off perforation — Nonpregnant patients who present with a long duration of symptoms (more than five days) and have findings of a contained perforation can be treated initially with antibiotics, intravenous fluids, bowel rest, and close monitoring. These patients will often have a palpable mass on physical examination and imaging may reveal a phlegmon or abscess. Many of these patients will respond to nonoperative management since the appendiceal process has already been "walled-off." Moreover, immediate surgery in patients with a long duration of symptoms and phlegmon formation is associated with increased morbidity due to dense adhesions and inflammation. Under these circumstances, appendectomy often requires extensive dissection and may lead to injury of adjacent structures. Complications such as a postoperative abscess or enterocutaneous fistula may ensue, necessitating an ileocolectomy or cecostomy. Because of these potential complications, a nonoperative approach is a reasonable option if the patient is not ill-appearing. (See "Management of acute appendicitis in adults", section on 'Perforated appendicitis'.)
Although there is good evidence to support this approach to walled-off perforation in nonpregnant individuals, there is only sparse evidence in pregnant persons. In a single report including only two patients, antibiotic therapy (ampicillin, gentamicin, and clindamycin), intravenous fluids, and bowel rest were associated with improvement in symptoms over two to three days . In one patient, interval appendectomy was performed two months post-vaginal delivery. In the other patient, appendectomy was performed at cesarean delivery because of breech presentation with preterm labor; this patient had an appendiceal phlegmon that had been treated conservatively seven weeks earlier, but with recurrence of acute appendiceal inflammation. In both cases, treatment with antenatal glucocorticoids to induce fetal lung maturation and tocolytics was avoided due to concerns of suppressing clinical manifestations of worsening infection and delaying delivery if intraamniotic infection was also present. On the other hand, a letter to the editor described two deaths related to appendicitis in pregnant individuals who appeared to recover after treatment with antibiotics and were discharged from the hospital . Until more information on nonoperative management of ruptured, but contained, appendicitis during pregnancy is available, we suggest that these patients be carefully monitored in the hospital for maternal sepsis and preterm labor.
While there is some support for interventional drainage of appendiceal abscesses in children, data on this approach in pregnant patients is lacking.
Medical management with antibiotics — At this time, antibiotic therapy alone for pregnant individuals with appendicitis should be considered experimental as available data are limited to a few observational studies, two of which reported increased risks with antibiotic-only management [7,61,72]. While antibiotic-only therapy in pregnancy is not standard of care, pregnant patients for whom antibiotics may be appropriate include those who decline surgery or those in remote areas where appropriate surgical intervention or skill may not be readily available . Proper counseling on the possible increase in maternal morbidity should be discussed .
Available data include:
●Supporting antibiotic-only therapy – In an observational study of 20 pregnant persons with uncomplicated simple appendicitis who underwent a four-day trial of antibiotics, 15 percent (3 of 20) required immediate surgical appendectomy (two suppurative and one perforated appendix) . By 10 months of follow-up, 25 percent required appendectomy. Uncomplicated appendicitis was defined by appendiceal diameter ≤11 mm and no presence of appendicoliths, perforation, or abscess. The patients received IV cefmetazole (2000 mg/day) and metronidazole (1500 mg/day) for 48 hours followed by two additional days of oral antibiotics if they remained stable. Median gestational age was 17.8 weeks (range 8 to 28 weeks' gestation, five patients in their first trimester and 15 patients in their second trimester). One patient elected pregnancy termination at the time of surgery but no other poor obstetric outcomes were reported.
●Concerns for antibiotic-only therapy
•Inpatient database cohort study – In a retrospective review of 8087 pregnant individuals presenting with complicated appendicitis between 2003 and 2015, antibiotic-only therapy was successful in one quarter (954 in 3600, 26.5 percent) of those who attempted this approach while the remainder who initially received antibiotics (2646 in 3600, 73.5 percent) underwent delayed surgery . More than half of all included pregnant patients (55.5 percent) underwent immediate operation.
