Appendicitis during pregnancy

Posted by e-Medical PPT Wednesday, October 10, 2012
Appendicitis:
The most common surgical condition of the abdomen
Lifetime occurrence of 7%
Peak incidence 10-30y

Appendiceal lumen obstruction :
      lymphoid hyperplasia
      fecaliths
      parasites
      foreign bodies
      crohn’s disease
      metastatic cancer
      carcinoid syndrome

Incidence during pregnancy:
Suggested relation with female sex hormones – incidence variations during the menstrual cycle .
Reduced incidence of appendicitis during pregnancy, especially in third trimester
Protective effect of pregnancy ?

Physical examination:
Tenderness – RLQ
Rebound & Guarding (peritoneal signs)
Rovsing sign
Dunphy’s sign
Psoas sign (retroperitoneal retrocecal appendix)
Obturator sign (pelvic appendix)
Rectal examination tenderness (cul-de-sac)
Low grade fever

DDx
Preterm labor
Placenta abruption
Chorioamnionitis
Adnexal torsion
Ectopic pregnancy
Pelvic inflammatory
Round lig. pain

Diagnostic problems:
Position of appendix:
   normally 70% intraperitoneal
                  30% pelvic, retroileal, retrocolic
   pregnancy – anatomical changes
   gravid uterus ---> displacement upward &    
   outward ---->flank pain (3rd trimester) (Baer,1932)
   increased separation of peritoneum  decreased perception of somatic pain and localization

Graded compression ultrasound:
Normal appendix (<6mm) rules out appendicitis.
Nonpregnant – Sensitivity 85%
                            specificity 92%
Pregnant – cecal displacement & uterine imposition makes precise examination difficult

Surgery:
Uncomplicated / complicated surgical procedure ---> pregnancy outcome
Perinatal morbidity in nonobstetrical surgery in pregnancy tributable to the disease itself                                                                                          
Laparotomy –
   Incision choice in all trimesters–McBurney’s point 
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