Acute Appendicitis in Pregnancy, A Ten-Year Survey*

ACUTE APPENDICITIS IN PREGNANCY, A TEN-YEAR SURVEY* EDWIN

S.

HoFFMAN, M.D., AND MASAMICRI

SuzuKI,

M.D.,

DETROI'r, lVIICH.

(From Section II, Obstetrical and Gynecological Sc1·vice of the Division of Gynecology and Obstetrios, The Grace Hosp·ital)

HE diagnosis of appendicitis is frequently difficult in the very young, the very old, the obese, and the pregnant patient. We are concerned with the latter. Acute appendicitis is a serious abdominal condition and when it occurs during pregnancy it presents a problem of greater magnitude. The mother and fetus are exposed to dangers besides the usual complications and sequelae of pregnanry. In 1947, a young primipara in the seventh month of pregnancy was adJnitted to the Obstetrical Service of The Grace Hospital and died shortly thereafter as the result of a ruptured appendix, without benefit of operation. vVe then reviewed all cases of appendicitis in pregnancy for a ten-year period, 1943l9G2, inrlnsive. A preliminary study, 1943-1947, inclusive/· 2 has been reported in The (hace Hospital B'ulletin, and The Western ,Jounwl of Surgery, Obstetrics (~nd Gynecology. Since 1943, 126 appendectomies have been done on pregnant women. Of these, 45 cases were acute, with or without peritonitis, and 81 were reported by the pathologist as ehronir, atrophic, obliterative, etc.

T

Roentgen Studies of the Appendix and Cecum During Pregn~cy In 1905, Fueth 3 investigated the displacement of the cecum during pregnane,v. In 1932 Baer and associates• reported their observations on the displacement of the cecum and appendix in 28 pregnant patients. From a clinical standpoint, none of these patients had ever had appendicitis. Baer concluded, '' During rwrmal preguancy there is a gradual shifting in the position of the base of the appendix from its normal low-lying position in the iliac fossa to one somewhat above the iliac crest near term. In addition, the long axis of the appendix changes from the normal downward and inward direction, first to the vertical, oft<'ll emvillg around the ntcrinc fundus. This gradual outward and npward
1338

Volume 67 Nctmber 6

1339

in position and direction of the appendix Juring pregnancy, and Figs. 2, 3, 4 show x-ray evidence of the displacement of the appendix and cecum at the end of the third, sixth, and eighth months, respectively. 4 Bvcre made on patimt,<~ who presented no subjeetivc symptoms of appendieiti~. In our series of 4G eases ( 43 op('l"ations), 41 per ePnt of the appendi<'('S were fn'('\y movable, while G9 per cent wct'e retroeecal or fixed hy adhesions ('I' able VI).

F'ig. 1.-Changes in position and direction of appendix ;luring pregnancy. and "\rens.')

(From Dacr, Hcis,

Incidence 4

Baer and his co-worket~ report an incidence of 0.17 per cent in Hi,5-+3 pregnancies. Cosgrove" reports 0.072 per cent in 2,500 pregnancies. The fetal loss in Cosgrove's series was 16.6 per cent in 18 cases and there was one maternal death in the eighth month of pregnaney. Meiling6 reports 21 eases of acute appendicitis in 49,681 deliveries with two maternal deaths; the fetal loss was 42.8 per cent. Musscy'· 8 • ~ reports au incidence of 2.0 per cent. Coodall 10 stated that he had seen 5 cases of aculc appendicitis in 3,000 deliveries; while Greenhill 11 has had 3 cases in 2,500 deliveries. DeLee 6 is quoted to have said that in 30 years of obstetric practice, he had seen only 4 cases of appendicitis late in pregnancy. In our series of 44,242 deliveries at The Grace Hospital from 1943-1952, inclusive, there were 45 cases of pathologically proved acute appendicitis. This gives an incidence of 0.101 per cent. It is evident, therefore, that pregnancy does not predispose to appendicitis. In M:ussey 's 7 • 8 • 9 series of 75 cases he found that 50 per cent of the patients gave a history of previous attacks of appendicitis. Baer and associates 4 report a similar incidence in their

HOFJ!'MAN AJ'.:ll

1340

Sl~ZLTKI

\m.

J.

Obot. & Gynec. June, 1954

series of 28 cases of appendicitis in pregnancy. ln the -.1:5 cases ot: acute appendicitis comprising this study, 23, or 51.2 per cent, gave a history of previous attacks (Table II, B).

