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Diagnosing appendicitis during pregnancy
Diagnosing Appendicitis During Pregnancy
Kathleen Masters, MD, San Antonio, Texas Barry A. Levine, MD, San Antonio, Texas Harold V. Gaskill, MD, San Antonio, Texas Kenneth I?. Sirinek, MD, PhD, San Antonio, Texas
Appendicitis during pregnancy, particularly when associated with perforation, peritonitis, or both, has been associated with increases in premature labor and fetal and maternal death. Diagnostic delay has been assumed to be largely responsible for the incidence of these complications, primarily because a prolonged symptomatic duration might logically be expected to increase the likelihood of appendiceal perforation. To determine possible methods for improving diagnostic accuracy, the hospital records of all pregnant patients who underwent exploratory celiotomy for suspected appendicitis over a 10 year period were reviewed. Material and Methods From January 1973 to December 1982,36 patients with a preoperative diagnosis of appendicitis underwent exploratory celiotomy during pregnancy. Twenty-nine patients had appendictis confirmed by pathologic examination. Seven patients were designated as having negative celiotomy findings. Of 29 patients with appendicitis, 2 presented in the first trimester, 17 in the second, and 10 in the third. Perforation with peritonitis occurred in 12 patients. The patient data were analyzed in two separate ways: First, diagnostic accuracy, type and duration of symptoms, laboratory data, and incidence of perforation and complications were correlated with the patient’s trimester of pregnancy. Then, the patients were further classified into those with uncomplicated appendicitis and those with peritonitis secondary to perforation. They were then compared to determine whether perforation was related to diagnostic delay and if it increased the maternal and fetal complication rates.
Results Thirteen patients initially presented with the classic symptom of periumbilical pain which later radiated to the right lower quadrant of the abdomen (Table I). Abdominal pain of the right lower quadrant developed before operation in an additional four patients. Nausea and vomiting were more common initial complaints than was anorexia. Presenting symptoms showed no correlation with the trimester of pregnancy. Neither signs nor symptoms differed significantly among those with and those without appendicitis. Seventy-two percent of those with appendicitis, with or without perforation, had temperatures of less than 99.6OF (Table II). On physical examination, at least 25 percent of those with appendicitis had no guarding, almost half had no rebound tenderness, and less than half had rectal tenderness. Seven patients with appendicitis also had abnormal results of urinalysis that led to an initial incorrect diagnoses in three instances. Six patients with appendicitis had a normal leukocyte count (less than 10,000 cells/ mm3). Three of these patients had perforation, and only 58.6 percent had a significant left shift (more than 88 percent granulocytes). Abdominal radiographs obtained in nine patients were not helpful in the diagnostic workup. When diagnostic accuracy was determined from impressions at initial examination, the correct diagnosis was made 52.7 percent of the time (19 of 36 patients). It improved to 77.7 percent (28 of 36 patients) as observation and repeated examinations eliminated other causes. Seven patients with appendicitis (24 percent) underwent
From the Department of Surgery, The University of Texas Health Science Center, San Antonlo. Texas. Requests for reprints should be addressed to Kenneth R. Slrlnek. MD. DepMmmt of Sugary, The Uniiity of Texas Health Scii center. 7703 Floyd Curl Drive, San Antonio, Texas 78284. Presented at the 36th Annual Meeting of the Southwestern Surgical Congress, Honolulu, Hawaii. April 21-28, 1984.