Compared with pregnant persons who went directly to surgery, adjusted analysis reported :
-Successful medical management was associated with increased likelihood of amniotic fluid infection (adjusted odds ratio [aOR] 4.35, 95% CI 2.22-8.53) and sepsis (aOR 1.52, 95% CI 1.10-2.11) but with similar risks of preterm birth, preterm labor, and abortion.
-Unsuccessful medical management that resulted in delayed surgery was associated with a 45 percent increased risk of preterm birth, preterm labor, and abortion (aOR 1.45, 95% CI 1.24-1.68). In multivariate logistic regression analysis, each day of surgical delay was associated with a 23 percent increased risk of preterm birth, preterm labor, and abortion (aOR 1.23, 95% CI 1.18-1.29).
•Population-based cohort study – In a study including over 7100 pregnant individuals with noncomplicated appendicitis, medical management was associated with increased risk of complications compared with appendectomy . In adjusted analysis, specifically increased risks included (presented as adjusted odds ratios):
-Peritonitis – 1.6, 95% CI 1.3-2.1
-Venous thromboembolism – 2.5, 95% CI 0.9-7.4
-Sepsis syndrome – 2.6, 95% CI 1.4-4.8
-Septic shock – 6.3, 95% CI 1.9-20.8
While data were derived from analysis of a hospital inpatient database and the inclusion criteria for conservative management with antibiotics were unclear, it suggests caution in this protocol until well-designed trials are published.
Concomitant cesarean birth — Cesarean birth is rarely indicated at the time of appendectomy. For patients who remain undelivered, the risk of dehiscence of the appendectomy incision during labor and vaginal birth should not be increased when the fascia has been appropriately reapproximated .
Choice of approach — When the diagnosis is relatively certain, both open and laparoscopic appendectomy are considered and are reasonable. No randomized trials have been performed to suggest that one technique is better than another, and the choice of technique is based on the patient's clinical status and preferences, gestational age, and the surgeon's experience level.
The relative benefits and concerns for the two different approaches were evaluated in a meta-analysis of 20 studies (19 retrospective, 1 prospective) including over 6200 pregnant women who underwent appendectomy (1926 laparoscopic and 4284 open procedures) :
●Favoring laparoscopic approach – The laparoscopic approach was associated with lower overall complication rates (odds ratio [OR] 0.48, 95% CI 0.29-0.80, 1835 patients) and shorter hospital stays (mean difference -0.94 days, 95% CI -1.55 to -0.33, 2211 patients) compared with open procedures.
●Favoring open approach – Those who underwent open surgery had a reduced risk of fetal loss and increased gestational age at the time of term delivery compared with patients who underwent laparoscopic surgery (for laparoscopy, risk of fetal loss OR 1.82, 95% CI 1.30-2.57, 4867 patients and mean difference in gestational age -0.46 weeks, 95% CI -0.87 to 0.04, 543 patients).
●Similar – Similar outcomes were reported for operative times, birth weight, incidence of preterm birth (<37 weeks of gestation), and cesarean delivery rates.
However, this meta-analysis had important limitations. As the data were obtained from a large international cohort, the range of patients, surgeons, and surgical settings limits the applicability to any one patient group. Additionally, the meta-analysis included only one prospective study. Other limitations included the small number of studies that had more than 50 patients in each study arm (4 of 20) and the lack of information on gestational age in the three largest studies that accounted for more than 50 percent of the study population. When the largest study, which did not include information on gestational age, was removed from the analysis, there was no longer a statistical difference in loss rate between the two surgical approaches.
Open appendectomy — When performing an open appendectomy in a pregnant person, a transverse incision is made at McBurney's point or, more commonly, over the point of maximal tenderness [14,15]. When the diagnosis is less certain, we suggest a lower midline vertical incision since it permits adequate exposure of the abdomen for diagnosis and treatment of surgical conditions that mimic appendicitis. A vertical incision can also be used for a cesarean delivery, if subsequently required for the usual obstetric indications. It is prudent to minimize traction on the uterus and uterine manipulation, although an association between these maneuvers and preterm birth is unproven.
