Patient management and outcome
An open appendectomy was performed. The appendix was inflamed and enlarged as suspected. The histology showed neutrophilic infiltration of mucosa, muscle, and serosa (FIGURE 5). Postoperatively, the patient recovered in Labor and Delivery to monitor for possible preterm labor. She did not develop any signs or symptoms of preterm labor, and was transferred to a regular antepartum floor after being observed for 6 hours.
She did well during her hospitalization, and was sent home on post-op day 2. Her abdominal pain had resolved, and she had very little post-op tenderness.
FIGURE 5
Histology
Discussion: Appendicitis in pregnancy
Acute appendicitis is the most common condition requiring surgery during pregnancy.2 Suspected appendicitis accounts for nearly two thirds of all nonobstetric exploratory laparotomies performed during pregnancy; most cases occur in the second and third trimesters.
The incidence of appendicitis is 0.4 to 1.4 per 1000 pregnancies.2 Although the incidence of appendicitis in not increased during pregnancy, rupture of the appendix occurs 2 to 3 times more frequently in pregnancy secondary to delays in diagnosis and operation. Maternal and perinatal mortality and morbidity rates are greatly increased when appendicitis is complicated by peritonitis.
A difficult diagnosis
Diagnosis is difficult because many symptoms are considered to be normal during pregnancy. Many times, pain in the right lower quadrant of the abdomen may be attributed to round ligament pain or urinary tract infection. After the first trimester, the appendix is gradually displaced above McBurney’s point, with horizontal rotation of its base. This upward displacement occurs until the eighth month of gestation, when more than 90% of appendices lie above the iliac crest, and 80% rotate upward and toward the right subcostal area.2,3