Appendicitis in Pregnancy

What is Appendicitis in Pregnancy?

Acute appendicitis is a condition where the appendix becomes inflamed. This inflammation is usually confirmed through medical tests that study the tissue under a microscope. Normally, symptoms of acute appendicitis appear suddenly within a day. However, if the appendix has ruptured and formed a contained abscess, the symptoms might progress more slowly.

It can be tricky to diagnose acute appendicitis, especially in expecting mothers, as the symptoms can vary a lot between patients. It’s worth mentioning that appendicitis is the most common cause of non-pregnancy related surgery during pregnancy. It is critical to diagnose and treat appendicitis during pregnancy promptly, to prevent possible serious complications for both the mother and her baby.

Still, diagnosing appendicitis during pregnancy can be quite tricky. The typical signs and symptoms might not be so obvious or could mimic common pregnancy symptoms. Plus, the growing womb can move the appendix, making the diagnosis even more complex. Common laboratory tests used to diagnose appendicitis might also not be as reliable during pregnancy.

The overall process for understanding, diagnosing, and treating appendicitis during pregnancy is similar to that in those who are not pregnant. However, there are some adjustments to consider the normal bodily changes during pregnancy, and the wellbeing of the developing baby.

What Causes Appendicitis in Pregnancy?

Acute appendicitis typically occurs due to a blockage in the appendix, most often caused by a hardened piece of stool known as an appendicolith. This blockage may also be due to growths in the appendix, intestinal parasites, or swollen lymph tissue. In children, swollen lymph tissue is more common, whereas infections, hardened feces, or tumors are common reasons in adults.

The appendix naturally contains bacteria, including the types known as Escherichia coli and Bacteroides spp. When the appendix gets blocked, these bacteria can multiply too much, leading to acute inflammation and sometimes forming an abscess. Recent studies using advanced sequencing techniques found that people with an extremely acute type of appendicitis, known as perforated appendicitis, have a significantly higher amount of bacteria.

For pregnant women, the causes of acute appendicitis are similar to those of non-pregnant adults. However, there are specific bacteria, such as Fusobacterium nucleatum, often found in the mouth and associated with gum disease, that are related to complications during pregnancy like inflammation of the amniotic sac, premature birth, stillbirth, newborn blood infection, and high blood pressure during pregnancy. However, there isn’t enough evidence yet to confirm any specific bacteria responsible for acute appendicitis during pregnancy.

Risk Factors and Frequency for Appendicitis in Pregnancy

Acute appendicitis, a common cause of severe stomach issues, affects about 100 to 223 out of every 100,000 people each year. In fact, it’s the reason for around 300,000 hospital visits in the U.S. every year. Appendicitis is most often seen in individuals between the ages of 5 and 45, with the average age of diagnosis being 28.

• Interestingly, acute appendicitis is just as common in pregnant and non-pregnant individuals, affecting 1 out of every 181 to 1700 pregnancies.
• The highest incidence is in the second trimester of pregnancy.
• It’s worth noting that acute appendicitis is responsible for two-thirds of non-trauma related surgical emergencies during pregnancy.

Signs and Symptoms of Appendicitis in Pregnancy

Acute appendicitis usually starts with a widespread stomach discomfort that tends to focus on the lower right side as time progresses. Symptoms can vary widely but most patients report feeling ill within 24 hours of the start of discomfort. Pregnant individuals might experience less noticeable or less typical symptoms, especially later in pregnancy.

The most common symptom of acute appendicitis is abdominal pain. The location of the pain can vary due to the appendix’s position, which depends on the individual; it could sit in a variety of positions within the abdomen. This pain begins as a vague discomfort in the middle regions of the stomach, caused by inflammation triggering certain nerves. This discomfort then localizes to the lower right side as inflammation spreads. However, it’s important to note that not all patients with acute appendicitis experience this progression of pain.

In typical cases of acute appendicitis, stomach pain is often accompanied by a lack of appetite, and feeling nauseous, with or without issues of vomiting. Around 40% of patients also have a fever, usually occurring later on.

There are also those who experience less common symptoms of acute appendicitis, which might include overall feeling of discomfort, heartburn, bloating, constipation, or diarrhea. If the appendix is located in the lower part of the abdomen, other symptoms could manifest as frequent urge to urinate, painful urination, an urge to empty the bowels, and diarrhea.