Laparoscopic appendectomy — Case reports, case series and small cohort studies on the use of laparoscopic appendectomy in pregnancy suggest that laparoscopy can be performed successfully during all trimesters and with few complications [4,73-85]. The decision to proceed with a laparoscopic approach should take into consideration the skill and experience of the surgeon, as well as clinical factors such as the size of the gravid uterus. Suggestions for modification of laparoscopic technique during pregnancy include slight left lateral positioning of the patient during the second half of pregnancy, avoiding the use of any cervical instruments, use of open entry techniques or placement of trocars under direct visualization, and limiting intraabdominal pressure to less than 12 mmHg . The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) guidelines recommend insufflation pressures of 10 to 15 mmHg and that the port position should be adapted for fundal height . (See "Laparoscopic surgery in pregnancy".)
However, concern has been raised that laparoscopic appendectomy appears to be associated with higher rates of preterm delivery and fetal loss [73,88-90]. In the largest meta-analysis to date, including 20 studies and over 6200 pregnant women with appendicitis, laparoscopic surgery was associated with an increased risk of fetal loss (OR 1.82, 95% CI 1.30-2.57, 4867 patients) . Limitations of this study include that 19 of 20 studies were retrospective and that the gestational age and timing relative to surgery at the time of loss were not identified.
In our practice, we find the use of laparoscopy safe, especially when patients are appropriately monitored and no overt signs of preterm labor exist. Laparoscopy affords optimal visualization and recovery when performed by experienced surgeons. We use slightly lower intraabdominal pressures of 10 to 12 mmHg (which provides excellent visualization), an open entry technique, and directly visualized trocar insertion.
Intraoperative management and monitoring — The intraoperative management of pregnant patients undergoing nonobstetric surgery and monitoring of the fetus are reviewed separately. Cesarean birth is rarely indicated at the time of appendectomy. For patients who remain undelivered, the risk of dehiscence of the appendectomy incision during labor and vaginal birth should not be increased when the fascia has been appropriately reapproximated. (See "Anesthesia for nonobstetric surgery during pregnancy".)
OBSTETRIC AND CHILD OUTCOMES — The long-term prognosis for individuals who undergo appendectomy during pregnancy is generally good, but data are limited to observational series. It appears that preexisting morbidities, and not the surgery itself, are the greater risk factors for postoperative adverse obstetric events.
●Maternal and obstetric outcomes – In a national cohort study of nearly 20,000 women who underwent either appendectomy or cholecystectomy during pregnancy, risk factors most strongly associated with an adverse obstetric outcome included cervical insufficiency, preterm labor during the current pregnancy (but prior to surgery), vaginitis or vulvovaginitis, and sepsis . Other factors that had a more moderate impact on risk included Medicaid insurance, drug abuse or dependence, multiple gestation, and open surgery (ie, laparotomy).
●Child outcomes – In general, appendectomy performed during pregnancy does not appear to negatively impact the offspring, but data are limited to small studies of observational data.
•No impact on outcome – In a prospective observational study of pregnant patients who underwent appendectomy, none of the study respondents (29 patients, 56 percent) reported developmental delays in their children after a mean of 47 months of follow-up (range 13 to 117 months) .
•Concern for neonatal outcome – A study comparing 33 pregnant individuals who underwent laparoscopic appendectomy but had negative pathology with 50 pregnant individuals undergoing diagnostic laparoscopy for presumed ovarian torsion, negative appendectomy was associated with lower neonatal birth weights and increased risk of small for gestational age (SGA). The mean gestational ages at the time of surgery differed for the groups (17.8 ± 7.5 weeks versus 11.3 ± 6.3 weeks), which may have impacted the study results.
