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Ruptured appendix in pregnancy
Volume 122 Number 2
in hormonal excretion by the placenta before and during labor.'' In cases of prolonged labor, the rise in LAP activity was also not significant, hut the mean values at all stage~ were significantly lower than those of normal labor ( p = 0.00 I ) . The difference could be ascribed to stres' caused by the prolonged labor which elevates corticosteroid excretion and, as a result, lowers LAP values. REFERENCES
I. Pulishuk, W. Z., Diamant, Y. Z., Zuckerman, H., and
2. :l. 4. :).
Sadovsky, E.: AM. J. OR STET. GYXECOL. 107: 601, 1970. Polishuk, W. z., Sadovsky, E., Diamant, Y. Z., and Zuckerman, II.: Harefuah 78: 155, !970. Vaccari, F., Sabatts, B.. and Manzini, E.: Blood 10: 7:50, 1953. Kaplow, L. S.: Am. J. Clin. Pathol. 39: 439, !963. Smith, 0. W.: Acta Endocrinol. (Suppl.) 104: I, 1966.
Ruptured appendix 1n pregnancy RONALD T. BURKMAN, M.D. ROBERT L. FRIEDLANDER, M.D. Department of Obstetrics and Gynecology, Albany Medical College and Albany Medical Center Hospital, Albany, New York
A c t: T E A P p E :r.; D I c I T r s , although uncommon in pregnancy, can lead to significant fetal and n1aternal morbidity and deaths. The following case illustrates the complications which may occur with unrecognized appendicitis, and the fortunate outcome demonstrates the usefulness of consultants from various medical disciplines in managing the critically ill obstetric patient.
Communications tn brief
265
cernible, and the fetal weight was estimated at four pounds. At exploratory laparotomy, a large quantity of foulsmelling, purulent material was encountered. There was generalized peritonitis with thick, edematous adhesions between fibrin-coHred loops of small intestine. Normal anatomic relationships could not be discerned because of the multiple adhesions. Copious irrigation was carried out, and four-quadrant drains were placed in the peritoneal cavity. Only the fascia was closed. She was given high doses of cephalothin and chloramphenicol, and subsequent cultures revealed mixed gram-negative bacilli including Bacteroides. The postoperative course was characterized by multiple complications. On the evening after the operation, the patient went into labor and was delivered vaginally of a living four pound, five ounce male infant, who despite sepsis and anemia, survived. During the subsequent -±8 hours after operation, the patient developed evidence of right lower lobe pulmonary consolidation and respiratory failure. The respiratory status deteriorated, and intubation and positive-pressure ventilation were required for a threeday period. The ileus slowly improved, and after multiple debridements the wound was secondarily closed. On the ninth postoperative day, the patient had a grand mal seizure. Thorough neurological "·ork-up revealed only a transient left-to-right midline shift on an echogram, and no further neurological sequelae occurred. The patient was discharged on the twenty-second hospital day. Interval appendectomy and tubal ligation were performed four months later, revealing multiple filmy adhesions, bilaterally thickened oviducts, and a thickened appendix adht"rent to the right oviduct. Although a site of perforation could not be clearly identified, the final diagnosis was a probable ruptured appendix.
The sun.·i\·al of this mother and infant was accomplished through the team effort of physician~ in obstetrics, surgical intensi\·e rare, neonatology, pulmonary care, and nt>urology. Certainly; the role that medica! centrrs "·ith such expertise play in managing critically ill patients is shown. Earlier recognition of appendicitis in this pregnancy \\·ould ha\·e prevented many of the complications encountered, but the diagnosis is often difficult to make. As pregnancy advances, the appendix is displaced up\\·ard
A 19-year-old, gravida three, para two patient was transferred at 32 w~eks of gestation- to the Alb~ny Medical Center after three weeks of care at another institution. Her history revealed that she was admitted three weeks earlier with complaints of nausea, vomiting, right flank pain, and fever. The initial diagnosis was a urinary tract infection, and a \·ariety of antibiotics \vere en1ployed \Vith lirnited response. In the week prior to transfer, she developed increasing abdominal distention, umbilical erythema, and high spiking fevers and was given high doses of ampiciliin and chloramphenicol. The diagnosis at the time of transfer was an abdominal abscess of unknown etiology. On admission to the Albany Medical Center, the patient appeared critically ill with tachycardia (heart rate 1:~0 beats per minute), temperature of 101 o F., and a markedly distended and extremely tender abdomen. The abdominal wall was edematous and erythematous, especially at the umbilicus. Fetal heart tom•s wf're dis-
appendiceal origin may be difficult to distinguish from pyclotwphritis. Howe\·er, such localized pain and fever associated with nausea and vomiting in the latter half of pregnancy require im·estigation with consideration of the diagnosis of appendicitis.' The case is also another example of Bacteroides infection in obstetrics and further deinonstrate~ that proper management of such infections requires surgical drainage before antibiotics will be effective.~
Reprint requests: Dr. Ronald T. Burkman, Department of Gynecology and Obstetrics, Woman's Clinic John Hopkins Hospital, Baltimore, Maryland 21205.
J. 1: 1938, 1960. 2. Ledger, W. J., Sweet, R. L., and Headington, Surg. Gynecol. Obstet. 133: 837, 1971.
and latrra!!y, and pdin or tenderness in the right flank of
REFERENCES
I. Black, W. P.: Br. Med.
J.