763
exploration
more than 48 hours after the
onset of symptoms. When initial impressions were inaccurate, significant operative delay (more than 24 hours after admission) occurred in only three patients, all with perforation. In the remaining four patients, treatment delay was entirely due to patient
Tha American Journal of Surgery
Diagnosing Appendicitis During Pregnancy
TABLE I
Prasentlng Symptoms at lnitlal Examination In Patients With and Without Appendicitis
Symptoms Abdominalpain RLQ RLQ (periumbilical) RUQ R flank Epigastrium Diffuse Anorexia Nausea Vomiting Constipation Diarrhea Qysuria
Perforated
Appendicitis(II = 29) Nonperforated
2 2
2 11
1 3 2 2’
3 0 1 0
8 10 11 0 0 1
11 18 14 1 1 0
Total
%
29
100 13.7 55
4 13
Negative Ceiiotomy (n = 7)
13.7 10.3 10.3 8.8
19 28 25 1 1
85.5 89.8 88.2 3 3
Both patients presented with uterine contractions only. R = right;RLQ = right lower quadrant;RUQ = rightupper quadrant. l
TABLE II
hesantlng Signs and Laboratory Data At lnltid Examlnatlon III Patlonts With and Without Appandkltls Nagative Signs
Perforated
Appendicitis(n = 29) Nonperforated
Celiotomy Total
Abdominalguarding Reboundtenderness Psoastenderness
a
5 9
14 11 9
22 18 18
Rectal tenderness Absent bowel sounds
4 5
9 9
Temperature I99.8“F 99.7-100.4’F >lOl’F
7 5 0 4
Laboratorydata Abnormalurinalysis White bloodcell count I 10,000/mm3
%
(n = 7)
75 55
4 2
13 14
82 44.8 48.2
5 8 3
13 2 2
20 7 2
72 24 8.8
3 2 2
3
7
24
0
3
3
1 l-15,000/mm3 > 18.000fmm3
3 a
a 8
a 11 12
20.8 37.9 41.3
2 1 4
Granulocyte count 280% 288%
9 a
14 9
23 17
79.3 58.8
8 3
delay in seeking medical care rather than physician error. A prolonged symptomatic period (51,54, and 72 hours and 8 days) was associated with appendiceal perforation in four patients. One premature birth occurred in this group. In the three patients who had neither perforation nor peritonitis, one premature birth occurred. The symptom durations were similar (72 and 72 hours and 7 days) to those in patients with peritonitis. Prompt surgical intervention occurred within 24 hours after admission in 26 of 29 patients with appendicitis (89.6 percent), yet in this group, one intrauterine fetal death and five premature births occurred.
There were no maternal deaths, and no complications occur& in patients who underwent negative explorations. Pulmonary complications (atelectaeis) occurred in 5 of 36 patients. One intrauterine fetal death (2.7 percent incidence) did occur in a 33 year old woman who presented at 18 weeks gestation with a nonperforated appendix. She wae operated on within 24 hours after the onset of symptoms. At 39 weeks gestation, she delivered a macerated fetus judged to have a gestational age of 32 weeks. Premature labor occurred in six patients with appendicitis. All resulted in live birtha at a mean gestational age of 34 weeks (range 33 to 39 weeks). Two patients
789
Masters et al
with a perforated appendix presented in the third trimester with premature labor as their only symptom. In one patient, premature birth occurred in the presence of a perforated appendix with peritonitis. In the second patient, labor stopped and she went on to deliver a healthy term infant 12 weeks after appendectomy. The remaining four patients had premature deliveries at 3, 11, 12, and 18 weeks after appendectomy. When those patients with complications were compared with those without complications, no differences were found in symptom duration, antibiotics administration, the type and duration of anesthesia, the quantity of blood loss, or the method of surgical approach. Comments Abdominal pain, particularly in the right lower quadrant, is considered the most reliable symptom of appendicitis during pregnancy [l-6]. Although abdominal discomfort was present in all of our patients, classic right lower quadrant abdominal pain was either absent or minimal at initial examination in 12 patients (41.8 percent). Anorexia is usually not the pathognomonic symptom in pregnancy that it is when associated with appendicitis in the nongravid patient [1,6]. This symptom was present in only 67 percent of our patients, whereas nausea and vomiting occurred more frequently and was found in 86 to 90 percent of our patients. There were no consistent differences between those patients who had appendicitis and those who did not (Table II). Abdominal guarding, rectal tenderness, and a positive psoas sign were noted with equal frequency in both groups. Rebound tenderness, although considered by some to be a particularly valuable finding, was present in only 55 percent of our patients [7]. Cunningham and McCubbin [3] proposed that the absence of this symptom may be related to abdominal muscle laxity in the gravid patient. In the present study, an additional interesting association between the presence of rebound and the anatomic position of the diseased appendix was noted. When rebound could not be elicited in 13 patients with appendicitis, 11 were found to have their appendices located in a retrocecal position. The development of urinary tract infection is not uncommon in pregnancy and certainly occurs more frequently than does appendicitis. Thus, when fever and bacteruria accompany vague abdominal or flank pain, appendicitis may often be overlooked. In the event urinary infection is confirmed by abnormal results of urinalysis or culture, as occurred in seven of our patients, appendicitis still cannot be excluded [3,4]. White blood cell counts are also unreliable in establishing the diagnosis of appendicitis because of the physiologic leukocytosis of pregnancy [5,6]. In our series, 17 patients with appendicitis had a white blood cell count of more than 15,000 cells/mms. Al-