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Imaging in pregnancy".)
SUMMARY AND RECOMMENDATIONS
●Background – Acute appendicitis is the most common general surgical problem encountered during pregnancy. (See 'Introduction' above.)
●Clinical manifestation – The clinical manifestations of appendicitis in pregnancy are like those in nonpregnant individuals; however, the following points should be noted:
•Location of pain – Right lower quadrant pain is the most common symptom and occurs within a few centimeters of McBurney's point in most pregnant individuals, regardless of the stage of pregnancy. In late pregnancy, pain may be the right mid or upper quadrant. Rebound tenderness and guarding are less prominent in pregnant patients, especially in the third trimester. (See 'Patient presentation' above.)
•Leukocytosis in pregnancy – Mild leukocytosis can be a normal finding in pregnant people: the total leukocyte count may be as high as 16,900 cell/microL in the third trimester and 29,000 cells/microL during labor, so leukocytosis may or may not be a sign of appendicitis. (See 'Laboratory' above.)
●Clinical diagnosis – The clinical diagnosis should be strongly suspected in pregnant individuals with classic findings: abdominal pain that migrates to the right lower quadrant, right lower quadrant tenderness, nausea/vomiting, fever, and leukocytosis with left shift. (See 'Diagnosis' above.)
With a nonclassical presentation, which often happens in late pregnancy, imaging is indicated. The primary goal of imaging is to reduce delays in surgical intervention due to diagnostic uncertainty. A secondary goal is to reduce, but not eliminate, the negative appendectomy rate.
●Imaging – We take a stepped approach to selecting imaging studies for pregnant individuals with suspected appendicitis. (See 'Imaging' above.)
•Ultrasound – We suggest graded compression ultrasonography in pregnant patients suspected of having appendicitis. Appendicitis is diagnosed if a noncompressible blind ended tubular structure is visualized in the right lower quadrant with a maximal diameter greater than 6 mm. (See 'Ultrasonography' above.)
•MRI – If clinical findings and ultrasound are inconclusive, or in centers where experience with sonographic examination of the appendix is limited, we suggest noncontrast magnetic resonance imaging (MRI), where available, because it avoids fetal exposure to ionizing radiation and performs well in diagnosis of lower abdominal/pelvic disorders. (See 'Magnetic resonance imaging (MRI)' above.)
•CT – We perform CT when clinical findings and ultrasound examination are inconclusive and MRI is not available, because of its proven value in nonpregnant individuals. (See 'Computed tomography (CT)' above.)
•Decision to perform surgery – The decision to proceed to surgery should be based upon the clinical findings, diagnostic imaging results, and clinical judgment. Delaying intervention for more than 24 hours increases the risk of perforation. (See 'Management and short-term outcome' above.)
•Surgical approach – When the diagnosis is relatively certain, we advise appendectomy by the method that the surgeon is most skilled at performing, whether it be by minimally invasive or open surgery. If being done by an open approach, we suggest using a transverse incision over the point of maximal tenderness (Grade 2C). When the diagnosis is less certain and if laparoscopy is not available, then we suggest using a lower midline vertical incision (Grade 2C). (See 'Surgical approach' above.)
•Management of perforated appendix – Management of perforated appendix depends on whether it is free or walled-off. A free perforation can cause intraperitoneal dissemination of pus and fecal material. These patients are typically quite ill and may be septic. Urgent laparotomy is necessary for appendectomy with irrigation and drainage of the peritoneal cavity. (See 'Perforated appendix' above.)
●Medical management with antibiotics only – Antibiotic therapy alone is not advised because it is associated with both short-term and long-term failure and limited safety data are available for pregnant patients.
ACKNOWLEDGMENT — The editorial staff at UpToDate acknowledge William Barth, Jr, MD, and Joel Goldberg, MD, FACS, who contributed to an earlier version of this topic review.
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