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Appendicitis during Pregnancy
APPENDICITIS DURING An Unusual Case
PREGNANCY
WARNER (From
Modesto
City
M. SOELLING, M.D.,
MODESTO,
CAIJF.
Hospital)
PPENDICITIS is recognized as one of the more important surgical complications of pregnancy. The reported fetal loss has been from 20 to 40 per cent and the mat,ernal mortality is in the neighborhood of 5 per rent.’ The incidence of appendicitis in pregnancy is believed to be the same as in the nonpregnant, and is variously given as 0.1 to 0.5 per cent.2 It is one come plication of pregnancy in particular in which prompt diagnosis permitting early surgical intervention is mandatory, as rupture of the appendix doubles the risk of ahort,ion’ and jeopardizes the life of the mother. It is generally agreed that the symptoms are the same as in the nonpregnant except for the location of pain. The belief is widely held that the pain may be higher and more to the side because of the upward displacement of the head of the cecum with advancing pregnancy.? In the last trimester the appendix is presumed to rise above the level of the iliac crest and, accordingly, the pain may be expected considerably higher than the level of the acetahulum as is usual in the nonpregnant. The following case is presented to show how reliance upon this prcsump tion may contribute to a false conclusion.
A
A 2-Lyear-old gravida ii, para i, who was 6 months pregnant, was admitted to thr: hospital because of progressively severe low abdominal pain of 3 days’ duration. She ha~i had two atypical menstrual flows following her recent conception, and had complained 01’ heartburn for two lveeks prior to admission. The progress of this pregnancy otherwise had been unrventful. Her one delivery, which a pelvic infection, apparently required rehospitalization for
took place 2 years before, salpingitis, which developed several days and subsided
had been unremarkable exe-ept a week following confinement. after 6 weeks.
for II
During the 3 days immediately preceding admission, the patient experienced geucralizcatl abdominal soreness and intensification of the epigastric distress. Her appetite and bowel functions were normal. On the third day the soreness became most prominemt in both lower quadrants. It was dull and constant but apparently not severe enough to keep hrr from going to work. Physical examination upon admission revealed an acutely distressed patic,ut when appeared moderately ill. The blood pressure was 11X/80 mm. Hg and the pulse ratr XI~ per minute. The temperature was 99.8” F. Enlargement of the abdomen corresponded with that in the sixth month of pregnancy. The hypogastric and iliac regions were t.Pndel on palpation and moderate guarding was noted which appeared at least partly voluntary. 1291
Am. J. Obst. 8r Grnec. December. 1958
SOELLING Costovertebral angle tenderness, present bilaterally, examination elicited extreme tendernrss which was no impression fullness in the cul-de-sac. Initial laboratory count of 19,100 with catheterized urine.
studies a shift
was more pronounced was not localized to
on t,he right. Rectal either sidt,, and there
showed a hemoglobin of 11.0 Gm. per 100 CC., a white blood to the left, and 15 to 25 white cells per high-power ficald of
On the basis of the physical findings, the conditions presenting themselves for differentiation were pyosalpinx and appendicitis. Pyuria can occur because of the proximity of an inflamed appendix or other pelvic appendage to the ureter or bladder, and it was felt that the acute clinical picture could not be attributed to the pyelonephritis which that laboratory finding suggested. The region of maximal abdominal tenderness was situated 2 inches below McBurney’s point. This decidedly low locat,ion, together with the history of antcccdent pelvic infection, favored the impression of pyosalpinx. The patient was given large doses of antibiotics, parenteral fluids including 1 pint of blood, and progesterone. In the ensuing 2 days, the temperature fluctuated between 98.8 and 99.8” F., and re-examination of the white cells and urine showed no significant changes. There was no obstipation but a flat plate of the abdomen showed considerable air scattered throughout the bowel, suggesting the possibility of ileus. The patient complained of increasing pain and required more medication for relief. A ruptured appendix or pyosalpinx was suspected, and 48 hours following admission a laparotomy was performed through a right midrectus incision. A walled-off mass was found in the lower right side of the abdomen about. an edematous ceeum which was not displaced above its usual site in the nonpregnant patient. Incorporated in the pus-containing mass were a massively perforated gangrenous appendix and a large fecalith several centimeters removed. An appendectomy was performed and adhesions involving the right Fallopian tube were cut. The postoperative course was remarkably good, and the patient was able to leave the hospital 10 days following operation. The uterus was quiescent throughout the illness, including the time of actual operation. Two months later, at what was estimated to be the thirty-eighth week of pregnancy, the patient was delivered of a normal child weighing 7 pounds, 4 ounces.