Stage of Gestation It is the consensus that appendicitis is most frel1uently encountered during the first and second trimesters of pregnancy. In our series, the distribution is shown in Table I. It is thought that the beginning displacement of the appendix and cecum plays more than a coincidental part in those cm:cs with a history of prC\'ious infection. As shown in Table III, this was not trne in our series. Prom our stndy, statistically at least, the displacement of the app0ndix after the third month of pregnancy is more signifieant than the history of pl'evious attacks. Percentagewise, 64.5 per cent of the rases occurred after the third month of gestation irrespective of previous infec·tion (Table~-: I, III). TABLE

!.

PAinTY AND DURATION lH' PREGNANCY LOCALIZED TO THE APPENDIX (28 CASES)

Wl'l'H PERITONl'l'IS (17 CASES)

I. Parity.A. Primiparous

B. Multiparous II. Duration of Pregnancy.A. First Trimester B. Second Trimester C. Third Trimester

-~-~

12 ( 42.8%) 16 (57.2%)

6 (115.2%) 11 (64.8%)

12 (42.8%)

4 (23.5%) 7 (4I.2%) () (35.3%)

11 (39.2%)

5 (18.0%) TABLE

Typical 2. Atypical

B. History of Pre·vio11s

.Attaoks.1. No previous attacks

C.

2. Previous attacks

Bymptornatology.·1. Nausea

2. Vomiting 3. Generalized abuominal pain 4. Right lower quadrant pain 5. 'l'wo or more of above symptoms D. D1trration of Symptoms ( 43 Cases Operated 1Jpon).1. 24 hours or less 2. 25-71 hours 3. More than 71 hours

TOTAL CASES)

(45

II.

18 (40%J 27 (60%) 16 (35.5%) lil (40.0%) 11 (24.5%)

CLINICAL HTS'l'OltY

21 (75.1)%) 7 (25.0%) ]3 (46.5%) 15 (53.5%)

12 (70.5'/r.)

5 (29.5%)

12

fl (52.0%)

23 ( 48.8%) 23 ( 51.2%)

s

(47.1%)

20 ( 71.4(/c) 17 (60.7%) 22 (78.3%)

12 (70.5%) 10 (58.8%) 14 (82.3%)

"'~ (71.1%) 27 (60.0%) 36 (80.0%)

18 (64.2%)

15 (88.2%)

33 (73.3%)

~-)

33 (73.3%)

20 (71.4%) 6 (21.4%) 2 (07.2%)

8 (53.3%) 5 (33.3%) 2 (13.4%)

28 (65.1%) 11 (25.5%) 4 (09.4%)

Symptomatology and Diagnosis The symptoms of appendicitis are the same in the gravid as in the nongravid patient. As pregnancy advances, the pain is higher and more lateral.

Volu me

(,j

:'\' nrn her 6

ACUTE APPENDICITIS I N PREGN ANC r

F ig. 2.-Appendix at end of th ird m onth of pregnancy. o f the cecum and th e a ppe n d ix points vertically.

1341

The r e is a littl e upward displace m e nt (From Bae r, R e is, ancl Arens.')

Fig. 3.-End of the s ix th m o nth. The appendix is horizonta l a nd points media lly. The cecum a n d appendix have b een displaced upward and lie w e ll abo ve the iliac crest. (Fr om Baer, Reis, and Arens')

Am, .1. Ob~t. & Gynec.

IIOFFM AN AKD SL"ZUKI

1342

.hne, 1954

Nausea, yomiting, muscle spasm, tigidity, r~·vf'l', aud leukocytosis at'\' usually present in most cases, but the interpretation o£ these findings in the last six months of pregnancy may be difficult, be<' a usc of the displacement or 1!tc ;1 ppcndix nnd e<•emn (Table II, .:1).

M'Tl~R

i"II<.:S'l'

lliil'l'ORY Or' l'REVIUUS A'l"l'Af'KR

----No----22 (48.8%)

'l'HDIES'l'J-:Il

,

SJ!~('Ui\"tJ

rl'Illl~U

'I'RJ).fES1'Eil

Tli[).!J£S'l'ER

--~--7-------~--~"=--.-=---} (ti8.l'i(, 8

I

""'

I,

THIRD MONTH

A!\'"IJ IRltF:RPEC'l'lVE Ol<'

PREVlOlTS

'

ATTACKS

--~-~-

/--------()-{,;;'JD

4

1! ti:l.~r/c. I

The evaluation of sym]Jtoms referable to the gastroinic~tinal tnwt. dt~ring pregnancy may prove mtlwr confusing·. This is especially i rue in <•.asvs of acute retrocecal appendicitis or in ease~ where 1he appendix is high in the 1·egion of the right kidney. '\Ve have luul an experience with S1l<'h a ease, as has l\Teiling." Neither of these patients llad any prenatal care prior to being admitted to the hospital. ( Jur ease will be briet!y outlined later in this paper. Titus1 " helievcd that a rising leukoeyte ('onnt and a sedimentation rair whic·h is beroming acceleratrd arc indications fm· ill!mediate surgery. 'rhe lcukoryte counts are shown in 'l'able V. IV.