770
though 23 patients had 80 percent granulocytes (considered significant by Parker and Brant [5,6]), this also occurred in 6 of the 7 patients with negative findings on celiotomy. Since 1848, when Henry Hancock [S] first reported an operative cure of appendicitis associated with pregnancy, the prevailing recommendation has been aggressive management with early operative intervention. Most investigators have agreed with Babler [9] who stated in 1908 that the mortality of appendicitis in pregnancy is the mortality of delay. He found a maternal mortality of 24 percent and a fetal mortality of 40 percent in his series of 207 cases. In the presence of peritonitis, fetal mortality escalated to 78.8 percent. Although maternal mortality declined overall to 0.01 percent by 1976 and is rarely encountered today, fetal loss, which has decreased to 8.7 percent in patients with simple appendicitis, increases to 35.7 percent when peritonitis occurs [1,7,10,11]. Many investigators blame the physician for the unacceptably high complication rates. They assume that if the diagnosis was made earlier, appendicitis would be less likely to result in perforation, peritonitis, or adverse fetal and maternal outcomes [I ,3]. We agree that prompt evaluation and surgical intervention are of critical importance in forestalling complications and believe that this approach has been responsible at least in part for the decrease in mortality rates [7,12]. However, we have not found a significant correlation between diagnostic delay produced by physician error and the incidence of perforation, premature birth, or fetal loss. Delay in seeking treatment by five patients resulted in two perforations and two premature births. The physiologic changes of pregnancy often obscure the diagnosis which results in treatment delay. As Baer et al [13] reported in 1932, the uterus displaces the appendiceal base upward and outward as it enlarges. This frequently alters the classic location of maximum tenderness from the right lower quadrant to the right upper quadrant, epigastrium, or right flank. Atypical pain occurred in 12 of our patients in the second and third trimesters and led to an error in initial diagnosis in 8. However, all but three patients underwent an abdominal exploration within 24 hours after admission. Prompt surgical intervention was also accomplished in the six patients who experienced fetal complications (one intrauterine fetal death and five premature births). All but one patient came to operation within 24 hours after admission. Despite accurate diagnosis and prompt management, prevention of premature birth or fetal loss is in no way guaranteed. Summary In a 10 year period, 29 of 36 pregnant patients (81 percent) thought preoperatively to have appendicitis
The American Journald Surgery
Diagnosing Appendicitis
had the diagnosis confirmed at operation. Postoperative fetal complications included one intrauterine death and five premature births. There were no maternal deaths and morbidity was limited to atelectasis in five patients. Prompt surgical intervention in 90 percent of our patients did not prevent fetal complications. References
5. 6. 7. 8. 9. 10. 11. 12. 13.
Babaknia A, Parsa H, Woodruff JD. Appendicitis during pregnancy, Obstet Gynecol 1977;50:40-4. Thomford NR, Patti RW, Teteris NJ. Appendectomy during pregnancy. Surg Gynecoi Obstet 1969; 129:489-92. Cunningham FG, McCubbin JH. Appendicitis complicating pregnancy. Cbstet Gynecoi 1975;45:415-9. Saunders P, Milton PJD. Laparotomy during pregnancy: an assessment of diagnostic accuracy and fetal wastage. Br Med J 1973;3:165-7. Parker RB. Acute appendicitis in late pregnancy. Lancet 1954;1:1252-7. Brant HA. Acute appendicitis in pregnancy. Obstet Gynecoi 1967;29: 130-8. Gomez A, Wood M. Acute appendicitis during pregnancy. Am J Surg 1979;137:180-3. Hancock H. Disease of the appendix caeci cured by operation. Lancet 1848;2:881-2. Babier EA. Perforative appendicitis complicating pregnancy. JAMA 1908;51:1310-3. Frisenda R, Roty AR, Kiiway JB, Brown AL, Peeien hi. Acute appendicftis during pregnancy. Am Surg 1979;45:503-6. McComb P, Laimon H. Appendicitis complicating pregnancy. Can J Surg 1980;23:92-4. CYNeiiiJP. Surgical conditions complicating pregnancy. Part I. Acute appendicftis real and simulated. Aust NW Obstet Gynaecoi 1969;9:94-9. Baer JL, Reis RA, Arens RA. Appendicitis in pregnancy with changes in position and axis of normal appendix in pregnancy. JAMA 1932;98: 1359-64.