Comment The possibility of an acute condition within the abdomen complicating pregnancy calls for careful evaluation with a minimum of delay. While laparotomy may precipitate abortion or premature labor, postponement of surgical intervention carries the risk of an inflamed appendix proceeding to rupture, with attendant greater threat to the life of the mother and fetus. The lessening of the danger of localized or generalized peritonitis from rupture of the appendix by antibiotic therapy is not sufficient to justify a policy of watchful expectancy nor to minimize the urgency of prompt diagnosis permitting early operation. In the case present.ed the patient was 6 months pregnant and, in accordance with the generally accepted changes in position of the appendix with advancing pregnancy, the pain was to be expected at about the level of the iliac crest. Since it was actually suprapubic, the diagnosis of appendicitis appeared less likely. own observations lead us to believe that the apEastman2 stated, “Our pendix may be situated at a considerably higher level in some cases while in
L-olumeir,
Nmlber
0
APPENDICITIS
DURING
PREGNANCY
1293
This case supports the view that disothers it is found at the usual site.” placement of the cecum is not sufficiently consistent to constitute a rule of probability in the differential diagnosis of acute abdominal conditions complicating pregnancy, and suggests that undue reliance upon presumed changes in location of appendiceal pain is best avoided,
References 1. Briscoe,
C. C.: The Surgical Complications of Pregnancy, in Lull, C. B., and Rimbrough, R. A.: Clinical Obstetrics, Philadelphia, 1953, J. B. Lippineott Company, p. 341. 2. Eastman, N. J.: Williams Obstetrics, ed. 10, New Pork, 1950, Appleton-Century-Crofts, Inc., p. 768. 3. Requarth, W.: Diagnosis of Acute Abdominal Pain, Chicago, 1953, The Year Book Pub. lishers, Inc.
PREGNANCY
WARNER (From
Modesto
City
M. SOELLING, M.D.,
MODESTO,
CAIJF.
Hospital)
PPENDICITIS is recognized as one of the more important surgical complications of pregnancy. The reported fetal loss has been from 20 to 40 per cent and the mat,ernal mortality is in the neighborhood of 5 per rent.’ The incidence of appendicitis in pregnancy is believed to be the same as in the nonpregnant, and is variously given as 0.1 to 0.5 per cent.2 It is one come plication of pregnancy in particular in which prompt diagnosis permitting early surgical intervention is mandatory, as rupture of the appendix doubles the risk of ahort,ion’ and jeopardizes the life of the mother. It is generally agreed that the symptoms are the same as in the nonpregnant except for the location of pain. The belief is widely held that the pain may be higher and more to the side because of the upward displacement of the head of the cecum with advancing pregnancy.? In the last trimester the appendix is presumed to rise above the level of the iliac crest and, accordingly, the pain may be expected considerably higher than the level of the acetahulum as is usual in the nonpregnant. The following case is presented to show how reliance upon this prcsump tion may contribute to a false conclusion.
A
A 2-Lyear-old gravida ii, para i, who was 6 months pregnant, was admitted to thr: hospital because of progressively severe low abdominal pain of 3 days’ duration. She ha~i had two atypical menstrual flows following her recent conception, and had complained 01’ heartburn for two lveeks prior to admission. The progress of this pregnancy otherwise had been unrventful. Her one delivery, which a pelvic infection, apparently required rehospitalization for
took place 2 years before, salpingitis, which developed several days and subsided
had been unremarkable exe-ept a week following confinement. after 6 weeks.