T.:
in hormonal excretion by the placenta before and during labor.'' In cases of prolonged labor, the rise in LAP activity was also not significant, hut the mean values at all stage~ were significantly lower than those of normal labor ( p = 0.00 I ) . The difference could be ascribed to stres' caused by the prolonged labor which elevates corticosteroid excretion and, as a result, lowers LAP values. REFERENCES
I. Pulishuk, W. Z., Diamant, Y. Z., Zuckerman, H., and
2. :l. 4. :).
Sadovsky, E.: AM. J. OR STET. GYXECOL. 107: 601, 1970. Polishuk, W. z., Sadovsky, E., Diamant, Y. Z., and Zuckerman, II.: Harefuah 78: 155, !970. Vaccari, F., Sabatts, B.. and Manzini, E.: Blood 10: 7:50, 1953. Kaplow, L. S.: Am. J. Clin. Pathol. 39: 439, !963. Smith, 0. W.: Acta Endocrinol. (Suppl.) 104: I, 1966.
Ruptured appendix 1n pregnancy RONALD T. BURKMAN, M.D. ROBERT L. FRIEDLANDER, M.D. Department of Obstetrics and Gynecology, Albany Medical College and Albany Medical Center Hospital, Albany, New York
A c t: T E A P p E :r.; D I c I T r s , although uncommon in pregnancy, can lead to significant fetal and n1aternal morbidity and deaths. The following case illustrates the complications which may occur with unrecognized appendicitis, and the fortunate outcome demonstrates the usefulness of consultants from various medical disciplines in managing the critically ill obstetric patient.
Communications tn brief
265
cernible, and the fetal weight was estimated at four pounds. At exploratory laparotomy, a large quantity of foulsmelling, purulent material was encountered. There was generalized peritonitis with thick, edematous adhesions between fibrin-coHred loops of small intestine. Normal anatomic relationships could not be discerned because of the multiple adhesions. Copious irrigation was carried out, and four-quadrant drains were placed in the peritoneal cavity. Only the fascia was closed. She was given high doses of cephalothin and chloramphenicol, and subsequent cultures revealed mixed gram-negative bacilli including Bacteroides. The postoperative course was characterized by multiple complications. On the evening after the operation, the patient went into labor and was delivered vaginally of a living four pound, five ounce male infant, who despite sepsis and anemia, survived. During the subsequent -±8 hours after operation, the patient developed evidence of right lower lobe pulmonary consolidation and respiratory failure. The respiratory status deteriorated, and intubation and positive-pressure ventilation were required for a threeday period. The ileus slowly improved, and after multiple debridements the wound was secondarily closed. On the ninth postoperative day, the patient had a grand mal seizure. Thorough neurological "·ork-up revealed only a transient left-to-right midline shift on an echogram, and no further neurological sequelae occurred. The patient was discharged on the twenty-second hospital day. Interval appendectomy and tubal ligation were performed four months later, revealing multiple filmy adhesions, bilaterally thickened oviducts, and a thickened appendix adht"rent to the right oviduct. Although a site of perforation could not be clearly identified, the final diagnosis was a probable ruptured appendix.
The sun.·i\·al of this mother and infant was accomplished through the team effort of physician~ in obstetrics, surgical intensi\·e rare, neonatology, pulmonary care, and nt>urology. Certainly; the role that medica! centrrs "·ith such expertise play in managing critically ill patients is shown. Earlier recognition of appendicitis in this pregnancy \\·ould ha\·e prevented many of the complications encountered, but the diagnosis is often difficult to make. As pregnancy advances, the appendix is displaced up\\·ard
A 19-year-old, gravida three, para two patient was transferred at 32 w~eks of gestation- to the Alb~ny Medical Center after three weeks of care at another institution. Her history revealed that she was admitted three weeks earlier with complaints of nausea, vomiting, right flank pain, and fever. The initial diagnosis was a urinary tract infection, and a \·ariety of antibiotics \vere en1ployed \Vith lirnited response. In the week prior to transfer, she developed increasing abdominal distention, umbilical erythema, and high spiking fevers and was given high doses of ampiciliin and chloramphenicol. The diagnosis at the time of transfer was an abdominal abscess of unknown etiology. On admission to the Albany Medical Center, the patient appeared critically ill with tachycardia (heart rate 1:~0 beats per minute), temperature of 101 o F., and a markedly distended and extremely tender abdomen. The abdominal wall was edematous and erythematous, especially at the umbilicus. Fetal heart tom•s wf're dis-
appendiceal origin may be difficult to distinguish from pyclotwphritis. Howe\·er, such localized pain and fever associated with nausea and vomiting in the latter half of pregnancy require im·estigation with consideration of the diagnosis of appendicitis.' The case is also another example of Bacteroides infection in obstetrics and further deinonstrate~ that proper management of such infections requires surgical drainage before antibiotics will be effective.~
Reprint requests: Dr. Ronald T. Burkman, Department of Gynecology and Obstetrics, Woman's Clinic John Hopkins Hospital, Baltimore, Maryland 21205.
J. 1: 1938, 1960. 2. Ledger, W. J., Sweet, R. L., and Headington, Surg. Gynecol. Obstet. 133: 837, 1971.
and latrra!!y, and pdin or tenderness in the right flank of
REFERENCES
I. Black, W. P.: Br. Med.
J.
T.: