Appendicitis in Pregnancy

• Appendicitis

  The most common general surgical problem encountered during pregnancy
• Diagnosis of appendicitis in pregnancy


  • Particularly challenging due to relatively high prevalence of abdominal/gastrointestinal discomfort, anatomic changes related to enlarged uterus, and physiologic leukocytosis of pregnancy
  • Appendiceal rupture occurs more frequently in pregnant individuals, especially in the third trimester, possibly because of these challenges and reluctance to operate on pregnant people delays diagnosis and treatment
• Stages of pregnancy


  • 1st trimester - conception to 12 weeks
  • 2nd trimester - 13 to 27 weeks
  • 3rd trimester - 28 to 40 weeks
• Incidence of appendicitis in pregnancy


  • Suspected in 1 in 600 to 1 in 1000 pregnancies
  • Less common in pregnant/postpartum than nonpregnant females
  • Slightly higher incidence in 2nd trimester than 1st/3rd trimesters or postpartum
  • 2nd trimester is the most common time of occurrence
• Clinical features of appendicitis in pregnancy


  • Pregnant people are less likely to have a classic presentation, especially in late pregnancy
  • Most common symptom (right lower quadrant pain) occurs close to McBurney's point in majority of pregnant individuals, but location of appendix migrates upwards with enlarging uterus so in 3rd trimester pain may localize to lower right upper quadrant
  • McBurney's point tenderness may be less prominent during pregnancy because gravid uterus lifts and stretches anterior abdominal wall away from inflamed appendix, and less rebound tenderness or guarding due to uterus inhibiting contact between omentum and inflamed appendix
• Signs and symptoms of appendicitis

  • Symptoms: Abdominal pain, Nausea, Vomiting, Anorexia, Dysuria
  • Signs: RLQ tenderness, Rebound tenderness, Abdominal guarding, Rectal tenderness, RUQ tenderness, Temperature of > 38
• Laboratory findings in appendicitis in pregnancy


  • Mild leukocytosis can be a normal finding in pregnant individuals, with total leukocyte count as high as 16,900 cells/microL in 3rd trimester and 29,000 cells/microL during labor
  • Microscopic hematuria and pyuria may occur when inflamed appendix is close to bladder or ureter, but in less than 20% of patients
  • Mild elevations in serum bilirubin (>1.0 mg/dL) can be a marker for appendiceal perforation
  • Elevated C-reactive protein is a nonspecific sign of inflammation
• Diagnosis of appendicitis in pregnancy


  • Imaging is indicated with a nonclassical presentation, which often happens in pregnancy
  • Primary goal is to reduce delays in surgical intervention due to diagnostic uncertainty
  • Secondary goal is to reduce, but not eliminate, the negative appendectomy rate
• Diagnostic imaging modalities


  • Ultrasound - initial choice for diagnostic imaging of the appendix in pregnancy
  • MRI - preferred next test if ultrasound is inconclusive, avoids ionizing radiation of CT
  • CT - performed when clinical findings and ultrasound are inconclusive and MRI is not available
• Differential diagnoses to consider in pregnancy

  • Ectopic pregnancy
  • Pyelonephritis
  • Preeclampsia and HELLP syndrome
  • Abruptio placenta
  • Uterine rupture
  • Ovarian vein thrombophlebitis (in postpartum patients)
• Management of appendicitis in pregnancy


  • Appendectomy is the conventional treatment, with perioperative antibiotic treatment providing Gram-negative, Gram-positive, and anaerobic coverage
  • Prompt diagnosis and surgical intervention are indicated, as delaying more than 24 hours increases risk of perforation
  • Negative laparotomy is generally considered acceptable given difficulties in clinical diagnosis and significant risk of fetal mortality with perforation
• Management of perforated appendix


  • Free perforation - requires urgent laparotomy for appendectomy and peritoneal cavity irrigation and drainage
  • Walled-off perforation - can be initially treated with antibiotics, IV fluids, and bowel rest, with interval or concurrent appendectomy
• Surgical approach


  • Both open and laparoscopic appendectomy are considered reasonable when diagnosis is relatively certain
  • Open appendectomy via transverse incision at McBurney's point or lower midline vertical incision if diagnosis less certain
  • Laparoscopic appendectomy can be performed safely in all trimesters by experienced surgeons
• The typical anatomic and physiologic changes of pregnancy can make the diagnosis of acute appendicitis challenging
• Complication of Late diagnosis of Appendicitis in pregnancy? If the diagnosis of acute appendicitis is not made in a timely fashion, the risk to the gravida and the fetus is significant and includes sepsis, preterm labor resulting in preterm birth, and fetal loss