'1'.\BLE

Cr.JNICAL OBSERVA'l'!ONS

LOCALIZED 'l'O THE APPENDIX CJ;ll\ilCAJ.- OBS£KVA'I'IONS

\l'l1'H Pl.;RI'rONJTIS

A. Fever.1. Below 99o F, 7 25.0%) 21 2. 99°·100.4° F. 75.0%) 3. 100.5°-102° F. 0 4. Above 102° F. 0 B. Abdominal Findings.28 (100.0%) 1. Right lower quadrant tenderness 2. Muscle spasm 9 ( 67.8%) :~._ E~t,.nt~o~n_____________ 2 ( 07.1%) TABLE

V.

3 11 3

17.ti%) 64.8%) 17.6%) 0

17 (100.0%)

10 ( 22.2%)

.12 ( 71Y!o)

:l ( 06.7%) ()

45 ( 100.0%)

1 I ( 6±.8%)

30 ( ti6.ti%) :l__ ( _1_7_.6_(1;_/0___c.)_____ 5_(_ 2~~5_%)__-

LABOJUTORY FlNIJJKGS II

\VlT!! l'F.Rl'PONITIB I 17 CAf;ES)

(41*

0

0 1-t (S2.:l%) :l(17.7%l

:11 ( 7D.n% 1 :l (07.4%)

15 (62.5'/(;)

I;) (RR.2%)

.10 (/:l.l%)

1:! (50.0%)

12 (70.5%)

2-! (5S.5%)

T.(ICAL17.ED r_ro

1'HE

APPI,K!IIX

~-..~~-A~B~O_RA~'l~'O~R~Y~~Fr,N,'D/l>N_G_S~~--~(_2~4-*_C~A_S~~~;~~)___

A. White Blood Cell Count.1. Below 10,000 2. 10,000-20,000 3. Above 20,000 B. Polymorphonudear Leukocytes.Above 80% C. N onfilamento~ts Polymorphonu-clear Leukocytes.Above 10%

TOTAl,

~(~_98__c_cA_~_·rc_·s~)----~--~(_1_~_,_C_A~S~E~S~)----~~(~4~5~CASESI

7 (29.2%) 17 (70.8%)

*No blood count done in 4 cases.

TO'l'AL CASE~)

7 (l'i.Ori()

Volume 67 :!'\umber 6

ACUTE APPENDICITIS lN PREGNANCY

1343

If a patient had two or more o£ the subjective Hymptoms listed in 'l'able II, 0, the history was considered typical. In our series 33, or 73.3 per ~ent, were considered to he typical and 12, or 26.7 per cent, atypieal. 0[ the atypical eases 11, or 91.6 per cent, occurred after the third month of pregnancy.

:B~ig. 1.-

Bnd of th e eighth month. The cecum and appendix arc dist;laeed still higher above the iliac crest. ( Fron1 Bat~r. }{eis, and Arens.")

The differential diagnosis of arute appendic-itis during the three trimesters should include the following: 1. During the first trimester:

a. Ectopic pregnancy b. Salpingitis c. Early abortion d. Ovarian tumors e. Kidney or ureter stones 2. During the second trimester: the above plus a. Nephritis and pyelitis b. Gall bladder disease c. Intestinal obstruction d. Peptic ulcer e. Mesenteric lymphadenitis and thrombi f. Carbuncle of kidney 3. During the third trimester: the above plus a. Premature labor b. Placenta previa c. Abruptio placentae d. Eclampsia

13-t-4

\rn.

HOFFMAN ANTl SUZFT\I TABLJC V 1.

()1,-,t. & (~ym~c. f IJHC,

Iq

~""'-

OI'EJL\TI0:-1

LOCALJ7,ED •ro APPENiliX

'!'HE

(28 CASES)

OI'BRA'l'I0:-1

J

A. Anesthesi:a.1. General

I

L_

WITH l'lmiTONITIS ( t5·* CASES)

'l'OT.\L

(43*

2. Spinal

CASES)

~~5

(81.4%)

8

(1~.6%)

10 G 24 .'l

(23.2%) (13.9%) (55.8%) (07.1%)

B. Incision.1. McBurney's :l. Midline 3. Right rectus

e.

4. Other Mobility of Apptndix.--1. Freelv movahli! 2. Rectrocecal ;{. FixeJ hJ· w1l,esionH *Two

TABLB

caRe;-:;

VII.

4 (26.6%) 5 (33.3%)

14 (50.0%) 11 (39.2%)

3 ( lO.Ro/n)

18 (4J.!l%) :25 (;).'J.J%)

6 ( 40.1 o/())

-----

not opera.tP1l upon.

COURSE OF PRBGNANCY DURING 'l'HE ACU'l'E PHASE 01<" '!'HE DISEASE \VII!LE IN ~'HE HOSPITAL

-------Yt;LL· BX'rEN'l' OF

TER~I

INFECTION

LABOR

Localilled to appendix

25

2

0

0

I

MOlt'l'ALI'rY

I

I

I

~IATER:-!AL I

YE'l'AL

1

0

1 ( 3.5%)

1

2

(6.8%) 4 (29.4%)

"~~~-.-----'

With pnritonitis

9tl.4%

----------,

29.4%

Total

1 (2.2%)

38

ll (1:l.:l%)

(84.5'/r)

Abortion and Premature Labor StatiNtics vary from 2 to 26 per ('ent. Tlwst> eomplieations are morP rommon whe11 the disease has spn•a1l lwyoud the appendix (Table VII). During thr acute phase of the di:·>ease, before the patient lrft the hospital, the alJoltion and prrmatnre rate was 13.3 per cent. Th<' :mh:>cquent eourse of the pregnaney aftrr leaYing the hospital was followed in all Pases (Table VIII). In this group tlw fetal Joss amount<>d to 1:u p<>r e<>nL TADLE

VIII.

FOLLOW-UP i:l'l'P1>Y OF TJIJ<; SUBI:lEQllBKT COURSE OF PREGKAKCY T:\ 'l'Jm UKnELIVJCRKn PA1'IENTs

:;s

·--···----

KNOWN

~·o

HAVE !JELIVERED

EXTENT 01•' INI"EC'I'IOK

Loealized to appellllix

With

peritoniti~

n

'Foial *Feta1 losf; due to placenta

11.1% 0

0

9 (81.9%) 2

(18.1%)

AC1:TE APPENDICI'l'IR lN PREGNAXC\'

Volume G7 1\umber 6

Fetal Mortality The fetal mortality has been reported by 1\Ieiling" as 34.6 per cent. In our series the fetal loss during the acute phase of the illness was 13.3 pl'r eent. In the breakdown of our statistics, we found that when the disease was limited to the appendix, the fetal loss was 3.5 per cent. \Vhen the disease had spread beyond the confines of the appendix, the mortality increased to 29.4 per cent. Thirty-eight patients delivered after leaving the hospital. In this group the fetal loss was 11.1 per cent when the disem;e was limited to the appendix, and 18.1 per cent when peritonitis was pr(•srnt. The over-all fetal loss in this group was 13.1 per cent (Table VIII). The over-aU fetal loss for both immrcliate and late cases was 20.4 per cent; when the disease was limited to the appendix, 11.1 per cent; with peritonitis 35.2 per cent (Table IX). TABLE

to appendix I--

WHILE

EXTF.NT OF INFECTION

Loealiz<'d

IX.

FETAL MORTALITY

IN HOSPITAL CASES)

(45

~-1·m-28

( H.i3%) -! in 1 i

With peritonitis n--:-:;-;-----------~(39.4%) 5 in 45 Total

(11.1%)

I

A~'TER DISCHARGE (37 CASES)*

-----

TOTAL CASES)*

(44

2-in 3~6:c-'---~-~-:c:l---;-in---o27 (11.1%) ( 7.6%) 6 in 17 :3 in 11 (lS.l%!

