Appendicitis in Pregnancy*

APPENDlCITI8 BY

ARCHIBALD

L.

MCDONALD,

IN PREGNANCY” M.D.,

F.h.(‘.S.,

~ULUTII,

MINNESOTA

T

HE following experience stimulated this paper. A colleague telephoned concerning a patient at full-term pregnancy with acute appendicitis, for whom he proposed cesarean srction and appendecTwo objections at once l’rrst~nt~~d-obstetrical : cesarean se’ctomy. tion for cause other than dyatocia should be avoided if more conservative method of delivery is available ; surgical : an acute abdomen with probable peritonitis is an unfavorable field for hysterotomy. ii, gave a history of at,tueks of pain and vomiting Mrs. G., 21 years old, para For two days there had been severe previous to and earlier in t.his pregnancy. colic, vomiting, fever to .l(Il” F., 1eucoc.ytc.n 1X,000. During last twelve LOWS condition was progressively worse ; pain was more ccmstallt :11141 severe, suggesting impending labor, vomiting persistent and distressing, fever higher, leucoeytes 23,000. patient anxious, in marked dist,ress, \omit,ing fecal in character, Examination: uterus at full term and in :I state of hypertonus with no definite relaxntion (II contraction. Vaginnlly : head floating, membranes unrupturctd, cervix soft and thin, admitted one finger. Diagnosis : ac’nte appendicitis with peritonitis, labor impending. Rurgica,l indication for immrdiate appendectomy au1 drainage unmistakable. Labor being imminent, it, nas d~idcd first to empty the uterus by the most conservative method possible. Ulldcr ethylene anesthesia the cervix was dilated manually, and a full-term, living child was delivered by version and extraction, followed by spontaneous cspulsion of the placc~~ta. There mere no lacerations. Tho abdomen was then opened by ;L right, rc&s incision disclosing free purulent fluid. A gi~llgR*~Ous app~n~lis Igin;: t&wreu cbuils of intestine nloscl to the sterns was removed. Cigarcttc Ilr:titls were 111:.1c~tl in tIlla I)cklvis :IIIII to thrl (‘t’cI1111. Tlte l?lltire pY~,:‘!‘lur,! wcpiI’c‘tl IPHS tll:lIl :,,, 11~1111.. (‘olL\:ll,wIlc,~ was ,111 wrr~plic::cttvl

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wert*

ww tlisclur‘gc~tl

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f~iurt,Pr9ttlt

Motlll~~

11111.~‘II

lIC’1. 11;1t,,v tllIY,I1gII

day.

The result was entirely satisfactory. Search of the> Jit,erature, however, discloses a number of radica.1 proposals. DeLeel has practiced and recommends cesarean section and appendectomy in acute attacks. The same procedure and also hysterectomy in badly infected cases have been carried out by various foreign authors (Fritz Michel,2 G. Conrad,” Pankow”) . Vaginal cesarean section has been done preceding abdominal operation for gangrenous appendicit.is (Otto Wolfring,j Rosenthal). Acute suppurating appendicitis late in pregnancy or with impeuding labor is not common. While ten fellows’” of this association state they have never met it, accurate data concerning 33 well-defined ca.ses have been furnished by other members. From the literature, 37 welldrscribed cases have been added. Emil Jer10v7 has studied the en-

MCDONALD

:

APPENDICITIS

IN

PREGNANCY

111

tire experience, with this condition, in 22 Swedish hospitals over period of twenty years, and furnishes valuable information. On the basis of data thus derived, three questions are presented.