for II
During the 3 days immediately preceding admission, the patient experienced geucralizcatl abdominal soreness and intensification of the epigastric distress. Her appetite and bowel functions were normal. On the third day the soreness became most prominemt in both lower quadrants. It was dull and constant but apparently not severe enough to keep hrr from going to work. Physical examination upon admission revealed an acutely distressed patic,ut when appeared moderately ill. The blood pressure was 11X/80 mm. Hg and the pulse ratr XI~ per minute. The temperature was 99.8” F. Enlargement of the abdomen corresponded with that in the sixth month of pregnancy. The hypogastric and iliac regions were t.Pndel on palpation and moderate guarding was noted which appeared at least partly voluntary. 1291
Am. J. Obst. 8r Grnec. December. 1958
SOELLING Costovertebral angle tenderness, present bilaterally, examination elicited extreme tendernrss which was no impression fullness in the cul-de-sac. Initial laboratory count of 19,100 with catheterized urine.
studies a shift
was more pronounced was not localized to
on t,he right. Rectal either sidt,, and there
showed a hemoglobin of 11.0 Gm. per 100 CC., a white blood to the left, and 15 to 25 white cells per high-power ficald of
On the basis of the physical findings, the conditions presenting themselves for differentiation were pyosalpinx and appendicitis. Pyuria can occur because of the proximity of an inflamed appendix or other pelvic appendage to the ureter or bladder, and it was felt that the acute clinical picture could not be attributed to the pyelonephritis which that laboratory finding suggested. The region of maximal abdominal tenderness was situated 2 inches below McBurney’s point. This decidedly low locat,ion, together with the history of antcccdent pelvic infection, favored the impression of pyosalpinx. The patient was given large doses of antibiotics, parenteral fluids including 1 pint of blood, and progesterone. In the ensuing 2 days, the temperature fluctuated between 98.8 and 99.8” F., and re-examination of the white cells and urine showed no significant changes. There was no obstipation but a flat plate of the abdomen showed considerable air scattered throughout the bowel, suggesting the possibility of ileus. The patient complained of increasing pain and required more medication for relief. A ruptured appendix or pyosalpinx was suspected, and 48 hours following admission a laparotomy was performed through a right midrectus incision. A walled-off mass was found in the lower right side of the abdomen about. an edematous ceeum which was not displaced above its usual site in the nonpregnant patient. Incorporated in the pus-containing mass were a massively perforated gangrenous appendix and a large fecalith several centimeters removed. An appendectomy was performed and adhesions involving the right Fallopian tube were cut. The postoperative course was remarkably good, and the patient was able to leave the hospital 10 days following operation. The uterus was quiescent throughout the illness, including the time of actual operation. Two months later, at what was estimated to be the thirty-eighth week of pregnancy, the patient was delivered of a normal child weighing 7 pounds, 4 ounces.
Comment The possibility of an acute condition within the abdomen complicating pregnancy calls for careful evaluation with a minimum of delay. While laparotomy may precipitate abortion or premature labor, postponement of surgical intervention carries the risk of an inflamed appendix proceeding to rupture, with attendant greater threat to the life of the mother and fetus. The lessening of the danger of localized or generalized peritonitis from rupture of the appendix by antibiotic therapy is not sufficient to justify a policy of watchful expectancy nor to minimize the urgency of prompt diagnosis permitting early operation. In the case present.ed the patient was 6 months pregnant and, in accordance with the generally accepted changes in position of the appendix with advancing pregnancy, the pain was to be expected at about the level of the iliac crest. Since it was actually suprapubic, the diagnosis of appendicitis appeared less likely. own observations lead us to believe that the apEastman2 stated, “Our pendix may be situated at a considerably higher level in some cases while in
L-olumeir,
Nmlber
0
APPENDICITIS
DURING
PREGNANCY
1293
This case supports the view that disothers it is found at the usual site.” placement of the cecum is not sufficiently consistent to constitute a rule of probability in the differential diagnosis of acute abdominal conditions complicating pregnancy, and suggests that undue reliance upon presumed changes in location of appendiceal pain is best avoided,
References 1. Briscoe,
C. C.: The Surgical Complications of Pregnancy, in Lull, C. B., and Rimbrough, R. A.: Clinical Obstetrics, Philadelphia, 1953, J. B. Lippineott Company, p. 341. 2. Eastman, N. J.: Williams Obstetrics, ed. 10, New Pork, 1950, Appleton-Century-Crofts, Inc., p. 768. 3. Requarth, W.: Diagnosis of Acute Abdominal Pain, Chicago, 1953, The Year Book Pub. lishers, Inc.