In pregnant patients, despite the shifting of the stomach due to the growing uterus, most will still experience abdominal discomfort. The pain is most likely to be felt in the lower right side, but as the pregnancy progresses and the uterus expands, the pain might be felt higher up on the right side.

The early signs of acute appendicitis – in pregnant and non-pregnant patients – can be subtle. However, as inflammation progresses, signs of inflammation around the lining of the abdomen could develop. The most common findings during a physical examination for acute appendicitis include pain in the lower right side of the abdomen, increased discomfort when pressure is released (rebound tenderness), and involuntary tightening of the abdominal muscles. If the appendix is located behind the colon, pain will likely be noticed during a vaginal or rectal examination, even in pregnant patients. If it is located in the lower part of the abdomen, pain might be felt below the usual area for appendicitis.

Testing for Appendicitis in Pregnancy

There are several systems used to swiftly diagnose acute appendicitis, the most popular of which is the Alvarado score. These scoring systems consider things like medical history, physical examination, lab tests, and imaging techniques such as abdominal ultrasound.

When suspecting acute appendicitis in non-pregnant individuals, doctors typically analyze the total white blood cell count, the prevalence of a type of white blood cell known as neutrophils, and the concentration of C-reactive protein (CRP) in the blood. Increased white blood cell and CRP levels are often indicative of appendicitis. Blood in the urine and pus, although not as common, may be found when the inflamed appendix is close to the bladder or ureter.

However, when it comes to pregnant individuals, these indicators may not be as reliable. For instance, high white blood cell counts can be a normal occurrence during pregnancy, especially during the third trimester and labor. Hence, doctors cannot solely rely on these for diagnosing appendicitis in pregnant patients. Other markers like serum bilirubin levels or the ratio of neutrophils to lymphocytes and platelets to lymphocytes may, however, increase diagnostic accuracy.

Imaging tests can also play a significant role in confirming the diagnosis of appendicitis, particularly when the diagnosis is uncertain. The most commonly used imaging techniques are ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI). Ultrasounds, while not as specific as CT scans, avoid radiation exposure, which makes them a safe option for pregnant women and children. MRI might also be a useful tool for pregnant women with indefinite ultrasound results.

Abdominal ultrasound is widely used when a patient reports experiencing acute abdominal pain. Findings suggestive of appendicitis on an ultrasound may include an enlarged appendix, the presence of a hardened mass known as an ‘appendicolith’, and unusually high echoes from the fat around the appendix. However, the accuracy of ultrasounds can be hindered by factors such as obesity due to their inherent limitations and operator-dependency.

CT scans are usually more accurate than ultrasounds in diagnosing acute appendicitis, with their accuracy typically above 95%. Guiding features for diagnosing appendicitis on a CT scan include an enlarged appendix, thickening of the appendix wall, and the presence of an appendicolith. The main concern with CT scans is exposure to radiation; however, the average exposure is only a bit above the background radiation. Still, in pregnant patients, the use of CT should be limited to cases where ultrasounds are inconclusive and MRI is not available.

MRI, on the other hand, has high precision for diagnosing acute appendicitis without the risk of radiation exposure, which makes it a preferred choice for pregnant women. MRI results consistent with acute appendicitis include enlargement of the appendix, thickening of its wall, and the presence of excess fluid around the appendix. Although MRI has performed extremely well in several retrospective studies, its high cost and limited availability restrict its usage to specific patient groups. Nevertheless, if available, it is recommended to use MRI in pregnant women suspected to have acute appendicitis to reduce the chances of unnecessary surgeries.

Treatment Options for Appendicitis in Pregnancy

The standard treatment for acute appendicitis (inflammation of the appendix) without rupture is usually surgery, known as an appendectomy. During the surgery, patients are given antibiotics to protect against both Gram-negative and Gram-positive bacteria. Typically, a second-generation cephalosporin is used along with clindamycin or metronidazole, which are effective against anaerobes. It’s important not to delay the surgery for more than 24 hours after the symptoms begin, as this can increase the risk of the appendix rupturing.

There are two main types of surgery for appendicitis: laparoscopic, or keyhole surgery, and open surgery. Neither method has been proven superior so the choice depends on various factors including the patient’s condition, the size of the patient’s uterus if they are pregnant, and the surgeon’s experience. Current guidelines suggest that laparoscopic surgery is preferred for pregnant patients. It is considered safe and allows the surgeon to check for other potential issues in the abdomen.

However, studies comparing open and laparoscopic surgeries in pregnant patients show a slightly higher chance of fetal loss with the laparoscopic method. On the other hand, laparoscopic surgery typically results in shorter surgery and hospitalization times. Both methods have comparable outcomes for pregnancy, supporting laparoscopic surgery as an effectively option for pregnant patients with appendicitis.

During laparoscopic surgery on pregnant patients, recommended practices include positioning patients slightly on their left after 20 weeks gestation, using an open-access method for the initial trocar (a device used in surgery) to avoid injury to the uterus, limiting the pressure of insufflation (blowing gas into the abdomen), and adjusting the port position based on the uterus’s size.

For open surgery, the incision is typically made where the patient feels the most pain, instead of the traditional McBurney point. If the diagnosis isn’t clear, a vertical incision down the middle of the lower abdomen may be used to expose the abdomen for diagnosis and treatment.

Though non-surgical management of appendicitis with antibiotics has been explored, it has been linked with negative outcomes in pregnant individuals and so surgery remains the preferred treatment method during pregnancy.

When a patient with a perforated appendix presents, their treatment plan depends on the nature of the perforation. If the appendix ruptures and pus or fecal material spreads into the abdomen, a patient may actually become quite sick and there’s risk of premature labor, delivery and fetal loss in pregnant individuals. These patients need an emergency appendectomy and cleaning of the abdominal cavity.

Patients that aren’t pregnant and have longer-standing symptoms suggestive of a contained (limited) perforation, are generally managed with antibiotics, hydration, and rest. Immediate surgery in these cases is associated with higher morbidity due to increased inflammation and potential injury to surrounding structures. Postoperative complications such as abscesses or abnormal connections between the intestine and skin that require further surgery may occur.

Unfortunately, information on how to best manage a contained perforation of the appendix in pregnant patients is limited. It’s advisable to proceed with caution, monitoring these patients in the hospital to avoid septicemia, preterm labor, or loss of the fetus. There’s currently no available information on draining appendiceal abscesses in pregnant patients.

What else can Appendicitis in Pregnancy be?

When a pregnant individual reports symptoms similar to appendicitis, doctors must also consider conditions that tend to occur in people not currently pregnant. This could include:

• Urinary tract infections
• Inflammatory bowel disease
• Kidney stones (renal colic)
• Conditions specific to the female reproductive system, such as an abscess in the fallopian tubes and ovaries
• Inflammation of the pelvic region
• Ruptured ovarian cyst
• Ovary torsion
• Syndromes involving the diverticula in the digestive system

Importantly, the doctor must also consider conditions associated with pregnancy that could result in similar symptoms. These include problems related to the placenta, a potentially dangerous condition where the uterus ruptures and conditions leading to high blood pressure during pregnancy. A condition known as HELLP syndrome, which affects the red blood cells, liver, and platelets, also needs consideration.

During early pregnancy, ectopic pregnancy, where the fertilized egg implants outside the uterus, needs to be ruled out. Lastly, ’round ligament syndrome’ – a common cause of lower abdominal pain during times of rapid belly growth – is also considered.

Surgical Treatment of Appendicitis in Pregnancy

Appendiceal malignancies, or tumors in the appendix, are quite rare in the United States, with only about 1.2 cases for every 100,000 people. Most people diagnosed with these types of cancer are usually between the ages of 50 to 55. Yet, these tumors can also appear during a person’s reproductive years. In around 30% of cases, the cancer shows up suddenly and acutely. The most usual types of appendiceal tumors are gastroenteropancreatic neuroendocrine tumors (GEP-NETs), goblet cell carcinoma, colonic-type adenocarcinoma, and mucinous neoplasms.

GEP-NET tumors are the most frequently seen type of appendiceal malignancies. These tumors hardly ever spread to the liver or lymph nodes, but if there’s a suspicion that someone has a GEP-NET, it’s essential that doctors check these areas just to be safe. The size of this type of tumor can also affect the necessary treatment methods.

Goblet cell carcinomas case is a type of cancer commonly found in appendiceal tumors. It has some similar characteristics to both adenocarcinoma and neuroendocrine tumors. To ensure a correct diagnosis of this carcinoma, a comprehensive evaluation of the membrane lining the abdominal cavity (peritoneum) is necessary.

