What is acute appendicitis?
Acute appendicitis is a condition in which a saclike appendage of the colon, called the vermiform appendix, swells up. Treating acute appendicitis is very routine and safe, so long as it is recognized early. However, it is a surgical emergency, and pregnancy can make the condition difficult to recognize. The confusion can lead to delays and complications. Acute appendicitis differs from a similar condition called chronic appendicitis, which is rare and typically is not an emergency.
How common is appendicitis during pregnancy?
In developed countries, as many as 75 to 100 cases of acute appendicitis are reported each year for every 100,000 people, but rates have decreased slightly since the 1940s in the United States and Europe. It can happen at any age but occurs most often in older children and younger adults. Males are affected a little more frequently than females during childhood, but from age 30 and upward, females are affected as frequently as males. Because of this, females during their reproductive years carry a substantial risk of developing appendicitis. About 1 in 800 to 1 in 1,500 pregnancies is complicated by acute appendicitis. This incidence represents a decrease compared with the condition in non-pregnant women of similar age, which means that pregnancy may provide some level of protection against appendicitis. When it does develop, however, appendicitis can occur at any point from conception through term, although it is most likely during the second trimester and least likely during the third.
How is acute appendicitis diagnosed during pregnancy?
Normally, acute appendicitis is diagnosed based on the patient having a combination of symptoms that indicate appendicitis, the findings of a physical examination, and the results of laboratory tests. Typical symptoms of acute appendicitis include nausea, anorexia (lack of appetite), vomiting, fever, and especially abdominal pain that begins gradually around the navel (dull, periumbilical pain) and then, over 12-48 hours, moves to, and concentrates in, the right side of the lower abdomen.
On physical examination, acute appendicitis produces a handful of classic signs. One sign is called guarding, which means that the abdominal muscles tense up when the examiner puts pressure on the abdomen. Another sign is that the pain in the lower right increases when the examiner pushes slightly on the lower left (Rovsing sign). Pain also amplifies if the examiner applies pressure to the abdomen and then suddenly releases the pressure such that the abdomen rebounds. Another sign is pain that happens when the thigh is extended by the examiner, and the patient is asked to try flexing her hip, and there are still other signs.
Typically, acute appendicitis dramatically elevates the number of white blood cells in a persons blood. Thus, if there is a 15-year boy with the classic abdominal pain in the lower right, the typical symptoms, and an elevated white blood cell count, for instance, its fairly easy for a doctor to diagnose acute appendicitis, but for a 30-year old woman who is pregnant things get more complicated for several reasons. To begin, certain classic appendicitis symptoms such as nausea and abdominal pain that moves about are part of pregnancy. Second, pregnant patients with appendicitis very often do not have a fever. Their pain may never localize to the lower part of the right abdomen, because growth of the uterus shuffles the internal organs around, moving the appendix upward, especially toward the end of the second trimester. Thus, more often the pain of appendicitis is in the upper right part of the abdomen, but the pain also may not be as severe as it is in non-pregnant people. Because the appendix and other internal structures are shifted, the classic signs of appendicitis often are missing. As for the white blood cell count, it is not very helpful, because pregnancy itself tends to raise the white blood cell count to a level only a little below the average level that occurs in a pregnant woman with appendicitis.
As a result of all of this, the diagnosis of acute appendicitis during pregnancy frequently comes down to imaging of the abdomen. The preferred imaging test to perform first is an abdominal ultrasound. If this technique demonstrates a swollen appendix, the diagnosis can be made, in which case the appendix is removed usually in a procedure called laparoscopic appendectomy. Its important not to make a false diagnosis, however, because the risk to the developing baby from an unnecessary appendectomy is equal to the risk to the baby from an uncomplicated appendicitis. At the same time, missing an appendicitis diagnosis is even more dangerous, because this can result in a perforated appendix, which puts both the mother and the baby at especially high risk, so doctors accept the risk of performing unnecessary surgery. Consequently, if the ultrasound testing comes out negative, the next step is to get a better look at the abdomen with magnetic resonance imaging (MRI). If MRI is not available, or if the womans condition is so severe that the time needed for MRI is too long, the abdomen must be imaged with computed tomography (CT), which is thought to be safe for the developing baby in this type of emergency setting, despite a great deal of concern and controversy surrounding the radiation exposure that one receives during an abdominal CT scan.
Does acute appendicitis cause problems during pregnancy?
Yes. The condition is an emergency because if left untreated, the appendix can perforate, leading to infection and inflammation within the abdomen (peritonitis when the infection is throughout the abdomen, or an abscess when the infection is in one spot), which can be fatal. The risk of perforation occurring may be reduced slightly during pregnancy, but peritonitis and other signs of perforation may be more difficult to detect if it does happen. The risk of perforation increases substantially if diagnosis and surgery are delayed for 24 hours or more.
Does acute appendicitis during pregnancy cause problems for the baby?
Yes. If the appendix perforates and causes an infection throughout the abdomen, this can cause premature delivery or a miscarriage.
What to consider about taking medications when you are pregnant or breastfeeding:
- The risks to yourself and your baby if you do not treat the appendicitis
- The risks and benefits of each medication you use when you are pregnant
- The risks and benefits of each medication you use when you are breastfeeding
What should I know about using medication to treat appendicitis during pregnancy?
Antibiotic medications have two potential roles in the management of appendicitis. One role is in medical treatment, rather than surgical treatment, of some instances of appendicitis. However, this non-surgical approach has been shown not to work well when appendicitis occurs during pregnancy. The other role for antibiotics is that they are given just prior to, during, or just after surgery to prevent infection. Such antibiotics are selected based on their ability to cover infections of the two major groups of disease-causing bacteria: Gram-negative and Gram-positive bacteria and both aerobic (oxygen-breathing) and anaerobic (not oxygen-breathing) bacteria. All of this means that antibiotic therapy includes a drug called metronidazole, or a drug called clindamycin, plus it also includes a drug from a family of antibiotics called cephalosporins.
In the event of perforation, and peritonitis or abscess, antibiotics also are given but in massive doses compared with the treatment for preventing infection during surgery.
Who should NOT stop taking medication for acute appendicitis during pregnancy?
It is not prudent to avoid antibiotic treatment around the time of surgery, because the consequences of infection are severe both for the mother and the developing baby.
What should I know about choosing a medication for my acute appendicitis during pregnancy?
Antibiotic medications are necessary to eliminate the risk of infections during surgery, but they are chosen to minimize risk to the developing baby.
You may find Pregistrys expert reports about the individual medications used to treat acute appendicitis here. Additional information can also be found in the sources listed at the end of this report.
What should I know about taking a medication for my acute appendicitis when I am breastfeeding?
If you suffer acute appendicitis near the end of pregnancy, or afterward, the regimen of antibiotics that you are given to support the surgery is short and thus is not an issue for breastfeeding.
What alternative therapies besides medications can I use to treat my acute appendicitis during pregnancy?
The main treatment for acute appendicitis during pregnancy is surgical removal of the appendix. Antibiotic medications play only a supportive role.
What can I do for myself and my baby when I have acute appendicitis during pregnancy?
Prompt recognition of the condition is vital so that surgery can be performed immediately, as delays are associated with severe complications.
Resources for acute appendicitis in pregnancy:
For more information about appendicitis during and after pregnancy, contact http://www.womenshealth.gov/ (800-994-9662 [TDD: 888-220-5446] or check the following links: