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Acute Appendicitis in Pregnancy: Literature Review

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Acute Appendicitis in Pregnancy: Literature Review REVIEW ARTICLE FRANCA NETO AH ET AL. Acute appendicitis in pregnancy: literature review ANTÔNIO HENRIQUES DE FRANCA NETO1, MELANIA MARIA RAMOS DO AMORIM2, BIANCA MARIA SOUZA VIRGOLINO NÓBREGA3 1Master’s degree and coordinator of the PRM in Obstetrics and Gynecology at the Federal University of Campina Grande (UFCG), Campina Grande, PB, Brazil 2PhD and professor of Gynecology at the UFCG, Campina Grande, PB, Brazil 3Specialist and resident physician of Obstetrics and Gynecology at the Faculty of Nursing and Medicine Nova Esperança (FAMENE), João Pessoa, PB, Brazil SUMMARY Introduction: suspected appendicitis is the most common indication for sur- gery in non-obstetric conditions during pregnancy and occurs in about one in 500 to one in 635 pregnancies per year. This occurs more often in the second tri- mester of pregnancy. Acute appendicitis is the most common general surgical problem encountered during pregnancy. Methods: a literature review on research of scientific articles, under the terms “acute appendicitis” and “pregnancy”, in PubMed, Lilacs/SciELO, Scopus, Co- chrane Library and Uptodate databases. Results: the clinical manifestations of appendicitis are similar to non-pregnant women, however, without a classic presentation, which often occurs, diagnosis is difficult and must be supported by imaging. Discussion: clinical diagnosis should be strongly suspected in pregnant wom- Study conducted at the Federal University of Campina Grande, Campina en with classic findings such as abdominal pain that migrates to the right low- Grande, PB, Brazil er quadrant. The main purpose of imaging is to reduce delays in surgical inter- vention due to diagnostic uncertainty. A secondary objective is to reduce, but Article received: 3/19/2014 Accepted for publication: 7/3/2014 not eliminate, the negative appendectomy rate. Differential diagnosis of suspect- ed acute appendicitis usually includes pathologies considered in non-pregnant *Correspondence Address: Rua Carlos Chagas, SN people. São José Conclusion: the imaging study of choice is ultrasound, MRI may be used when Campina Grande, PB – Brazil Postal code: 58100-000 the former is not conclusive and, as a last resort, a CT scan can be performed. [email protected] The treatment remains appendectomy by laparotomy, since the feasibility of vid- eo-assisted surgery in these cases remains controversial. http://dx.doi.org/10.1590/1806-9282.61.02.170 Conflict of interest: none Keywords: appendicitis, pregnancy, pregnancy complications. INTRODUCTION bly due to these difficulties and the reluctance to operate Suspected appendicitis is the most common indication on pregnant women, which ultimately delays diagnosis for surgery for non-obstetric conditions during pregnan- and treatment.2 cy and occurs in approximately one in 500 to one in 635 pregnancies per year.1,2 Appendicitis occurs most often METHODS in the second trimester of pregnancy.1-3 Abdominal sur- A search of scientific articles was performed using the terms gery during pregnancy, particularly appendectomy, can “appendicitis” and “pregnancy” in the PubMed, Lilacs/Sci- increase the risk of unfavorable outcomes.4 ELO, Scopus and Cochrane Library databases, in addition Diagnosis is particularly difficult during pregnancy, to Uptodate, last reviewed on February 28th, 2014. 68 sci- because of the relatively high prevalence of abdominal entific articles were analyzed and included in this review. discomfort and gastrointestinal complaints, as well as anatomical changes related to the increase in uterine vol- RESULTS ume and the physiological leukocytosis that occurs dur- Acute appendicitis is confirmed in 1/800 to 1/1500 preg- ing this period. A ruptured appendix is more common in nancies.3-6 Pregnant women seem less likely to have ap- pregnant women, especially in the third trimester, possi- pendicitis than non-pregnant women matched by age 170 REV ASSOC MED BRAS 2015; 61(2):170-177 ACUTE APPENDICITIS IN PREGNANCY: LITERATURE REVIEW (OR 0.78, 95% CI 0.73% - 0.82%), with a slightly higher in- several limitations, including the selection of non-consec- cidence in the second trimester of pregnancy.7 utive cases in addition to those diagnosed before the wide- spread use of current diagnostic imaging procedures. Ta- Clinical characteristics ble 1 presents the signs and symptoms of appendicitis re- Classically, patients describe the appearance of abdomi- ported in this review. nal pain as the first symptom. It begins with periumbili- cal pain, which then migrates to the right lower quadrant TABLE 1 Percentage appearance of signs and symptoms to the extent that the inflammation progresses.8,9 Anorex- of acute appendicitis. ia, nausea and vomiting, if present, appear after the pain. Symptoms Percentage appearance Fever of up to 38.3oC and leukocytosis may subsequent- Abdominal pain 95% Right lower quadrant: 75% ly develop.9 Right upper quadrant: 20% Many patients have atypical presentation, with symp- Nausea 85% toms such as heartburn, bowel irregularity, flatulence Vomiting 70% and/or nonspecific discomfort. If the appendix is ret- Anorexia 65% rocecal, patients complain of diffuse pain in the right lower quadrant, rather than localized sensitivity. Digi- Dysuria 8% tal rectal or vaginal examination in these patients gen- Signs Percentage appearance erally causes more pain than the abdominal examina- Sensitivity in the lower right 85% tion. A pelvic appendix can cause sensitivity below quadrant McBurney’s point, complaints of an increase in urinary Pain upon decompression 80% frequency and dysuria or rectal symptoms, such as te- Abdominal guarding 50% nesmus, which can confuse the examiner and delay di- Rectal sensitivity 45% agnosis.10 Sensitivity in the upper right 20% Pregnant women are less likely to have a classic pre- quadrant sentation of appendicitis, but the most common symp- tom of appendicitis, i.e. pain in the lower right quadrant, About 80% of non-pregnant patients with appendicitis occurs near McBurney’s point in most pregnant women, have preoperative leukocytosis of over 10,000 cells/mL irrespective of the stage of pregnancy.5,11,12 As the location with a left shift.18-21 However, mild leukocytosis may be a of the appendix migrates a few centimeters toward the normal finding in pregnant women: the total leukocyte head with the increase in uterine volume, in the third tri- count can reach 16,900 cells/mL in the third trimester, mester, the pain may be located in the flank or in the right rising to levels of around 29,000 cells/mL during labor, upper quadrant.13.14 including a slight left shift.22 McBurney’s sign is described as pain upon palpation Microscopic hematuria and leukocyturia may occur about 1.5 to 2.0 centimeters from the anterior superior when the inflamed appendix is located near the bladder iliac spine in a straight line from that point to the navel.15 or ureter, but these results are reported in less than 20 This sensitivity may be less prominent during pregnancy percent of patients.16,18,23,24 Slight increases in the total se- because the pregnant uterus lifts and stretches the ante- rum bilirubin have been described as a marker for perfo- rior abdominal wall, increasing the distance to the in- ration of the appendix (70% sensitivity and 86% specific- flamed appendix.16.17 Since direct contact between the area ity25). C-reactive protein also rises in appendicitis, but it of inflammation and parietal peritoneum is prevented, is a nonspecific sign of inflammation.21 there is less sensitivity, pain upon decompression or ab- dominal guarding. The pregnant uterus may also prevent Diagnosis contact between the omentum and inflamed appendix, Acute appendicitis is a histological diagnosis. Clinical di- which increases the possibility of diffuse peritonitis, since agnosis should be strongly suspected in pregnant wom- the fetal membranes would not be able to block the in- en with classic findings, such as abdominal pain, which flammatory process.17 migrates to the right lower quadrant, tenderness in the The largest review, which describes the frequency of right lower quadrant, nausea and/or vomiting, fever and clinical signs and symptoms of appendicitis during preg- leukocytosis with a left shift.1 nancy, included 720 cases with 75% relating to acute in- With an atypical presentation, which often occurs flammation and 25%, to perforation.18 However, it has during pregnancy, imaging studies are recommended.3 REV ASSOC MED BRAS 2015; 61(2):170-177 171 FRANCA NETO AH ET AL. The main objective of these examinations is to reduce de- population, in which sensitivity and specificity were 86 lays in surgical interventions due to diagnostic uncertain- and 96%, respectively.34 Several factors influence the per- ty. A secondary objective is to reduce, but not eliminate, formance of ultrasound diagnosis of appendicitis in preg- the negative appendectomy rate. In such cases, ultra- nancy, including gestational age, body mass index (BMI), sounds can reveal the possible cause of the patient’s symp- and most importantly, the training and experience of the toms (e.g. ovarian cyst or torsion, degeneration or torsion examiner.35 of myoma, nephrolithiasis, cholecystitis).3 Nuclear magnetic resonance imaging (MRI) is an ex- Diagnosis of acute appendicitis in a patient during cellent method to exclude acute appendicitis in pregnant labor requires a high level of suspicion, is especially dif- women when the clinical examination and ultrasound ficult and may not be possible. Labor may be associated are inconclusive.36 MRI is an attractive
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