Then, there’s a very rare type of appendix cancer, known as Non-Hodgkin lymphomas (NHL). This type of lymphoma, including its sub-category called Mucosa-Associated Lymphoid Tissue (MALT) lymphomas, sometimes shows up initially as appendicitis. Its treatment usually involves a simple removal of the appendix. However, doctors need to evaluate the patient systemically to rule out the spread of the disease.

Adenocarcinoma, another form of appendix cancer, typically shows up as appendicitis. Despite being a rare type of cancer, and regardless of its size or if it involves the lymph nodes, the standard treatment is to perform a right hemicolectomy, which means removing the right side of the colon.

Last but not least, an appendiceal mucocele – a mass in the appendix that is filled with mucous, can sometimes show up as appendicitis. There are certain radiological features that could point to this being a case of mucocele — one of them is a capsule-like structure in the right lower abdomen. However, to truly confirm the diagnosis, a surgical analysis and a look at the tissue under a microscope are necessary. To treat a mucocele, ordinarily, doctors perform an appendectomy. However, this needs to be done with great care to avoid rupturing the capsule. A thorough look into the peritoneal region is necessary, and sometimes a laparoscopic approach could be a treatment option, specifically if scans suggest a uniform, cyst-like structure.

What to expect with Appendicitis in Pregnancy

An appendectomy, a type of surgery to remove the appendix, is usually a safe procedure. According to a worldwide study, the overall death rate for appendicitis – an inflammation of the appendix – was just 0.28%. However, some factors make it more likely for people to suffer complications or even death from appendicitis. These factors include being more than 80 years old, having a weakened immune system, having serious heart disease or any other severe illnesses, having had appendicitis before, and previously taking antibiotics.

If appendicitis is diagnosed quickly and treated right away, patients usually recover in about one or two days. In cases where the patient has complex abscesses (collections of pus), peritonitis (inflammation of the lining of the abdomen), or sepsis (a dangerous response to infection), recovery may take longer and could require additional surgeries.

In the long run, pregnant patients who have to undergo appendectomy typically have good outcomes. The surgical procedure itself does not significantly increase the risk of complications after delivery. Rather, if there are complications, it’s usually due to other health problems the patient had before surgery. The risks that pregnant patients face after an appendectomy are similar to those for patients who are not pregnant.

Possible Complications When Diagnosed with Appendicitis in Pregnancy

Appendectomy, which is the surgical removal of the appendix, carries certain risks during pregnancy. These include potential harm to the pregnancy itself, the unborn baby and the pregnant woman. Some of these risks include excessive bleeding, infections after surgery, the formation of an abscess within the abdomen, unintentional harm to nearby organs, discomfort and scarring. Leaving appendicitis untreated carries severe risks too, such as a burst appendix. This can spread infectious and fecal matter into the abdominal cavity, which can lead to premature labor or birth, and even loss of the pregnancy.

Here are some important statistics to remember:

• The risk of losing the pregnancy during a simple appendectomy procedure is around 2%.
• If there have been complications such as abscesses within the abdomen or widespread infection, the risk of losing the pregnancy rises to 6%.
• If the appendix has burst, the risk of losing the pregnancy can be as high as 36%.
• The chance of premature labor due to an appendectomy is about 4% and rises to 11% in cases of complicated appendicitis.
• The association between unnecessary appendix removal to premature labor and loss of the pregnancy is 10% and 4%, respectively.

Consequently, it’s crucial to quickly diagnose and treat acute appendicitis during pregnancy. This significantly decreases the chances of serious harm and even death for both the pregnant woman and her baby.

Preventing Appendicitis in Pregnancy

Acute appendicitis is quite a common illness that usually happens during a person’s child-bearing years. Interestingly, it’s also the most frequent surgical condition diagnosed during pregnancy that’s not related directly to the pregnancy. 

The good news is that an appendectomy (removal of the appendix) during pregnancy is generally safe for both the mother and the baby. It’s worth noting though that if the appendix ruptures, especially a free rupture, it can lead to serious health problems for both the mother and the baby. The chance that the appendix will rupture is not constant and can vary. However, it’s around 2% after symptoms have been present for 36 hours, increasing by about 5% every 12 hours after that.

It’s very important for pregnant women to immediately seek medical attention if they experience continuous belly pain – particularly if this discomfort is combined with a loss of appetite, feelings of nausea, vomiting, or a high temperature.