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App in Pregnancy PDF
App in Pregnancy PDF
BACKGROUND AMAÇ
Acute appendicitis is the most common surgical non-ob- Akut apandisit gebelikte en sık rastlanan obstetrik dışı
stetric pathology during pregnancy. In this report, pregnant cerrahi patolojidir. Bu yazıda son 3 yılda ameliyat edilen
patients operated with a diagnosis of acute appendicitis in gebelikteki akut apandisit olguları geriye dönük olarak de-
the last three years are evaluated retrospectively. ğerlendirildi.
METHODS GEREÇ VE YÖNTEM
Between January 2009 and January 2011, 20 pregnant pa- Ocak 2009 ve Ocak 2011 arasında 20 gebe hasta akut apan-
tients were operated for acute appendicitis. Patients were disit nedeniyle ameliyat edildi. Hastalar yaş, gebelik yaşı,
evaluated regarding age, gestational age, clinical and labo- klinik ve laboratuvar bulguları, görüntüleme sonuçları,
ratory examinations, imaging studies, operative findings, ameliyat bulguları, ortalama hastanede yatış süresi, ortala-
mean hospital stay, mean operative time, and outcome. ma ameliyat süresi ve sonuçlar açısından değerlendirildi.
RESULTS
BULGULAR
In 17 of 20 patients, acute appendicitis was confirmed and
Çalışmaya alınan 20 hastanın 17’sinde apandisit doğrulan-
appendectomy was performed. Ten of the patients were
dı ve apendektomi uygulandı. Hastaların 10’u laparosko-
operated with laparoscopic technique and the remaining
pik, diğer 10 hasta ise açık ameliyata alındı. Hastaların hiç-
10 had open appendectomy. There was no fetal or mater-
nal morbidity or mortality in any patient. All 20 patients birinde fetal morbidite ve mortalite görülmedi. Hastaların
delivered healthy babies during the postoperative course. tümü ameliyat sonrası gebelik sonunda sağlıklı bebekler
doğurdular.
CONCLUSION
Acute appendicitis is a challenging diagnosis in the preg- SONUÇ
nant patient; however, early surgical intervention should be Akut apandisit gebe hastada zor bir tanı olmasına rağmen
performed with any suspicion. The type of surgery depends şüphe anında erken cerrahi girişim yapılmalıdır. Cerrahinin
on the surgeon’s preference and experience. tipi cerrahın seçimine ve tecrübesine bağlıdır.
Key Words: Acute appendicitis; appendectomy; laparoscopy; Anahtar Sözcükler: Akut apandisit; apendektomi; laparoskopi;
pregnancy. gebelik.
Acute appendicitis is the most common surgical prevalence of nausea, vomiting and abdominal pain
condition requiring non-obstetric abdominal surgery in the normal obstetric patient population leads to the
during pregnancy, and its incidence is reported to be delayed surgical intervention.[4,5] In addition, there is a
between 1:1250 and 1:1500 pregnancies, with 50% of general reluctance to operate unnecessarily on a gravid
cases occurring in the second trimester.[1-3] The high patient. In any pregnant patient, right-sided abdominal
Department of General Surgery, Bakirkoy Dr. Sadi Konuk Training and Dr. Sadi Konuk Eğitim ve Araştırma Hastanesi,
Research Hospital, Istanbul, Turkey. Genel Cerrahi Kliniği, İstanbul.
Correspondence (İletişim): Selin Kapan, M.D. Dr. Sadi Konuk Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği,
Tevfik Sağlam Cad. No: 11., Zuhuratbaba, Bakirkoy 34147 İstanbul, Turkey.
Tel: +90 - 212 - 414 71 59 e-mail (e-posta): selinkapan@gmail.com
20
Management of acute appendicitis in pregnancy
pain, associated with guarding and rebound and ac- pendix, acute appendicitis was confirmed in 10 during
companied by fever should always be considered ap- the operation. The median time between consultation
pendicitis unless proven otherwise. Assessment of the and operation was 6 hours (3-10). The mean operation
white blood cell count may not be particularly helpful time was 54.1 minutes (12-135 min). The mean opera-
because pregnant patients often have a physiological tion time in open and laparoscopic approach was 51.7
leukocytosis. Careful physical examination is key to min (12-120) and 56.5 min (30-135), respectively. The
making the diagnosis.[6] Ultrasonography should be mean hospital stay was 1.1 days (1-2 days). In 8 of
used to assess for the presence of an obstetrical pa- the 10 laparoscopic procedures, the first trocar was in-
thology such as an ovarian cyst or torsion of an adnex- serted with open technique; in the remaining, Veress
al mass. In the general population, there are several insufflation was performed.
scoring systems available to aid the accuracy of diag- In 10 patients, diagnostic laparoscopy was per-
nosis of appendicitis, including the Alvarado scoring formed and seven of these patients had acute appen-
system. No such system is available for the obstetric dicitis. One patient had paraovarian cyst, whereas the
population.[3-5] other two patients had no pathology.