4 in 37 (10.8%)

(35.2%1 9 in 44 (20.4~_)_ _

*Fetal loss due to placenta previa in eighth month not incltHle
Maternal Mortality The maternal mortality is dependent upon the duration of' the infe<:tion and the period of gestation. After the seventh month of pregnancy, walling- off of the infection is unlikely, and wide~pread involvement of the prritoneal caYity is a gJ.'eat possibility. 1\Iussry'· 8 reports no deaths in 26 cases; but in anothrr series of 122 cases, he reports 2 draths, one in the sixth and one in the seventh months. Baer 4 reports no deaths in 28 cases, and l\Ieiling 6 2 deaths in 26 cases. Both of 1\Ieiling's deaths occurred during the ninth month. One patient was opcrateil upon with a diagnosis of perinephritic abscess and at operation the ahsccss, in the region of the right kidne,v, wm; found to be due to a JWrfornt(•d appendix. There was one maternal death in our series. Briefly the histor:-, of this <:ase is as follows: A 19-year·old gravida i, para 0, was admitted to the hospital on April 24, 19±7, with a ehlt:f eotllplalnt of hackaehe uf 24 hours' duration. The haekache \vas <"hh,fly on t1li' riglit ,;i \vith some radiation of pain to th,• right flank and thigh. Shr> was first ~<'Pn in n1P medieal outpatient clinic one month previously with a<'utp brom·hiti~. At that tim<' thl' pel'iod of gP~tation was eH\inmLed to l•e 6 monthH. Admitting physi<'al !'Xtunination revn:lled: t(•mpemture !.H.lo F., pnbe SK, rnspirationR :.'0, blood pr<'8~\ll'e 115/75; clear lung fid
\!!.

_!. i

)]ht. & (~\'!\{''

hmc. -,qq

She waR ambulatory on a<1rlliRRion, aucl in no a~utu distr.,ss. A voidPa'f• awl axilla, with de<·.n•as••d l>n•:•tlt smt]J(ls and voea.l :fr~:nlitu::;, ftiH1 frit·tir,n

i

u1J Wt'l'l' found on l'h~·:-'t examination.

Thl' alidonwn \\"a~

cks~rii>r
aR distcndPtl and tc·nse. X-ray of ti11· chest ta.kf'n lat t'r in tlw nwming· t•xhii>itPpneumoni~ infiltration in the right lower lolH·. Rl11• was pi:u·..,,] in an oxygen tPnL The doRage of p<'nieillin was inercasPcl, anPfon• death. Medical, urological, surgieal anrl ohstc·tri•·al <'onwltation:l wen• oLtainPd titroughout l11·r ('.nurse of illn<·:-;~. rfhe posbnortenl pathoJogieal diag'HO~i~ \Vas: 7~-~ lllOBth~' uterinp prt~g·naney, Ull
The history of the sc(•ond llOllOJll.'rativc ('HS<' 1s as follows: 1\[rs. B. H., a 22·year-old white graviola iii, para ii, was admitted in tl11• <'\'Piling of Marc·.h 15, Hl4G, with the history of irreguhr, laL•orlikc lo\\'f'r abdominal pains and pt•rsi:;tent 1

IguL HH' el yu;:ttli a.ut auu uauK pain:-;.

IIer laE->t rneru·•trual pt'riod

\Vas not aef~uratel.v

known,

but was thought to have been in the latter part of .July, l!J4;'i. III'r prenatal t•om·se had bPen tlllC\'<'ntful. 'l'h<' physical examination wa8 esst·ntially negative, except. for low-grad•• f<'VE'r (D9.S o F.), anfl norn1al preg·n~uwy \vhich \Y:l.H r:linieally fnll tenn. On rt'l'tn I ;_•xarnination, the <'Prvix was dilateu ::l em.; t lw presenting p:ut ( <·Pphalil') was at minnR L station, and tht· mc·mhranes \Ycre intaet.. Shmtl;' after admi:;sion, thu intermittPnt mild ut.•rine eontraetions subsided; howc•\-!'r, thr• right. lower qm<r a1lmission, her r·o, 11 lition suddenly became worse. The rigl1t lower quadrn nt pain p<'rsistetl ancl slw. hegan to t·muplain of epigastrie pain, Yomitcrl twic·P, ancl perspirPd prnfus<•ly. Ifpr t••mperatun• rose to 101.2° F. On tho morning of }fareh i7, slu• :qJpearecl :tl'Utt•ly ill twcl toxie. Examination sh"wecl normal chest finaings, but the ahJon1inal exarnination for the fin~t tin10 n~vealed nlo(1erate gaseous distention, moderate-to-acute tenclPrncss in tlw right flank and over McBurney's point. There was no muscle rigiuty and no intestinal persistalsis. A uiagnosis of ruptureu app('ndix was