a

1. To what extent does pregnancy modify the course, complications, and prognosis of acute appendicitis ? 2. TO what extent is eit,her abort.ion or labor a factor in the complications and course of the disease! 3. TO what extent do these considerations modify the surgical treatment of acute appendicitis and justify radical procedure to terminate the pregnancy or to empty the uterus? There are conditions during pregnancy which may have untoward effect on the course of appendicitis. 1. Recurrent attacks are claimed to be more frequent tha.n at other times because of constipation, stasis, and displacement of the cecum. Jerlov finds 96 cases with a positive history of previous attack, 109 with a negative history, and 59 with no data. Portes* quotes 16 instances where acute appendicitis had cleared under medical treatment, of which 11 developed an acute recurrence during the next pregnancy. Brindeau” and others discount this factor. 2. Displacement, of the cecum by the enlarging uterus is given serious consideration by some authors. It is denied much significance by Brindeau and Jerlov. While such displacement is of less importance than is frequently stated, it should be noted that unless held by adhesions the eecum and appendix are usually carried out of the pelvis by the enlarging uterus. They lie in the free peritoneum. Therefore pelvic exudate or abscess is rare, certainly in advanced pregnancy. 3. The omentum is lifted by the enlarging uterus. This together with the high position of the appendix favors diffuse peritonitis rather than localization by .protective adhesions as at other times. 4. Spread of infect.ion through communicating lymphatics to the right fallopian tube and endometrium has been described. This may be an occasional cause of septic endometritis or abortion. Serious complications are more frequent as pregnancy advances. After consideration of individual cases one may assert this is due to delayed treatment rather than to anatomic relations. Certain clinical conditions frequently confuse the picture and delay correct diagnosis until infection is far advanced. Nausea and vomiting are Occurring after so common they do not attract adequate attention. the middle of pregnancy, however, accompanied by local pain and tenderness, or with fever, these symptoms are significant. While leucocytosis is said to be frequent,, if exceeding 10,000 or if Pyelitis involving it should receive proper consideration. increasing,

112

THE

AMERICAN

JOURNAL

OF

OBSTETRICS

AND

GYNECOLOGY

the right kidney is a complication which may simulate acute appendicitis. In the literature several of the worst cases had been treated for some time as pyelitis, and the true condition was recognized only after diffuse peritonitis was present. Pyuria or bacilluria do not necessarily clinch the diagnosis of pyelitis. IIypertonic contraction of the uterus is a frequent result of peritoneal irritation (Lemeland”‘). It causes diffuse abdominal pain and suggests impending abortion or labor to the degree that nothing else is suspected. The relative frecluency of serious complications of appendicitis in the pregnant woman as compared with the nonpregnant woman is shown by comparat,ive figures. With regard for varying judgments of different authors, I have taken the classification of Quainll and compared it with two series in the pregnant: that of Jerlov’s 204 cases confirmed by operation, and the Western Surgical group of 33 cases combined with 37 from the literature. -

_~-

.--.--_.__

CONFINED APPENDIX

~--

NO.

Quain, 1OOOGGZXp~~t .Jerlov, 204 cases pregnant Western Surgical group and literature, 70 cases-___ pregnant

TO

WITH ABSCESS

PER CENT -.______-

551

55

GENERAL PERITONITIS

-

NO.

PER CENT

NO.

PER CEN’;’

289

28.9

IGO

16

__.-.

These figures show a comparative increase in the frequency general peritonitis and decrease of local abscess as complications. The comparative mortality is shown in the following table: --.-----__-__ I_CONFINED APPENDIX

NO. .__-

___--

DIED

.Jerlov, 204 CILB~S pregnant, 10s Western Surgical group and literature, 70 cases pregnant 35 Total, 274 cases pregnant 143 Quain, 1000 cases nonpwgumt___.~ . ...____ --.~~~.-. 6.51

TO

LOCAL ABSCESS

PER CENT

NO.

DIED

of

QENERAL PERITONITIS

PER CENT

NO.

DIED

--PER CENT

0

0

45

9

20

51

Iti

31

1 1.

3

6 51

3 311

50 23.5

“9 x0

x 24

57 311

7

2.4

IS

II ..-

0.71

:: 0.33 .~~_.~~~... ~

389

-.--

--.

16ll

--

-~-~--

~---.

.-

The mortality of complicated cases in pregnancy is rcslativoly high, especially when operated late in the attack. To what extent is abortion or premature labor a factor in the complications and course of acute appendicitis? The following table shows the frequency of this event in various types of the disease. CONFINED NO.

Jerlov, 204 cases 108 Western Surgical group and literature, 70 nasefi 2.5

T O APPENDIX

ABOKTED

Iti

4

PER CENT

LOCAL

ABSCESS

IiENERAL

PER CEN’T

PERITONITIS

NO.

ABORTED

NO.

ABORTED

PER CENT

13.8

45

25

55

51

32

63

11.4

6

4

66

L!!)