DiscussDon Brian Rowlands (Houston, TX): It is interesting that this group of patiente had the same number of normal and perforated appendices as we see in other large series of appendicitis in the literature. Dr. Sirinek, what technique did you use for laparotomy? Did you use a right iliac fossa
vobmo 148, Docombu lW4
During Pregnancy
or midline incision, and did this vary according to length of pregnancy? What is ybur policy regarding the use of prophylactic antibiotics in these patients? Do you have any information on the subsequent fertility of these patients, especially those with perforated appendices? What is the mechanism of premature labor occurring sometime after the episode of acute appendicitis? Is there placental insufficiency? Are there any new diagnostic noninvasive techniques that may allow earlier diagnosis of appendicitis in pregnant women? Alan Rosenberger (Denver, CO): I think that it is commendable that the authors were able to have only a 20 percent negative exploration rate for this difficult diagnostic problem in nonpregnant as well as in pregnant women. It is also commendable that in the nonappendicitis group there were no fetal or maternal complications. This shows extreme surgical, obstetric, and anesthetic skills which safely allow an extremely aggressive approach. I wonder if the rate of premature births expressed in this paper and in the literature is not exaggerated. Labor and delivery occurring 11, 12, and 18 weeks postoperatively could represent the normal 5 to 10 percent of births that occur before 40 weeks gestational age that are found in uncomplicated pregnancies. These births were well beyond the 30 day limit usually used to define postoperative complications in our own reviews of other surgical procedures. Dr. Sirinek, did you notice any neonatal complications in these three patients? Kenneth R. Sirinek (closing): Exploratory celiotomy was performed through a midline abdominal incision in the majority of patients. All patients received preoperative antibiotics which were continued for 5 to 7 days postoperatively. We do not have any postappendicitis fertility information on this group of patients. I would not want to hypothesize on how appendicitis could precipitate labor at a later date. However, I would be willing to go along with Dr. Rosenberger’s hypothesis that in some patients, it might have been the natural course of the pregnancy and totally unrelated to the prior episode of appendicitis. As far as new techniques on the horizon, ultrasonography may well play a role in the future. There were no neonatal complications in the postappendectomy patients who delivered prematurely.
771
Kathleen Masters, MD, San Antonio, Texas Barry A. Levine, MD, San Antonio, Texas Harold V. Gaskill, MD, San Antonio, Texas Kenneth I?. Sirinek, MD, PhD, San Antonio, Texas
Appendicitis during pregnancy, particularly when associated with perforation, peritonitis, or both, has been associated with increases in premature labor and fetal and maternal death. Diagnostic delay has been assumed to be largely responsible for the incidence of these complications, primarily because a prolonged symptomatic duration might logically be expected to increase the likelihood of appendiceal perforation. To determine possible methods for improving diagnostic accuracy, the hospital records of all pregnant patients who underwent exploratory celiotomy for suspected appendicitis over a 10 year period were reviewed. Material and Methods From January 1973 to December 1982,36 patients with a preoperative diagnosis of appendicitis underwent exploratory celiotomy during pregnancy. Twenty-nine patients had appendictis confirmed by pathologic examination. Seven patients were designated as having negative celiotomy findings. Of 29 patients with appendicitis, 2 presented in the first trimester, 17 in the second, and 10 in the third. Perforation with peritonitis occurred in 12 patients. The patient data were analyzed in two separate ways: First, diagnostic accuracy, type and duration of symptoms, laboratory data, and incidence of perforation and complications were correlated with the patient’s trimester of pregnancy. Then, the patients were further classified into those with uncomplicated appendicitis and those with peritonitis secondary to perforation. They were then compared to determine whether perforation was related to diagnostic delay and if it increased the maternal and fetal complication rates.