Volume 67

ld-17

:r\umber U

made. The patient was immediately placed on an intensive, conservative, nonoperative regimen, because her poor condition seemed to contraindicate surgery. The penicillin was increased to 100,000 units intramuscularly ewry 3 hours; intravenous fluids were instituted and she was placed in semi-Fowler·~ position. On the same evening she went into active labor and spontaneously delivered a full-terin living n1ale infant. The third stage was uneventful. Immediately post partum her g<>nl'ral condition was poor. Her temperature was 102o F.; she continued to have right lower quanicillin was reduce
Treatment of Acute Appendicitis 1. Prophylactic.-All pregnant patients should be watched closely for :-;igns and symptoms of acute appendicitis. This is especially true during the seeond and third trimesters, and if there is a history of previous infection. It is om· opinion that when the diagnosis of appendicitis has hren made, appendectomy should be done regardless of the age of the patient, whether married or single, whether pregnant or not. 2. During First Six llfonths.-Appendectomy is the procedure of choice. Maternal mortality is not increased and the diagnosis is not difficult. 3. During Last 1'Tirnester.-Some believe that, in the presence of acute appendicitis with perforation and generalized peritonitis, cesarean section should precede the appendectomy. Otlwrs believe that cesarean section should he done only in the rare case. "\Ve favor appendeetomy only, regardless of the stage of gestation, and would add that interference with the pregnancy is a violation of basic surgical principles. Vve belieye that, during the prenatal period, the obstetrician should watch for signs and symptoms of appendicitis, especially in those patients who give a history of previous attacks. During the first trimester this is not difficult. ·wlwn the subjective symptoms arc atypical the diagnosis may he delayed, especially during the last trimester when the interpretation of signs and symptoms may be more difficult. \Vhen in doubt, and regardless of the period of gestation, "\Ye helicYe the operation is indicated. When the appendix has been perforated more than 8 hours, and thrre if' evidcnee of spreading peritonitis, it appears that conservative management with antibioties, penicillin, and streptomycin is desirable. Following rupture of the appendix, ]oral peritonitis follows. Continued leakage leads to generaliz1•cl peritonitis with invasion of the peritoneum and 1ymphaties. The infection then heeomes systemie and operation with or without drainage will offer the patirnt noiniug·. I f. sueh a patient is operated upon and drainage instituted, the dl'ain soon hecomes walled off with omentum and intestines. In generalized peritonitis it is impossible to drain the entire peritoneal <'avity. Oeorge Cri]e, .Tr.,"'

\m. ! .

has been successful in tlte treatment of peritonitis with })Cllieillin. lie favors t!w nse of 100,000 nnits of penicillin every 3 lwms until the patient shows definite e\·idenee of impron·ment. The dosage is then cleereasccl to GO,OOO units. Kennedy, 1'\ieCadie, a11d ~\rminski 1 ' re1>orted a series oi' flO eases of peritonitis treated with pcnicill in. They favor a smaller dosage of penicillin ( GO,OOO units). hut state tlwt better rrsults an• obsern•d ".:lwn these l:lma llcr dosagei:l a1·e comhine
X.

FE'rAL

.:\.C(J'l'J~

r:o·ruJ[iZ(0Toarrei~JG:·---···-

With

Lnss, HJ±:3-W±T,

PHASE

(::!;) C'ASESJ

---- i in

H----

'· 7.2'/o) :l in !I

peritoniti~

- - - - - - - - ___________ (_1_7_.±%) *~'etal

JxcJXSJVE

c:JO.I%J

12:Ll'/oJ ~ in 5

--- _

0 in H

__<,::T.'i::lr'..L ____ -

_(~~~% ) --··

lofl;o:; in eighth n1onth due to vlaccnta previa not ineludet1.

ACFTE APPENDJ CIT IS IN l'REGNAXCY

PHASE CASES)

ACU'l'E

LA'l'E

(:l2

(::l I

c;c-L-o-ea--;lcciz-e~d.--tc-o-a_p_r-,e-.n~docix-·_______o--o(c-Ji'n

H I 09;)

±.:3%) TABLE

XU.

-u-

(0%J

0 in I

(12.2%! - - - - - - - 1 i n 2 2 __ _

Total

'rO'CAL

rw,~,:,,

1 in S

With peritoniti~

PHASE

'.\SJ•:s) , ( 2:l CASEH) -----
!iJf/c

o

1

ir1 :ll

( -±.5'/r

{ ()~;~)

DuRATioN ot·· Snu"ro~rs,

1 'in ,>J, 12.2'/r i io ~2

------------r (

I

lH-±:1-l!J±I

DCRATION
(21 r-~4

1

19±3-1947 CASES OPERATED

hoursm.-JeHS 2, 25~71 hours

UJCA"IZEI> '1'0

1\'l'I'JI

--'--~----c=-A_P--.oPc=E-cK,-D~!X~·- - '

-

3. More than 71 hours 'l'ABLE

7 (50.0%) ;') (35.7~fo) •>

XTI!.

