Residents’ Papers Obstetrics
Appendicitis in pregnancy: New information that contradicts long-held clinical beliefs

https://doi.org/10.1067/mob.2000.105396Get rights and content

Abstract

Objective: Our purpose was to elicit a better understanding of the presentation of acute appendicitis in pregnancy and to clarify diagnostic dilemmas reported in the literature. Study Design: We retrospectively reviewed 66,993 consecutive deliveries from 1986 to 1995 by a computer program. Selected records were reviewed for gestational age; signs and symptoms at presentation; complications including preterm contractions, preterm labor, and appendiceal rupture; and histologic diagnosis of appendicitis. Results: Of 66,993 deliveries, 67 (0.1%) were complicated by a preoperative diagnosis of probable appendicitis. Acute appendicitis was confirmed histologically in 45 (67%) of the 67 cases, for an incidence of 1 in 1493 pregnancies in this population. Distribution of suspected appendicitis in pregnancy was as follows: first trimester, 17 cases (25%); second trimester, 27 (40%); and third trimester, 23 (34%). Right-lower-quadrant pain was the most common presenting symptom regardless of gestational age (first trimester, 12 [86%] of 14 cases; second trimester, 15 [83%] of 18 cases; and third trimester, 10 [78%] of 13 cases). The mean maximal temperature for proven appendicitis was 37.6°C (35.5°C-39.4°C), in comparison with 37.8°C (36.7°C-38.9°C; not significant) for those with normal histologic findings. The mean leukocyte count in patients with proven appendicitis was 16.4 × 109/L (8.2-27.0 × 109/L), in comparison with 14.0 × 109/L (5.9-25.0 × 109/L) for patients with normal histologic findings. At the time of surgery, perforation had occurred in 8 cases. Of 23 patients at ≥24 weeks’ gestational age, 19 (83%) had contractions and an additional 3 patients (13%) had preterm labor with documented cervical change. One patient was delivered in the immediate postoperative period because of abruptio placentae. Conclusion: Pain in the right lower quadrant of the abdomen is the most common presenting symptom of appendicitis in pregnancy regardless of gestational age. Fever and leukocytosis are not clear indicators of appendicitis in pregnancy and preterm labor is a problem after appendectomy, but preterm delivery is rare. (Am J Obstet Gynecol 2000;182:1027-9.)

Section snippets

Methods

All pregnant patients delivered at Good Samaritan Medical Center in Phoenix, Arizona, from January 1, 1986, to December 31, 1995, were reviewed. Records that were coded as “rule out appendicitis” or “appendicitis” were selected. In addition, all patients who had an exploratory laparotomy performed were screened to ensure the greatest possible data accuracy.

Data gathered from these records included the presenting complaint, gestational age at presentation and delivery, history, physical

Results

There were 66,993 deliveries during the 10-year study period; 67 of the women (0.1%) had a preoperative diagnosis of probable appendicitis. Acute appendicitis was confirmed histologically in 45 (67%) of the 67 women, for a true incidence of 1 in 1493 women in our population. Suspected appendicitis occurred in 17 cases (25%) in the first trimester, 27 cases (40%) in the second trimester, and 23 cases (34%) in the third trimester. The false-positive rate was 33% and varied slightly by trimester:

Comment

In our pregnant population the incidence of appendicitis is slightly higher than in an age-matched group of nonpregnant women described in the surgery literature. The proven incidence of acute appendicitis is similar in pregnant and nonpregnant women. The acceptable false-positive rate in pregnancy is 30%, which is very similar to our findings.

The classic signs and symptoms of acute appendicitis are abdominal pain, nausea and vomiting, low-grade temperature elevation, and leukocytosis. The

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