Introduction:
Acute appendicitis is most commonly seen in pregnant women less than 30 years of age. Symptoms of appendicitis are similar to pregnancy symptoms; thus, it is difficult to differentiate them. Various laboratory tests have been done to differentiate it from pregnancy symptoms, as imaging techniques are limited due to their harmful effects. A common symptom is pain in the lower right quadrant. Other symptoms are nausea and vomiting, similar to pregnancy-related symptoms.
Early diagnosis of this condition is essential as delay causes both mother and infant mortality and morbidity. Early diagnosis is also necessary in these cases. CT scan is a valid confirmatory test for the diagnosis of appendicitis, but due to its radiation effect, its use in pregnant women is limited. Tests like MRI and ultrasonography can be used in necessary cases. There is no specific laboratory test for the diagnosis of appendicitis. Still, WBC and CRP are used chiefly. Other laboratory tests like leukocyte count, lymphocyte count, neutrophil count, and various other imaging techniques are also used in diagnosing appendicitis. Appendicitis is a case in which any of its symptoms arises, and treatment should be done within 24 hours.
What Are the Signs and Symptoms of Appendicitis in Pregnancy?
The first symptom of appendicitis is lower abdominal pain (belly). It is unbearable severe pain. Appendicitis pain starts from the belly button and then spreads to the right, more downside of the abdomen. Other symptoms include nausea, loss of appetite, and vomiting, and if the appendix gets infected, a high fever also occurs. As in pregnancy, the uterus grows. Thus, there is the displacement of the bowel, so the appendix gets moved. This causes difficulty in the diagnosis of abdominal pain. As pregnancy progresses, the pain may radiate to the upper right part of the abdomen, and the appendix location also changes. If appendicitis is left untreated, it causes various complications like a burst of the appendix, perforation, or leakage of infectious material into the abdomen. So early diagnosis is mandatory in the case of appendicitis in pregnancy.
What Are the Diagnostic Measures to Confirm Appendicitis in Pregnancy?
Symptoms of appendicitis are similar to pregnancy symptoms; thus, various measures such as laboratory tests and imaging are used to confirm the diagnosis.
- In non-pregnant patients with appendicitis leukocytes, the count will increase to more than 10000 cells/microL neutrophilic predominance. But in pregnancy, leukocytosis can be higher as 16000 cells/microL, or at the time of delivery, it is as high as 29000 cells/microL with neutrophilic predominance. Thus this method is not used as a valid indicator.
- In the case of the inflamed appendix close to the ureter or bladder, microscopic haematuria and pyuria will occur, but this symptom occurs only in a few patients.
- A slight change in serum bilirubin will also be there, but we cannot confirm appendicitis.
- The c-reactive protein level is also elevated.
- Neutrophil to lymphocyte ratio (NTR) and platelet to lymphocyte ratio (PTR) these two tests are used as diagnostic tools to confirm appendicitis in pregnancy.
Imaging techniques are also used to confirm appendicitis and avoid negative appendectomy risk.
- The use of ultrasound with graded compression of the right lower quadrant starts from the area of maximum pain and scanning between the iliac artery, pelvis, and psoas muscle border. Ultrasound is safe in pregnancy and easily available. Ultrasound is used in pregnant patients to find the fetus's development and well-being and the pregnancy-related cause of abdominal pain. In non-pregnant patients, it can be used to find an enlarged appendix.
- The use of MRI-Magnetic resonance imaging without gadolinium contrast is a safe alternative for confirming or ruling out appendicitis in pregnancy. MRI provides a better soft tissue resolution, lacks the risk of ionizing radiation, and gives good specificity in pregnant patients. In certain studies, MRI has been used to reduce the risk of negative appendectomy and appendiceal perforation.
- The usage of CT scan is also used in certain cases when the ultrasound is indecisive, or MRI is not available. In such cases, a CT scan is used to reduce the risk of negative appendectomy than using the clinical diagnosis alone. Certain studies confirmed that the radiation in a limited CT scan is less than the threshold that is required to cause malformation in a fetus. Most chances of appendicitis occurring are in the last trimester of pregnancy. Thus in that time, organogenesis is completed. So the risk of a CT scan is less.
How to Manage Appendicitis in Pregnancy?
The main treatment of appendicitis is appendectomy. Antibiotics are given preoperatively to provide coverage against gram-positive and gram-negative bacteria. This is usually done with second-generation cephalosporin and against anaerobes with clindamycin and metronidazole. In appendicitis, surgical treatment should be done within the first 24 hours because there is a risk of appendix burst and perforation. Treatment of perforation depends on the type of perforation. In case of free perforation, fluid, pus, and infected materials will be leaked into the peritoneum, causing complications like a septic patient, ill-looking, and increasing the risk of preterm delivery and even loss of the fetus.
This situation needs emergency medical attention, and urgent laparotomy for appendectomy with irrigation and drainage of the peritoneal cavity is needed. If a perforation that is walled off occurs in a pregnant woman, close monitoring of the patient is required in a hospital to avoid preterm labor, sepsis, and fetal loss. The two main treatment procedures are laparoscopic and open techniques. The selection of the procedure depends on various factors like the gestational age of the patient, the clinical status of the patient, and the surgeon's experience.
- The advantages of the laparoscopic approach are much safer in pregnant patients. It allows easy identification of variably positioned appendixes, enabling evaluation of the abdomen for any other pathogenesis.
- Some recommendations for laparoscopic procedures are slight lateral positioning of the patient, use of open access approach for initial trocar placement to prevent uterus injury, and controlling Intra abdominal insufflation pressure less than 12mmHg.
- In an open appendectomy procedure in pregnant patients, a transverse incision is made at the point of maximum tenderness. And if diagnostic confirmation is not obtained, a vertical incision is done to provide better exposure of the abdomen for diagnosis and treatment.
What Are the Complications of Appendicitis in Pregnancy?
Untreated appendicitis may cause complications with increased morbidity. Appendiceal perforation can be free, contained, or walled off. Open perforation causes leakage of content into the peritoneum that causes sepsis, ill-looking and increased risk of preterm delivery and fetal loss. Contained perforation causes peritoneal abscess and phlegmon around the burst appendix and requires antibiotic treatment. A complication of surgery is a postoperative abscess, bleeding, and injury to adjacent structures.
Conclusion:
Symptoms of appendicitis are similar to pregnancy, so confirming appendicitis in pregnancy is difficult. Various laboratory and imaging tests are done to verify appendicitis in pregnancy. Once confirmed, surgical treatment should be done within 24 hours to avoid complications like appendix burst and perforation. Thus fetal sepsis loss, a laparoscopic and open approach, is used in managing appendicitis.