Pi':ltl'l'll:-ll.'l'IS

_____ _ I

----:!(~ii-:69{)

·1- (57.1~{,)

I (H.:l%

(14.:~%)

Dl!RA'l'ION

[

1

-------------

ow

~'i.lll''l'
Ul+k-195:!

H~-(:f~.H%! 1 iO nr•/ ·, 1. ,..._.u 10!

o

.-,

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\'n\nmc 67

:\nmberCI

ACUTE APPEKDICITIS IN PREG:l\ANC'i

1349

c•cnta previa is not included.)

In the second five-year period, 1948-1952, inclusive, the fetal loss amounted to 4.5 per cent in 22 cases (Table XI). ~We would like to a1trilmt0 this increase in fetal salvage to early tliagnosis. In the fil'st G-~-par period, 42.9 pel' cent of the ca:-H's wne opl'rated npon \vithin 24 hours (Table XII), while during the last five-year pe1·iod S6.>~ per cent o [ th(• patients Wl're snhjeeted to surger~' within 24 hours ( Tahlc XIII). Tlw libeml usc of antibioties aml sedatives during the immrdiate pofltopcrative JH'l'i()(l ha,.; also ('tm1ribu1ed to the low fetal loss. We hnvr hml no expcrien(•e with progestrnme postopcnttiv('],\' in these eases.

References 1. 2. 3. 4. 5. (i,

7. 8. 9. 10. 11. 12. 13. 14.

Hoffman, Edwin S., and Suzuki, l\1.: Grare IIosp. Bull. 26: 25, 19Js. Hoffman, Edwin S., and Suzuki, M.: "\Vest. J. Surg. 57: 150, 1949. Fueth, H.: Quoted by Baer, .Joseph L.4 Baer, Joseph L., Reis, Halph, A.: and ATens, Robert A.: J. A. M. "\· 98: 135P, J9:l2. Cosgrove, S. A.: AM. J. 0BS'P. & GYNEC. 34: 469, 1937. Meiling, Riehard L.: i:lurg., Gynee. & Obst. 85: 512, 1941. Mussey, Robert D., aml Crane, Jacoh F.: Ar<'l1. Smg. 15: 729, 19~1. Twyman, H. A., Mussey, R. D., and Stalker, L. K.: Proe. Staff. itff•et., Mayo Clin. 15: 484, 19JO. Mussey, R. D.: PNsonal communication. Goodall, J. R.: Personal eommunication. Greenhill, J. P.: Personal rommuniration. Titus, Paul: The Management of ObHtetric Diffieu!ties, ed. 3, St. LouiR, 1945, The C. V. Mosby Company. Crile, George, .Jr.: Am. J. Surg. 72: 851), 19J6. Kennrdy, C. S., MrCadie, .T. H., nnrl Arminski, T. C.: Grace Hosp. Bull. 25: 107, ] 9·±7.

Discussion DR. GEORGE \VUL·:E,F, tJR., St. Louis, J\Io.-Acute appendicitis eomplicating prt.•gnan<:,y is admittedly an infreqnPnt dinical pieture confronting the awrage obstetrician. Although each of us has seen or !teanl of a case occasionally, ability to draw conclusions from one's personal expcriPnce with this condition is praetically in1possible. This obstetrical cmergew·y oceurs with an incidence of 0.1 per cent or lPss, as reported by various investigators. We are especially indebted, therefore, to Drs. Hoffman and Suzuki for their prolongecl study of this subject. Their paper presented this morning provides the largest series of cases of this disease reported in the current literature, and merits the elose scrutiny of all of us in the obstetrical spc<.Oialty. An attempt was made to compare the author's statistics with those of our own obstetrical service at Washington University. 'l'his was complicated, however, by the fact that surgery in acute cases is not performed in St. Louis Maternity Hospital, but in the adjacent Banw~ Hospital. Some of those pati(>nts operated upon at Barnes undoubtedly were delivered at other hospitals; therefore to have asoessed the~e surgical procedures aga.inst the dPliveries at Maternity Hospital would have been mioleading. Because of the conversion of our !"<'Cords to microfilm and the I.B.M. system, only thrPP years were available for comparison: 19J9, 1950, and 1951. During these years there wen' 10,317 deliveries, and there were 1l patients operated upon for the clinical diagnosis of acntl' appcnflicitis. Thefe cases occurred in au incidence, therefore, of 0.106 pn ct'nt (ratio of l case to 938 deliveries) whieh is almost identical with that presenterl lH'r<' this morning, anc1 with that of other t·eportl'c1 scrips. IIowEWPr, when we exclude the 4 patients whose deliveriP~ could not be positivPly traced to Matt'rnity Hospital, the remaining 7 eases repre~ent an incidence of only O.OfiS per eent (ratio of 1 case to 1,474 deli\•eries). A fnrtlwr lm•akolowu of these cases showed 6 to be pathologic-ally proved acute appnndicitis. Only one of our 7 cases resulted in prematurr termination of the pregnancy ancl that was an acute case in which the patient aborted a nve·month stillborn fetus seven days after