Results Thirteen patients initially presented with the classic symptom of periumbilical pain which later radiated to the right lower quadrant of the abdomen (Table I). Abdominal pain of the right lower quadrant developed before operation in an additional four patients. Nausea and vomiting were more common initial complaints than was anorexia. Presenting symptoms showed no correlation with the trimester of pregnancy. Neither signs nor symptoms differed significantly among those with and those without appendicitis. Seventy-two percent of those with appendicitis, with or without perforation, had temperatures of less than 99.6OF (Table II). On physical examination, at least 25 percent of those with appendicitis had no guarding, almost half had no rebound tenderness, and less than half had rectal tenderness. Seven patients with appendicitis also had abnormal results of urinalysis that led to an initial incorrect diagnoses in three instances. Six patients with appendicitis had a normal leukocyte count (less than 10,000 cells/ mm3). Three of these patients had perforation, and only 58.6 percent had a significant left shift (more than 88 percent granulocytes). Abdominal radiographs obtained in nine patients were not helpful in the diagnostic workup. When diagnostic accuracy was determined from impressions at initial examination, the correct diagnosis was made 52.7 percent of the time (19 of 36 patients). It improved to 77.7 percent (28 of 36 patients) as observation and repeated examinations eliminated other causes. Seven patients with appendicitis (24 percent) underwent
From the Department of Surgery, The University of Texas Health Science Center, San Antonlo. Texas. Requests for reprints should be addressed to Kenneth R. Slrlnek. MD. DepMmmt of Sugary, The Uniiity of Texas Health Scii center. 7703 Floyd Curl Drive, San Antonio, Texas 78284. Presented at the 36th Annual Meeting of the Southwestern Surgical Congress, Honolulu, Hawaii. April 21-28, 1984.
763
exploration
more than 48 hours after the
onset of symptoms. When initial impressions were inaccurate, significant operative delay (more than 24 hours after admission) occurred in only three patients, all with perforation. In the remaining four patients, treatment delay was entirely due to patient
Tha American Journal of Surgery
Diagnosing Appendicitis During Pregnancy
TABLE I
Prasentlng Symptoms at lnitlal Examination In Patients With and Without Appendicitis
Symptoms Abdominalpain RLQ RLQ (periumbilical) RUQ R flank Epigastrium Diffuse Anorexia Nausea Vomiting Constipation Diarrhea Qysuria
Perforated
Appendicitis(II = 29) Nonperforated
2 2
2 11
1 3 2 2’
3 0 1 0
8 10 11 0 0 1
11 18 14 1 1 0
Total
%
29
100 13.7 55
4 13
Negative Ceiiotomy (n = 7)
13.7 10.3 10.3 8.8
19 28 25 1 1
85.5 89.8 88.2 3 3
Both patients presented with uterine contractions only. R = right;RLQ = right lower quadrant;RUQ = rightupper quadrant. l
TABLE II
hesantlng Signs and Laboratory Data At lnltid Examlnatlon III Patlonts With and Without Appandkltls Nagative Signs
Perforated
Appendicitis(n = 29) Nonperforated
Celiotomy Total
Abdominalguarding Reboundtenderness Psoastenderness
a
5 9
14 11 9
22 18 18
Rectal tenderness Absent bowel sounds
4 5
9 9
Temperature I99.8“F 99.7-100.4’F >lOl’F
7 5 0 4
Laboratorydata Abnormalurinalysis White bloodcell count I 10,000/mm3
%
(n = 7)
75 55
4 2
13 14
82 44.8 48.2
5 8 3
13 2 2
20 7 2
72 24 8.8
3 2 2
3
7
24
0
3
3
1 l-15,000/mm3 > 18.000fmm3
3 a
a 8
a 11 12
20.8 37.9 41.3
2 1 4
Granulocyte count 280% 288%
9 a
14 9
23 17
79.3 58.8
8 3
delay in seeking medical care rather than physician error. A prolonged symptomatic period (51,54, and 72 hours and 8 days) was associated with appendiceal perforation in four patients. One premature birth occurred in this group. In the three patients who had neither perforation nor peritonitis, one premature birth occurred. The symptom durations were similar (72 and 72 hours and 7 days) to those in patients with peritonitis. Prompt surgical intervention occurred within 24 hours after admission in 26 of 29 patients with appendicitis (89.6 percent), yet in this group, one intrauterine fetal death and five premature births occurred.
There were no maternal deaths, and no complications occur& in patients who underwent negative explorations. Pulmonary complications (atelectaeis) occurred in 5 of 36 patients. One intrauterine fetal death (2.7 percent incidence) did occur in a 33 year old woman who presented at 18 weeks gestation with a nonperforated appendix. She wae operated on within 24 hours after the onset of symptoms. At 39 weeks gestation, she delivered a macerated fetus judged to have a gestational age of 32 weeks. Premature labor occurred in six patients with appendicitis. All resulted in live birtha at a mean gestational age of 34 weeks (range 33 to 39 weeks). Two patients
789
Masters et al
with a perforated appendix presented in the third trimester with premature labor as their only symptom. In one patient, premature birth occurred in the presence of a perforated appendix with peritonitis. In the second patient, labor stopped and she went on to deliver a healthy term infant 12 weeks after appendectomy. The remaining four patients had premature deliveries at 3, 11, 12, and 18 weeks after appendectomy. When those patients with complications were compared with those without complications, no differences were found in symptom duration, antibiotics administration, the type and duration of anesthesia, the quantity of blood loss, or the method of surgical approach. Comments Abdominal pain, particularly in the right lower quadrant, is considered the most reliable symptom of appendicitis during pregnancy [l-6]. Although abdominal discomfort was present in all of our patients, classic right lower quadrant abdominal pain was either absent or minimal at initial examination in 12 patients (41.8 percent). Anorexia is usually not the pathognomonic symptom in pregnancy that it is when associated with appendicitis in the nongravid patient [1,6]. This symptom was present in only 67 percent of our patients, whereas nausea and vomiting occurred more frequently and was found in 86 to 90 percent of our patients. There were no consistent differences between those patients who had appendicitis and those who did not (Table II). Abdominal guarding, rectal tenderness, and a positive psoas sign were noted with equal frequency in both groups. Rebound tenderness, although considered by some to be a particularly valuable finding, was present in only 55 percent of our patients [7]. Cunningham and McCubbin [3] proposed that the absence of this symptom may be related to abdominal muscle laxity in the gravid patient. In the present study, an additional interesting association between the presence of rebound and the anatomic position of the diseased appendix was noted. When rebound could not be elicited in 13 patients with appendicitis, 11 were found to have their appendices located in a retrocecal position. The development of urinary tract infection is not uncommon in pregnancy and certainly occurs more frequently than does appendicitis. Thus, when fever and bacteruria accompany vague abdominal or flank pain, appendicitis may often be overlooked. In the event urinary infection is confirmed by abnormal results of urinalysis or culture, as occurred in seven of our patients, appendicitis still cannot be excluded [3,4]. White blood cell counts are also unreliable in establishing the diagnosis of appendicitis because of the physiologic leukocytosis of pregnancy [5,6]. In our series, 17 patients with appendicitis had a white blood cell count of more than 15,000 cells/mms. Al-
770
though 23 patients had 80 percent granulocytes (considered significant by Parker and Brant [5,6]), this also occurred in 6 of the 7 patients with negative findings on celiotomy. Since 1848, when Henry Hancock [S] first reported an operative cure of appendicitis associated with pregnancy, the prevailing recommendation has been aggressive management with early operative intervention. Most investigators have agreed with Babler [9] who stated in 1908 that the mortality of appendicitis in pregnancy is the mortality of delay. He found a maternal mortality of 24 percent and a fetal mortality of 40 percent in his series of 207 cases. In the presence of peritonitis, fetal mortality escalated to 78.8 percent. Although maternal mortality declined overall to 0.01 percent by 1976 and is rarely encountered today, fetal loss, which has decreased to 8.7 percent in patients with simple appendicitis, increases to 35.7 percent when peritonitis occurs [1,7,10,11]. Many investigators blame the physician for the unacceptably high complication rates. They assume that if the diagnosis was made earlier, appendicitis would be less likely to result in perforation, peritonitis, or adverse fetal and maternal outcomes [I ,3]. We agree that prompt evaluation and surgical intervention are of critical importance in forestalling complications and believe that this approach has been responsible at least in part for the decrease in mortality rates [7,12]. However, we have not found a significant correlation between diagnostic delay produced by physician error and the incidence of perforation, premature birth, or fetal loss. Delay in seeking treatment by five patients resulted in two perforations and two premature births. The physiologic changes of pregnancy often obscure the diagnosis which results in treatment delay. As Baer et al [13] reported in 1932, the uterus displaces the appendiceal base upward and outward as it enlarges. This frequently alters the classic location of maximum tenderness from the right lower quadrant to the right upper quadrant, epigastrium, or right flank. Atypical pain occurred in 12 of our patients in the second and third trimesters and led to an error in initial diagnosis in 8. However, all but three patients underwent an abdominal exploration within 24 hours after admission. Prompt surgical intervention was also accomplished in the six patients who experienced fetal complications (one intrauterine fetal death and five premature births). All but one patient came to operation within 24 hours after admission. Despite accurate diagnosis and prompt management, prevention of premature birth or fetal loss is in no way guaranteed. Summary In a 10 year period, 29 of 36 pregnant patients (81 percent) thought preoperatively to have appendicitis
The American Journald Surgery
Diagnosing Appendicitis
had the diagnosis confirmed at operation. Postoperative fetal complications included one intrauterine death and five premature births. There were no maternal deaths and morbidity was limited to atelectasis in five patients. Prompt surgical intervention in 90 percent of our patients did not prevent fetal complications. References
5. 6. 7. 8. 9. 10. 11. 12. 13.
Babaknia A, Parsa H, Woodruff JD. Appendicitis during pregnancy, Obstet Gynecol 1977;50:40-4. Thomford NR, Patti RW, Teteris NJ. Appendectomy during pregnancy. Surg Gynecoi Obstet 1969; 129:489-92. Cunningham FG, McCubbin JH. Appendicitis complicating pregnancy. Cbstet Gynecoi 1975;45:415-9. Saunders P, Milton PJD. Laparotomy during pregnancy: an assessment of diagnostic accuracy and fetal wastage. Br Med J 1973;3:165-7. Parker RB. Acute appendicitis in late pregnancy. Lancet 1954;1:1252-7. Brant HA. Acute appendicitis in pregnancy. Obstet Gynecoi 1967;29: 130-8. Gomez A, Wood M. Acute appendicitis during pregnancy. Am J Surg 1979;137:180-3. Hancock H. Disease of the appendix caeci cured by operation. Lancet 1848;2:881-2. Babier EA. Perforative appendicitis complicating pregnancy. JAMA 1908;51:1310-3. Frisenda R, Roty AR, Kiiway JB, Brown AL, Peeien hi. Acute appendicftis during pregnancy. Am Surg 1979;45:503-6. McComb P, Laimon H. Appendicitis complicating pregnancy. Can J Surg 1980;23:92-4. CYNeiiiJP. Surgical conditions complicating pregnancy. Part I. Acute appendicftis real and simulated. Aust NW Obstet Gynaecoi 1969;9:94-9. Baer JL, Reis RA, Arens RA. Appendicitis in pregnancy with changes in position and axis of normal appendix in pregnancy. JAMA 1932;98: 1359-64.
DiscussDon Brian Rowlands (Houston, TX): It is interesting that this group of patiente had the same number of normal and perforated appendices as we see in other large series of appendicitis in the literature. Dr. Sirinek, what technique did you use for laparotomy? Did you use a right iliac fossa
vobmo 148, Docombu lW4
During Pregnancy
or midline incision, and did this vary according to length of pregnancy? What is ybur policy regarding the use of prophylactic antibiotics in these patients? Do you have any information on the subsequent fertility of these patients, especially those with perforated appendices? What is the mechanism of premature labor occurring sometime after the episode of acute appendicitis? Is there placental insufficiency? Are there any new diagnostic noninvasive techniques that may allow earlier diagnosis of appendicitis in pregnant women? Alan Rosenberger (Denver, CO): I think that it is commendable that the authors were able to have only a 20 percent negative exploration rate for this difficult diagnostic problem in nonpregnant as well as in pregnant women. It is also commendable that in the nonappendicitis group there were no fetal or maternal complications. This shows extreme surgical, obstetric, and anesthetic skills which safely allow an extremely aggressive approach. I wonder if the rate of premature births expressed in this paper and in the literature is not exaggerated. Labor and delivery occurring 11, 12, and 18 weeks postoperatively could represent the normal 5 to 10 percent of births that occur before 40 weeks gestational age that are found in uncomplicated pregnancies. These births were well beyond the 30 day limit usually used to define postoperative complications in our own reviews of other surgical procedures. Dr. Sirinek, did you notice any neonatal complications in these three patients? Kenneth R. Sirinek (closing): Exploratory celiotomy was performed through a midline abdominal incision in the majority of patients. All patients received preoperative antibiotics which were continued for 5 to 7 days postoperatively. We do not have any postappendicitis fertility information on this group of patients. I would not want to hypothesize on how appendicitis could precipitate labor at a later date. However, I would be willing to go along with Dr. Rosenberger’s hypothesis that in some patients, it might have been the natural course of the pregnancy and totally unrelated to the prior episode of appendicitis. As far as new techniques on the horizon, ultrasonography may well play a role in the future. There were no neonatal complications in the postappendectomy patients who delivered prematurely.
771