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Appendicitis in Pregnancy J Am Board Fam Med: first published as 10.3122/jabfm.19.6.621 on 7 November 2006. Downloaded from Appendicitis in Pregnancy Patricia A. Pastore, MSN, RN, FNP, Dianne M. Loomis, MSN, RN-CS, FNP, and John Sauret, MD, FAAFP Background: Our urban practice had two incidences of documented appendicitis in pregnancy in a 24-hour period with two unique outcomes that prompted an inquiry. Appendicitis in pregnancy is relatively rare, but it has significant morbidity and is a cause of maternal and infant mortality. Ab- dominal pain is the most common presenting symptom, and the consideration of multiple patho- logic disorders should be entertained. Accurate diagnosis of appendicitis in pregnancy is the larg- est challenge since the signs and symptoms may vary depending on the trimester in which the patient presents. Methods: We undertook a systematic review of English-language articles from 1975 to 2005 us- ing the key words “appendicitis,” and “pregnancy” using MEDLINE, CINAHL, and Cochrane Con- trolled Trials Register databases. Results and Conclusions: The accurate diagnosis of appendicitis during pregnancy requires a high level of suspicion and clinical skills, and not merely relying on the classic signs and diagnos- tic testing. Primary care providers play an important role in recognizing potential signs and symp- toms of appendicitis in pregnancy to initiate prompt action and reduce negative maternal and fetal outcomes. (J Am Board Fam Med 2006;19:621–6.) Case 1 office for increasing abdominal pain. She was re- A 22-year-old G1P0 of 16 weeks gestation awoke ferred back to the ER with a chief complaint of about midnight with periumbilical abdominal pain increasing pain localized to the RLQ. Now she had and presented to the hospital for evaluation. Phys- nausea and emesis but denied fever, chills, consti- ical examination showed mild abdominal tender- pation, or diarrhea. ness, and an ultrasound showed a viable fetus. The On examination, her temperature was 37.6°C, patient was discharged from the hospital with the heart rate 117, and blood pressure 133/76. Physical diagnosis of round ligament pain. Persistent peri- examination revealed gravid abdomen with RLQ umbilical and right lower quadrant (RLQ) pain tenderness with deep palpation along with guard- http://www.jabfm.org/ prompted her to seek care at her primary care ing but without rebound tenderness. Pertinent lab- office. She reported nausea but denied vomiting, oratory results were: white blood cell count, 17.5; vaginal discharge, bleeding, fever, or constipation. hemoglobin, 13; hematocrit, 37; platelets, 191,000; Examination revealed a gravid abdomen of 16 fibrinogen, 446 (170–410), liver function tests, weeks, tenderness, and guarding in the RLQ. Com- normal; electrolytes, normal; urinalysis, normal. plete blood count, complete metabolic profile, uri- Obstetrical and surgical consultations were ob- on 1 October 2021 by guest. Protected copyright. nalysis, and urine culture were sent to the lab. The tained. Ultrasound showed a normal appendix and patient was sent for repeat ultrasound, which was intrauterine pregnancy at 16 weeks. She was admit- negative for appendicitis and showed a viable fetus ted to the hospital for observation, where she de- of 16 weeks. Later that day, the patient called the veloped worsening pain and low-grade fever. A repeat ultrasound in the morning showed appendi- This article was externally peer-reviewed. citis. An open appendectomy was performed under Submitted 30 March 2006; accepted 17 April 2006. general anesthesia showing an acutely inflamed From the Department of Family Medicine, The State University of New York at Buffalo, Buffalo, NY (PAP, JS); nonperforated appendix. Postoperative course was Kaleida Health, Buffalo, NY (PAP, DML); and Niagara initially unremarkable with fetal heart tones Falls Memorial, Niagara Falls, NY (JS). Conflict of interest: none declared. present. However, 7 days postdischarge, she pre- Corresponding author: Patricia A. Pastore, Department of sented to labor and delivery with premature labor Family Medicine, The State University of New York at Buffalo, 462 Grider Street, Buffalo, NY 14215 (E-mail: and spontaneous vaginal delivery of a nonviable [email protected]). fetus. http://www.jabfm.org Appendicitis in Pregnancy 621 J Am Board Fam Med: first published as 10.3122/jabfm.19.6.621 on 7 November 2006. Downloaded from Case 2 and “pregnancy.” Studies included in this review A 39-year-old G7P6 at 20 weeks gestation reported were English-language and applicable to US clini- to an urban hospital ER with complaint of perium- cal practice. No articles were found that focused bilical abdominal pain that began about 9 hours specifically on appendicitis in pregnancy in the pri- prior. The pain intensified throughout the day, mary care setting. The bibliographies of all in- with localization to the right lower abdominal re- cluded articles were reviewed and selected for in- gion. She had associated nausea and slight fever. clusion. These case studies