Appendicitis in Pregnancy: A Surgeon’s Dilemma
M3 India Newsdesk Feb 27, 2023
This article clarifies the diagnostic challenge in the management of appendicitis in pregnancy and aids physicians in comprehending the clinical picture of the disease.
Background
Acute appendicitis is the most common general surgical emergency during pregnancy occurring in 1 in 800 to 1 in 1500 pregnancies with the second trimester being most commonly affected. The overall incidence does not appear to be any different from the non-gravid population.
Its clinical presentation always poses a challenge in diagnosing due to gravis status. Presenting symptoms are nonspecific and laboratory features are also sometimes misleading.
Objective
A better understanding of the clinical picture of the disease and clarify the diagnostic dilemma in the management of appendicitis in pregnancy.
The symptomatology of appendicitis in pregnancy is similar to non-gravid patients however the preoperative diagnosis is incorrect in 25% to 50% of patients for several reasons.
Diagnosing appendicitis is an emergency because it is a potentially life-threatening emergency for both the mother and may also affect the fetus with preterm labour, delivery or miscarriage.
Clinical picture
The most common presenting symptoms include:
- Right lower quadrant pain
- Anorexia
- Nausea
- Vomiting
Fever and tachycardia may not be present during pregnancy.
Location of pain
Important predictor- Recent studies concluded the pain of appendicitis radiates with the advancement of gestational from the right lower quadrant to the right upper abdomen while few studies suggest it remains localised to the right lower quadrant in all trimesters.
Mean temperature
There was no distinguishing temperature that separated true appendicitis from suspected cases which turned out to be falsely positive.
Leukocytosis
The incidence of leukocytosis was slightly higher in appendicitis in pregnancy however the overlap was substantial and negates the value of this test in reducing false-positive cases and possibly avoiding laparotomy.
How to diagnose?
- If a pregnant patient presents with pain in the right iliac fossa with clinical signs of appendicitis always have a high degree of suspicion to avoid unacceptable delay which may lead to increased morbidity and mortality.
- Laboratory investigations add little to diagnosis. There may not be leukocytosis and or elevated body temperature.
- In the first trimester or early second trimester consider pelvic ultrasound first, especially if the differential includes adnexal pathology. If the second (especially late) or third trimester considers going straight to a CT scan since this is more helpful and easier to interpret than an MRI.
Conclusion
- The accurate diagnosis of appendicitis during pregnancy requires a high degree of suspicion and clinical skills, and not merely relying on the classic signs and diagnostic testing.
- Early surgical intervention is essential.
- Pain in the right lower abdomen is the most common symptom.
- Temperature is not reliably elevated and leukocytosis is present but cannot be used to rule out acute appendicitis.
- It is yet to be determined which diagnostic test is best suited to diagnose acute appendicitis in pregnancy and often the correct diagnosis is determined only through surgical intervention.
- If in doubt after relevant investigations but have strong clinical suspicion one should go for appendicectomy preferably laparoscopically if feasible.
Disclaimer- The views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of M3 India.
About the author of this article: Dr Atul Kumar Sharma is MS- General Surgery, Government Medical College and Associated Government Hospitals, Kota.
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