Acute appendicitis in pregnancy

Acute appendicitis during pregnancy is an important complication that deserves careful consideration. It is perhaps the most common indication for performing a laparotomy for extrauterine lesions. Various anatomic and physiologic changes that occur during pregnancy contribute to the complexity of making the diagnosis of this disorder. The symptoms and signs of acute appendicitis during pregnancy may, however, mimic those commonly encountered in normal non-gravid women.Reports on acute appendicitis in pregnancy are rare. We report a case of 28 week pregnancy with acute appendicitis who underwent open appendectomy after which she developed preterm labour for which she was put on progesterone supplements and managed successfully.

IJBR (2014) 05 (01) www.ssjournals.com With diagnosis of G2P1L1 with 28 weeks period of gestation with acute appendicitis patient was taken for open appendectomy under spinal anaesthesia.
Operative findings:-Under spinal anaesthesia, laparotomy was done. Oblique incision centering the point of maximum tenderness. The caecum seen after gently pushing the uterus medially, which was delivered outside. Appendix inflamed, limsy adhesions released, vessels ligated. Appendix removed after ligation at base. The wound was closed in layers. postoperatively metrogyl 5 doses and paracetamol 100ml iv sos given. Histopathology:-report shows mucosa lined by columnar epithelium. Dense infiltration of mucosa, sub mucosa and muscularis propria with acute inflammatory cells like neutrophils seen.

Fig 4. Histologic appearance of the specimen
Her open appendectomy was done.post operatively she had uterine contractions for which she was put on tab. nicardia 20 mg stat followed by 10mg tid and cap.susten bd for 7 days. Stitches were removed on 7 th post operative day and she was discharged on 8 th post operative day.

Discussion
In the "classic" presentation, the patient describes the onset of abdominal pain as the first symptom. The pain is periumbili cal initially and then migrates to the right lower quadrant as the inflammatory process progresses [8][9][10] . Anorexia, nausea and vomiting, if present, follow the onset of pain. Fever up to 101.0ºF (38.3ºC) and leukocytosis develop later. Many patients have a nonclassical presentation, with symptoms such as heartburn, bowel irregularity, flatulence, malaise, or diarrhea. If the appendix is retrocecal, patients often complain of a dull ache in the right lower quadrant rather than localized tenderness. Rectal or vaginal examination in such patients is more likely to elicit pain than abdominal examination. A pelvic appendix can cause tenderness below McBurney's point. these patients often complain of urinary frequency and dysuria or rectal symptoms, such as tenesmus and diarrhea 11 .
Pregnant women are less likely to have a classic presentation of appendicitis than nonpregnant women. The most common symptom of appendicitis, ie, right lower quadrant pain, occurs close to McBurney's point in the majority of pregnant women, regardless of the stage of pregnancy 12,13 ; however, the location of the appendix migrates a few centimeters cephalad with the enlarging uterus, so in the third trimester, pain may localize to the mid or even the upper right side of the abdomen 14,15 . The diagnosis of appendicitis in nonpregnant patients can be difficult, with an accepted false-positive rate of ~15%. In pregnancy the diagnosis is made even more difficult by the growing uterus, which can cause inappropriate delay in making the correct diagnosis, leading to an unacceptable increase in maternal and fetal morbidity and mortality rates. As the pregnant uterus ascends into the abdomen, the appendix is displaced upwards and laterally so that the tip may be close to the right flank in late second trimester. This displacement further presents diagnostic difficulties. Acute pyelonephritis and even surgical causes of right hypochondrial pain will be included in the differential diagnosis. The upward and lateral displacement of the appendix effectively gaurd the inflamed appendix. Atypical presentation, rarely due to a pelvic appendix, displacement of the appendix by the growing uterus and the pathogenesis favoring ease of spread of infection into the peritoneum contribute to delay in diagnosis and contribute to increased morbidity and mortality to both mother and fetus. Clinical diagnosis remains the common mode. Imaging methods should not be awaited if delay in obtaining the service is anticipated as such delay in surgical intervention may not be wise in pregnancy in view of increased fetal and maternal morbidity and mortality. Fetal loss of 4-6 % and early delivery rates of 10-11% have been reported 16 .
Antiquity reliance on history and diagnostic difficulties in eliciting physical signs based on the anatomical displacement of the appendix with increasing gestational age is reiterated. Imaging studies and expertise in interpretation may not be forthcoming in centers with resource limitations and are not among the recommended routine especially when clinical assessment skews to a clear diagnosis of appendicitis. The increased risk of fetal loss and pre-term deliveries after surgery requires adequate counseling and obtaining informed consent for both imaging studies involving radiation and the type of surgical approach proposed for appendectomy. The team approach to management with involvement of obstetricians, pediatricians, surgeons and intensivists is vital. The use of dexamethazone for fetal lung maturity is relevant between 22-36 weeks gestation with facilities for caring of the pre-term baby should the need arise 17 .
The surgical incision made at open access surgery if laparotomy is elected for, is determined by the gestational age and ease of access to the appendix. Transverse, midline, McBurneys, and Lanz, etc incisions have been described. By convention, the incision should be such that appendectomy is facilitated together with ability to perform peritoneal toilet in indicated cases with minimal manipulation of the pregnant uterus. Adequate fluid replacement and optimization of electrolytes prior to surgery would reduce metabolic complications. A third generation cephalosporin with metronidazole or clindamycin (first trimester) would be appropriate. Long term antimicrobials are preferably continued till the patient remains afebrile for at least 48 hours after surgery completing about five days of treatment especially when there is a perforated appendix and peritonitis. Use of prophylactic tocolysis for advanced pregnancy is controversial. The general rule of thumb of initiating tocolysis is to ensure adequate time for dexamethazone to act for lung maturity in pre-term fetus and possible transfer for intensive care of the neonate is usually followed only if the clinical situation.

Conclusion
Appendicitis is a rare surgical complication and diagnosis can be difficult. Fetal morbidity and mortality are high in presence of perforation and generalized peritonitis. Diagnosis is difficult due to displacement of vermiform appendix along with advancing gestational age. open appendectomy is preferred than laparoscopic surgery especially if a diagnostic procedure was not the initial indication unless results of a large randomized trial favours laparoscopic method. 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. perioperative antibiotics are given frequently to reduce surgical morbidity.