were approved by the She denied any emesis, dysuria, frequency, diar- Health Sciences Institutional Review Board of the rhea, or vaginal symptoms, including irregular vag- State University of New York at Buffalo. inal bleeding or back pain. Her previous medical history was unremarkable except for six full-term Epidemiology vaginal births. The patient had no surgical history Although a rare presentation, appendicitis is one of or allergies and was on prenatal vitamins and iron the most common causes of an acute abdomen in supplementation for anemia. pregnancy, occurring in approximately 1 in 1500 On admission, her temperature was 36.3°C, pregnancies.1,2 This represents an overall incidence heart rate 102, respiratory rate was 16/min, and of 0.05% to 0.07% and does not appear to be any blood pressure 121/63. She appeared in moderate difference in the nongravid population.3,4 One re- distress. On physical examination, head, ears, eyes, port of a reduced incidence of appendicitis during nose and throat was normal; neck supple; lungs pregnancy suggested a possible protective effect, clear; cardiac rate regular; gravid abdomen; fundal and the mean age is 28 years.5 height at 21 cm; hypoactive bowel sounds, RLQ Incidence rates in the first trimester range from tenderness with mild palpation, positive rebound, 19% to as high as 36%.2,3,6,7 There is a higher psoas, and voluntary guarding. Pelvic examination incidence of appendicitis in the second trimester, was normal. Labs revealed white blood count of ranging from 27% to 60%.2,3,6 Although incidence 13.7, neutrophils 11.3, u/a with bacteria 26–100, decreases from 15% to 33% in the third trimester; epithelial cells, and trace hematuria. Sonogram in- some studies reported a 59% incidence in the third dicated gestational age at 20 weeks, 6 days consis- trimester.2,3,6,7 Perforation rates for pregnant pa- tent with last menstrual period, adequate fetal heart tients have been reported as high as 55% of cases, tones, and equivocal for acute appendicitis. compared with 4% to 19% of the general popula- Surgery was consulted and felt that she should tion.3,8,9 be transferred to a local hospital specializing in Due to the lack of specificity of the preoperative http://www.jabfm.org/ pediatrics and obstetrics for emergency appendec- evaluation; the pathologic diagnosis of appendicitis tomy secondary to clinical history and physical ex- is confirmed in only 30% to 50% of cases.2,6,7 The amination. Obstetrical consult was in agreement, first trimester yields a greater accuracy, but more and surgery was planned for the following morn- than 40% of patients in the second and third tri- ing. The second ultrasound was positive for acute mester will have a normal appendix. 10Overall, nor- appendicitis, while her pain improved slightly. mal histology was reported to be 11% to 50%.11,12 Open laparotomy under general anesthesia was Appendicitis was correctly diagnosed 50% to 86% on 1 October 2021 by guest. Protected copyright. performed the day following onset of symptoms. of the time.3,6,7,11 The risk of delay in diagnosis is Pathology established acute suppurative appendici- associated with a greater risk of complications such tis. Postoperative recovery was uneventful, and the as perforation, infection, preterm labor, and risks of patient delivered a healthy infant at term without fetal or maternal loss.6,8 Maternal mortality has complications. been reported from none to 2%.2,3,6,7 An unrup- tured appendix carries a fetal loss of 1.5% to 9%, while this rate increases up to 36% with perfora- Methods tion.2,6,13 Electronic review of the literature from 1975 to The risk of perforation increases with gesta- 2005 using MEDLINE, CINAHL, and Cochrane tional age, and perforation in the third trimester Controlled Trials Register databases was con- often results in preterm labor.3 Delay in surgical ducted by two family nurse practitioners and a intervention carries increased fetal loss.14 The risk family physician using the key words “appendicitis” for premature delivery is the greatest during the 622 JABFM November–December 2006 Vol. 19 No. 6 http://www.jabfm.org J Am Board Fam Med: first published as 10.3122/jabfm.19.6.621 on 7 November 2006. Downloaded from Table 1. Obstetrical and Gynecological Differential Diagnoses of RLQ Pain in Pregnancy Ruptured ovarian cyst Hemorrhagic ovarian cyst Appendicitis Idiopathic Ectopic pregnancy Ovarian torsion Pelvic inflammatory disease Tubo-ovarian abscess Threatened abortion Placental abruption Chorioamnionitis Degenerating leiomyoma Ventral hernia Pyelonephritis Salpingitis Adnexal torsion Ruptured corpus luteum cyst Round ligament syndrome Figure 1. Changes in position of the appendix as Preeclampsia pregnancy advances (MO, month, PP, postpartum). As modified from Baer and associates. With permission from The McGraw-Hill Companies. signs of appendicitis such as positive Rovsing’s and psoas sign have not been shown to be of any clinical significance in diagnosing an acute appendicitis in first week after surgery.
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