.\n1. .J. Ob·.t. & Gynec. June, t
1:350

the appendedomy. This 1·epre~ents a fetal lo's 11f 1"' per ,·,·nt, as all uf tlw ot hPr ti patient~ wen• ddin•red UJI<'Yl'Utfully at !Prm. Thne wa~ uu nmtc•nnd dPatlt in our group aud tltt' v:t~<':' \l'<'rt' alm11~t <'']Uali,Y tlividt•tl :unong thn thl'P(' 1rinte~tl'l':-i of J'l'l'g'll:tlli'.Y· Ln di:-;eu . . :-;ing tiu· stagn or prq~'lUliH'Y· ho\\"('\'('J', i1 i~ \Yell to cu1pllasif';t' Ua• stah•n:t·nt in tht• pap:•t .'~ni l:a\:' .iti~t !H·:u:l . that aft:•r tlH· ~.!'Vt>n1!! month of pregnaney, v;nlliug off of the infpt·.lion is tllllikPly, and ll·ide,-pre:ul ittl'tdl't•Jnt•nt of the peritoneal •·ayity is n gn•at po~sii>ility. Adually, t.lii,; i,; a Y<'r,Y IIHHl<':'t under,;tat•·uH'Ji\. rrhe iiH'l't'lU·dllg' dangPrR \Vhi('h <'Ollfl'onf. llS :t~ pn•gna111·y npJil'O:td!f~~ h•nn lll't• H'l'iOUS Olle~ awl must hu appn•eiah·d. BeeaU"<' u[ the initability of thP uten1" anti ib int<'nnitt.·nt •·olltrad:ious, ah"''""" furmation tak<·,- pl:we mnl'b lt'"" fn·,,. likdy to IH•:;itatc in onl<·r to Jlt:tk<• 11·!Jat ]Jl• f<'('l:--. is an •• irolJ('!nd'' preopera.tiv(' dlagno~i:..; . .\.:;Indy of tl1is n:1ture alll'a.\·,; stimnlat<'H interest in r<'i:t1t•<"<'~~ is interfenJ for tl11' author" to dist·t"'s this phas•• iu tlw filial publi,·ation of tl1eir work. !.£ \Ye I'l'Vi(~\Y tht•ir \\"ork <·arpfully a11d lu•(·~l their :ulvie1·, we too ~hall hP on t!w alert for this eumplication an
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] lli. HOFF..\LL'\ (Closing! .-We llttve 1nade sonte sttHlie:; of aeule appendicitis lc to make that a separate study. I certainly agree with llr. \Yulff that widt·~pread involvPment of thP peritoneal l'avily O('('lll'~ during the la::;t trhnester aft.Pr appt>11dix rupture is putting it rather modestly. The thing we want to Pmphasize, 1 lwliPn•, is that the P people with acutt• appencli<·itis wh" are thought to ha\·e pyelitis. It i~ intl•n•,;ting to note in our oeries that <'\·en though the fetal loss was ]ps,; ill the secon<1 Jive-year ;;Mil's, thl' nmnlwr of patieuts "["'rnted on with a preopterativP or ::I
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was no g-reater than in tl1e first fiYC-~'ear ~Pril·~. T would like (o make one "tatl'llHmt for whit"h 1 ha\'e no haHi~ in faet ,-(alistically or otherwiAe; it iH .iu~t an intuition, if you wish to <•all it that. I have the feeling, as w.go through thP H<'l'ies aml ~an,\· it ou for perhaps anotlwr Jil·e or tl'n year~, that we may iin