In this study, we present our cases of acute appen- In the remaining 10 patients, open appendectomy
dicitis during pregnancy in light of the related litera- was performed, and all 10 had acute appendicitis.
ture. There was no maternal or fetal mortality, morbidity, or
uterine injury in any of the patients. No case of fetal
MATERIALS AND METHODS
mortality was encountered. Twenty patients delivered
Twenty pregnant women who were consulted to 20 healthy infants. Demographic data of the patients
the Emergency Surgery Clinic for acute abdominal are given in Table 1.
pain from January 2009 to January 2011 were includ-
ed in this study. Clinical data collected retrospectively DISCUSSION
included physical examination findings, age of the Certain anatomic and physiologic changes specific
patients, week of pregnancy, presenting symptoms, to pregnancy may make the cause of the abdominal
ultrasonographic confirmation, leukocyte count, and pain difficult to ascertain in pregnant patients.[3,4] The
postoperative complications. All patients were as- uterus becomes an abdominal organ at around 12
sessed by a gynecologist and a general surgeon before weeks’ gestation and compresses the underlying ab-
and after surgery. The diagnosis of acute appendicitis dominal viscera. This enlargement may make it dif-
was based on clinical examination, ultrasound (US) ficult to localize the pain and may also mask or delay
and leukocyte count, and pregnancy was confirmed by peritoneal signs. The laxity of the anterior abdominal
US. Each patient was evaluated by the Alvarado scor- wall may also mask or delay peritoneal signs. The ure-
ing system. The period between surgical consultation ters became dilated as early as the first trimester and
and surgery was evaluated. remain dilated into the postpartum period. This dis-
Appendectomies were performed by laparoscopic tension may lead to urinary stasis, increasing not only
or open approach. General inhalational anesthesia the risk of urolithiasis, but also infection. Increasing
was employed routinely during the operation. Urinary progesterone increases respiratory drive. Functional
catheters were used routinely. residual capacity decreases. Hemostatic changes also
add to the challenge of evaluating and caring for preg-
RESULTS nant women. Pregnancy produces a thrombogenic
The mean age of the patients was 26 (19-35) years. state, with two-to-three-fold increase in fibrinogen
The mean gestational age at the time of LA was 17.6 levels. In pregnancy, physiologic leukocytosis oc-
weeks (4-33 weeks). Ten patients were in the second curs, and in our study, all patients had leukocytosis.[4]
trimester, 6 were in the first trimester and 4 were in the Anatomical changes related to the gravid uterus, ges-
third trimester of pregnancy. The mean Alvarado score tational symptoms, the physiological inflammatory re-
was 7.7 (7-9). The mean leukocyte count was 13920 sponse, and a wider differential diagnosis in pregnant
(7200-22300), and mean neutrophil % was 81.65% women result in poor diagnostic accuracy, reported to
(91.4%-67.3%). All 20 patients were admitted with range from 36% to 86%.[2] Acute appendicitis has a
complaints of abdominal pain. Thirteen patients had peak incidence in the second and third decades coin-
additional nausea and vomiting. Abdominal ultraso- ciding with the childbearing years, and the incidence
nography was performed in all patients after gyneco- in pregnancy appears broadly the same as in the non-
logical examination. Ultrasonography revealed acute pregnant, whereas the rate of perforation and subse-
appendicitis in seven patients. All these seven patients quent complications are greater.[2,7]
were acute appendicitis. In the remaining 13 patients, Fetal mortality is given as 5% after appendicitis,
in whom ultrasonography could not visualize the ap- whereas this rate increases to approximately 20% in a
perforated appendicitis. Similarly, maternal mortality in the presence of ruptured appendicitis.[2] A fetal loss
also increases in perforated cases.[3] rate of 3-5% is observed with an unruptured appendix;
this rate increases up to 20% if the appendix is rup-
Given the lack of sensitivity of the preoperative
tured. The risk of preterm labor is greatest during the
evaluation, it is not surprising that the pathologic
first week after surgery, but preterm delivery is rare.
diagnosis of appendicitis is confirmed in 36-50% of [4,8]
Furthermore, increasing gestational age reduces
cases.[5] In our study with laparoscopy, three patients
diagnostic accuracy and is associated with increased
were determined to have no acute appendicitis. Sev-
rates of appendiceal perforation and hence complica-
enteen of 20 patients were diagnosed as appendicitis,
tions.[2,9] We operated the patients in our series within
and pathologic investigation of the 17 specimens con-
12 hours. Contrary to the literature, in our study, there
firmed our diagnosis.
was no fetal loss or appendiceal perforation. The rea-
The accuracy of the diagnosis is greater in the first son for this difference was the short time period be-
trimester, but more than 40% of patients who undergo tween consultation and operation in our study.
appendectomy in the second and third trimester have
The authors suggest that none of the clinical pa-
a normal appendix. The negative laparotomy rate for
rameters investigated is useful in predicting appendi-
suspected appendicitis in obstetric cases is 25-50%,
citis in pregnancy. US and magnetic resonance imag-
compared with 15-35% in general surgical cases in
ing (MRI) are not associated with ionizing radiation,
non-obstetric patients.[2] In our study, 10 of 20 patients
have not been shown to have any deleterious effects
were second trimester, and three of them went to nega-
on pregnancy, and should be used when feasible.[4,9-11]
tive laparoscopy.
Retrospective studies have suggested that MRI of the
It has been nearly 100 years since Balber stated appendix is useful in delineating the presence of ap-
that ‘the mortality of appendicitis complicating preg- pendicitis in pregnant women, but the small number
nancy is the mortality of delay’. The wisdom of this of patients in these studies limits the inference that can
statement has been repeatedly demonstrated. Delay be drawn.[12] There are also studies using computed to-
in the diagnosis of appendicitis is associated with sig- mography (CT) for the diagnosis of acute appendicitis
nificant complications.[2] Delay to surgery is equally in pregnancy; however, due to the deleterious effects
risky, with rates of fetal loss reported to be 1.5-4% of ionizing radiation on the fetus, it is suggested to be
in uncomplicated appendicitis compared with 21-35% used only in severe trauma patients with pregnancy.
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