21

70Y

MCDONALD

:

.APPENDICITIS

IN

113

PREQNANCY

The above-mentioned figures indicate that the liability to abortion increases directly with the duration and severity of the appendicitis. In some of the more serious cases termination of pregnancy occurred before operation, proof that. it was due to the disease rather than to surgery. The complication is of some prognostic significance. There are factors predisposing to bring on interruption of pregnancy : (1) Fever and toxemia, as in pneumonia or influenza ; (2) Gastrointestinal disturbances of themselves are not important; (3) Reflex irritation from peritonitis causes hypertonic contraction of the uterus. This results in painful uterine spasm. While this contracture may go on to active expulsive contractions, the hypertonus often persists as such, for several days. (4) Extension of infection through communicating lymphatics to the right fallopian tube and endometrium may cause death of the fetus and abortion. In 57 cases of appendicitis complicated by abortion Jerlov found 12 with salpingitis of the right tube. (5) Operative manipulation adds little if anything to the danger of abortion provided the stability of the pregnancy is not already disturbed. Early operation is the best safeguard. Spinal anesthesia is contraindicated, Brindeau et Juge.12 It. causes undue relaxation of the cervix. Postoperative complications of the ordinary sort may ha.ve some untoward influence and must be controlled. The direct harmful effect of abortion or labor has been much exaggerated. This effect might be due to shock from prolonged labor, t,o excessive bleeding, to absorption and sepsis through the placental site or lacerations, or to disturbed relations in the abdomen. Jerlov concludes : in mild cases with no peritonitis, labor and involution whether premature or full term have no harmful effect. In cases wit,h peritonitis delivery, whether preceding or following operation, has some harmful effect. He gives the following figures: ABORTED

Early Late Late

General General Abscess

Peritonitis Peritonitis

10 19 34

DIED

1 12 8

PERCENT

10 63 33

NO ABORTION

15 7 21

DIED

0 3 1

PER

CENT

n 4.)‘l 4.8

The mortality is higher in the cases which aborted. This does not prove that abortion is the chief determining factor in the result, because extensive peritonitis and sepsis were also present. Study of many of the cases in my data indicates that abortion or labor occurred in persons already prostrated by sepsis and had but little influence in the untoward result. This could have been avoided by earlier surgical , intervention rather than by interruption of pregMany of them aborted because they were dying; they did nancy. not die because they aborted. To what extent does the danger and possible unt.oward influence

of abortion or labor modify the indications for surgical treatment of acute appendicitis, or justify radica,l measures to empty the uterus”! The dangers and complications of appendicitis in the pregnant, woman are those of the same condit,ion in the nonl)regnant: plus a confused clinical picture, delayed diagnosis, ant1 liability t,o general peritonitis rather t,han localization. Thcreforc~. pregnancy increases the urgent indication for prompt siml)lc surgical intervention with the following precautions : avoid spitin anestht%. iIVOid miIeLcwsarp manipulation of pelvic struct,ures of the lIterus, ovary, ot corpus luteum. Preveilt postoperative distnrbancc by cutr~rostomy when indicated or by sedatives. In early inicomplicatcd cases promptly treated the danger nf abortion or labor is slight. and rcquires no special consideration. Sl~oulcl cithcr ensue, t,br complication can be effectively and safely hanclled by the vaginal route. Abdominal hysterotomy offers no advantage. In none of the Western Surgical group of localized cases was hysterotomy done. Wit,11 extending lieritonitis or abscess thca liability to abortion 01 labor increases, anti a large l,crcc~nta,qe of those patichnts who ;ihort, will die. Can radical ter1niniltioil of prc’gnancy rc*lic>ve tli(a loatl ! In this Sot at all, unless the coiiiplicatiot~ is alrtlad). ini~)clltling. went prompt. cvarus illltl placental site is serious. Firm healing of tlicl uterin(I wolInt1 CilllHOt be assured ; it presents tit0 tlilllg.(~l’ of rnpturch of tll(b tlttlrns iI1 sltbsrcluclnt llregnan~y. Tn Illany instancrs 111~ child is dta;1(1 or pwlnwturc, Obstc4i~icwlly, it is high1.v ob~(~ctiO~lill)lt~ iti yoting or not viable. women with 110 ~l~‘IYlli~ll~~llt tl,I?tOc*iii. I cali find no Vjustifica.tion for abdominal hysterotomy Il~llWS lilbO1’ is imniiIIent tllltl ttlrIY is il(!tlliIt dystocia which prevents vaginal dclivckr,v. When either abortion or labor is impending.. mhot~ller at time of operation or during convalescence from appendicitis, there are definite advantages in rapid termination bp the vaginal route. In skilled hands this can be safely and effectively a.ccomplishetl by manual dilatation of the cervix or 11~ vaginal cesarran section, followed by version illld extraction, 01’ by for(+el)s. This will avoid prolonged labor and loss of blood. It will not add materially to extension of Tf delivery can be ~lrlwyc~l till convalescence from the infection. acute process is well advanced. the prognosis will be improved.

