The most consistent clinical symptom encountered in pregnant women with appendicitis is vague right-sided abdominal pain.2 Depending on the gestation, muscle guarding and rebound tenderness may or may not be present. Nausea, vomiting, and anorexia are usually present as in the nonpregnant patient. Twenty five percent of pregnant patients with appendicitis are afebrile, as our patient was.2,4
The leukocytosis of pregnancy makes it difficult to determine if there is an infection. Not all pregnant patients with appendicitis will have a white blood cell count greater than 16,000/μL, but approximately 75% of them will have a left shift in the differential.2 A urinalysis may reveal pyuria and hematuria and can mislead the physician to explain the symptoms as pyelonephritis.2
Treatment: Appendectomy, antibiotics if needed
Treatment of nonperforated acute appendicitis in pregnancy is appendectomy. In the first trimester, a laparoscopic appendectomy may be performed.2 Intravenous antibiotics are indicated with perforation, peritonitis or abscess formation.2,5
Tocolysis is unnecessary in uncomplicated appendicitis, but may be indicated if the patient goes into labor after surgery. In the late third trimester, with perforation or peritonitis, a cesarean section is indicated.
Evaluation is imperative
Fetal loss may occur in association with preterm labor and delivery or with generalized peritonitis and sepsis, and occurs only rarely in uncomplicated appendicitis. Fetal loss appears to be more closely associated with severity of appendicitis than with surgical intervention.2,5,6