MCDONALD’:

APPENDICITIS

IN

115

PREONANCY

CONCLUSIONS

1. Pregnancy as a complication of acute appendicitis presents problems for differential diagnosis but does not modify the indications for surgical treatment. 2. Abortion or labor gives a relatively grave prognosis. Obstetric procedures are indicated only when the event is actually impending. 3. Delivery should be completed by the most conservative method consistent with good practice. REFERENCES (1) DeLee, J. B.: Practical Medical Series, Obstetrics, p. 55, 1926; p. 82, 1927. (2) Michel, Frik: Zentralbl. f. Gyn;ik. 51: 2477, 1927. (3) Conrrad, G.: Zentralbl. f. Gynlk. 52: 162, 1928. (4) Pankow, 0.: Arch. f. Gytik. 133: 5, 1928. (5) Wolfring, Otto: Zentralbl. f. Gynlik. 52: 374, 1928. (6) Rose-nthd, M.: !&entralbl. f. Gytik. 52: 436, 1928. (7) Jerlow, &nil: Acta obstet. et gynec. Scandinav. 4: 1925. (8) Portes et Segury: Gydc. et Obst. 15: 114, 1927. (9) Brinaeau, A.: Leeons du Jeudi Soir, Clinique Tarnier, 1926, No. 3, Bigot Freres, Editeurs. (10) LemaZan&: Bull. Sot. d’obst. et gynec., No. 1, 29, 1926. (11) &u&n, E. P., and, WaZ&ch?nidt, R. H.: Arch. Surg. 16: 868, 1928. (12) Brindem et JugeN: Gynbc. et Obst. 14: 145, 1926. (13) Mussey, R. D.: Am. J. Obst. & Dis. Child. 77: No. 5. (14) Phmeuf: J. A. M. A. 88: 282, 1927. (15) Fairbairn, J. 8.: Brit. M. J. 1: 456, 1927. (16) Royson and Pishe+: AM. J. OBST. & GYNEC. 11: 184, 1926. (17) FFZZSON: Surg. Gynec. Obst. 45: 620, 1927. (18) Dmvis: Progressive Medicine, 1924. (19) DeLee, J. B.: 8. Clinics, N. America, 1: 1003, 1921. (20) Findley: .J. A. M. A. 54: 612, 1912. (21) Rattan: Gym&. et Obst. 2: 300. (22) Z’edmat: Bull. Soe. d’obst. et de gynec., No. 3, 240, 1925. (23) Couvelaire: Bull. Sot. d’obst. et de gynec., Dec., 1926. LYCEUM

BUILDING.

Sharlit, II., and Lorberblatt, J-. Lab. & Clin. Med.

14:

I.: 119,

Chemical

Test

of Blood

for

Sex

Differe,ntiation,

1928.

The blood stream of animals contains chemical units produced by the individual organs of internal secretion, On this basis, a chemical test for sex differentiation seems possible. By means ,of a modified quantitative Manoilov technic, readings based on calorimetric changes were made. In the original technic, the. end-result of a test on an extract of male origin, resulted in a colorless solution, of female origin in solutions ranging in color from pink to red or violet. Tests were made on whole &rated blood and urine. It was found that the end-results of the tests on blood, distributed themselves equally on both males and females. The sex of the donor, therefore, had no influence on either the Manoilov technic or its modification. The urines of more than 100 women were tested at different times, and a number of specimens were also obtained from the same individuals. The variations in the readings covered the entire range of color in the standard tubes. Chemically, the test is probably an oxidation reaction which in some cases is inhibited and in others may go to completion. No single chemical substance is required to play the part of inhibitor and it is unlikely that the same substances in blood or urine are being obtained. This test is probably not a specific one; the work requires further study. W. B. SERBIN.