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ORIGINAL ARTICLE
Year : 2017  |  Volume : 5  |  Issue : 3  |  Page : 111-115

Feasibilty of early surgical intervention for acute appendicitis in gravid patients


1 Department of Surgery, Government Medical College, Srinagar, India
2 Department of Medicine, Government Medical College, Srinagar, India
3 Department of Anesthesiology, Government Medical College, Srinagar, India
4 Department of BS, University of Kashmir, Jammu and Kashmir, India

Date of Web Publication6-Nov-2017

Correspondence Address:
Shabir Ahmad Mir
Department of Surgery, Government Medical College Srinagar, Jammu and Kashmir
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ssj.ssj_25_17

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  Abstract 

Background: Acute appendicitis is the most common surgical non-obstetric pathology during pregnancy. Unnecessary hesitation and hence delay in surgical intervention for acute appendicitis in pregnancy is common. In this background, while attempting early suspicion and surgical intervention (appendectomy) in our patients, we encountered no mortality and no significant morbidity in the in immediate postoperative period.
Materials and Methods: This prospective study was carried over a period of 3.5 years from June 2012 to November 2015, in the department of surgery, GMC (Government Medical College) Srinagar. Patients included were only those who had features of acute appendicitis on clinical grounds and/or imaging studies (ultrasound).
Objective: Our aim was to study the feasibility of early suspicion and surgical intervention in patients with features of acute appendicitis in pregnancy.
Results: The mean age of the patients was 28.84 years, ranging from 21 to 38 years. The mean gestational age of our patient cohort was 17.4 weeks (6-35 weeks). Majority of the patients presented in the 2nd trimester (55.9%) followed by 1st trimester (29.4%). The Alvarado score of the patients ranged from 5 to 9 (mean 6.76). WBC (white blood cell count) of our patients ranged from 5800 to 22400 (average 14150). Neutrophill count ranged from 64.4% to 92.2% (mean 79.20%). USG diagonosed 20 patients as acute appendicitis (58.82%) and 14 patients as negative for appendicitis (41.2%) with a sensitivity of 60.6% and specificity of 71.42 %. Intraoperatively 31 patients (22 inflamed and 9 perforated) had features of acute appendicitis, one had early lump formation, and two had grossly normal appendix. All patients were followed up strictly for 2 months postoperatively and no obstetrical complication was recorded.
Conclusion: Diagnosis of acute appendicitis in pregnancy can be difficult; however, surgical intervention should be performed with any suspicion. Fetal morbidity and mortality are high in the presence of perforation and generalized peritonitis. For minimizing the unnecessary delay in diagnosis and surgery, high clinical suspicion can only be supplemented and not replaced by imaging studies. Ultrasound is not only safe in pregnancy but also easily available and affordable. The decision to perform laparotomy should be based on clinical findings and diagnostic imaging. Delays over 24 hours for intervention increase the risk of perforation. We noted no immediate fetal or other major complications in our patients, hence we recommend early surgical intervention in patients with suspicion of acute appendicitis in pregnancy. There is also need for some unequivocal diagnostic scoring system which should be highly predictive of acute appendicitis in pregnancy, early in the course of disease before giving way to complications.

Keywords: Acute appendicitis, Alvarado score, appendectomy, early diagnosis, pregnancy, ultrasound


How to cite this article:
Mir SA, Wani M, Tak SA, Shiekh SH, Moheen HA. Feasibilty of early surgical intervention for acute appendicitis in gravid patients. Saudi Surg J 2017;5:111-5

How to cite this URL:
Mir SA, Wani M, Tak SA, Shiekh SH, Moheen HA. Feasibilty of early surgical intervention for acute appendicitis in gravid patients. Saudi Surg J [serial online] 2017 [cited 2017 Dec 15];5:111-5. Available from: http://www.saudisurgj.org/text.asp?2017/5/3/111/217744




  Introduction Top


Pregnancy is not a reason to delay surgery. Prompt diagnosis is the cornerstone of a good outcome, and early surgical intervention is indicated if acute appendicitis is suspected in pregnancy.[1] Appendectomy is known as the most common nonobstetrical operative procedure in a pregnant patient [2] with an estimated frequency of one case of acute appendicitis per 1500 pregnancy.[3] Pregnancy continues to obscure the accurate diagnosis of acute appendicitis due to gestational physiological changes.[4] The mortality of appendicitis during pregnancy is the mortality of delay.[5]

Acute appendicitis was first diagnosed in 1886,[6] and it is by far most common extrauterine surgical emergency encountered during pregnancy.[7] The diagnosis and management of acute appendicitis in pregnancy can be a challenge because of the nonclassical clinical presentation and the complications of a perforated appendicitis which carries a high rate of maternal and fetal death. Thus, achieving an accurate diagnosis and starting early treatment are crucial to prevent complications.

Acute appendicitis can occur at any time during pregnancy although it occurs most often during the 2nd trimester (45%) and the 1st trimester (30%) and the remaining 25% in the 3rd trimester.[8] The overall incidence being 0.15–2.10 per 1000 pregnancies.[8],[9]


  Materials and Methods Top


This prospective study was carried over a period of 3.5 years from June 2012 to November 2015, in the Postgraduate Department of Surgery, Government Medical College (GMC) Srinagar. Patients included were only those who had features of acute appendicitis on clinical grounds and/or imaging studies (ultrasound). The main bulk of this cohort was constituted by the patients referred from the Lal Ded Hospital (main gynecologic and obstetric hospital of Kashmir valley) and only a few patients reported directly to our hospital. Patients admitted were evaluated properly by thorough history, clinical examination, laboratory investigations, and imaging studies (ultrasound). Alvarado scoring was done in all patients. All patients ultimately included in the study group were operated (appendectomy). Histopathological examination of the specimens was done in the pathology department of GMC Srinagar.


  Results Top


Various variables related to our patients are given in [Table 1] and [Table 2].
Table 1: Various clinical, laboratory, and intraoperative parameters of the patients

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Table 2: Various time variables

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The mean age of the patients was 28.84 years, ranging from 21 to 38 years. The mean gestational age of our patient cohort was 17.4 weeks (6–35 weeks). Majority of the patients presented in the 2nd trimester (55.9%) followed by 1st trimester (29.4%). The Alvarado score of the patients ranged from 5 to 9 (mean 6.76). White blood cell (WBC) count of our patients ranged from 5800 to 22400 (average 14150).

Neutrophill count ranged from 64.4% to 92.2% (mean 79.20%). USG diagnosed twenty patients as acute appendicitis (58.82%) and 14 patients as negative for appendicitis (41.2%) with a sensitivity of 60.6% and specificity of 71.42%.

Intraoperatively, 31 patients (22 inflamed and nine perforated) had features of acute appendicitis [Figure 1], one had early lump formation, and two had grossly normal appendix. Among the two grossly normal appendices, one had acute appendicitis on histopathology examination (HPE). Rest of all patients had acute appendicitis on HPE.
Figure 1: (a) Inflamed appendicitis. (b) Appendectomy performed

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Time in hours between onset of symptom and surgery ranged from 5 h to 48 (mean 15.4). The mean operation time was 55 min (45–115 min). The mean hospital stay was 2.5 days (2–5 days).

Complications

Wound site infection developed in three of the nine patients with perforated appendicitis. The nature of the drain was feculent in one patient with intraoperative finding of appendicular lump which subsided completely by 15th postoperative day.

Follow-up

All patients were followed up strictly for 2 months postoperatively, and no obstetrical complication was recorded during this period. Fetal well-being was monitored by clinical and ultrasound examination. Four patients delivered successfully (two caesarean and two vaginal) during this short course of follow-up.


  Discussion Top


Appendicitis in pregnancy is the most common extrauterine acute abdominal condition with a frequency of 1: 1500 pregnancies.[2],[3] Diagnosis of acute appendicitis in pregnancy is usually not that simple, because its presentation often simulates the nonspecific symptoms of pregnancy itself. Cecum and appendix are progressively pushed to the right upper quadrant of the abdomen as pregnancy develops during the 2nd and 3rd trimesters. However, pain in the right lower quadrant of the abdomen remains the cardinal feature of appendicitis in pregnancy. Fetal loss occurs in 3%–5% of cases, increasing to 20% if perforation is found at operation.[10] In pregnancy, physiologic leukocytosis occurs, and our patients were no exception to this physiologic response.[11] Acute appendicitis has a peak incidence in the second and third decades coinciding with the childbearing years, and the incidence in pregnancy appears broadly the same as in the nonpregnant, whereas the rate of perforation and subsequent complications are greater.[12],[13]

The mean age of the patients was 28.84 years, ranging from 21 to 38 years. The mean gestational age of our patient cohort was 17.4 weeks (6–35 weeks). This was in concordance with the study by Kapan et al.[14]

Majority of the patients presented in the 2nd trimester (55.9%) followed by 1st trimester (29.4%). Our results are consistent with the recent studies showing approximately 30% cases in the 1st trimester and 45% cases in the 2nd trimester.[15]

The Alvarado score of our patients ranged from 5 to 9 (mean 6.76). Similar results were observed in other study by Kapan et al.[14] Diagnosis during pregnancy is made difficult by changes in position of appendix due to gravid uterus, nausea/vomiting, and raised leukocyte count during pregnancy,[16] making the application of Alvarado score less accurate in pregnancy.[17] This implies need for additional investigations such as pelvic examination, USG, and other modalities to reduce negative appendectomy rate in this gender.[18]

WBC count of our patients ranged from 5800 to 22400 (average 14150). Neutrophill count ranged from 64.4% to 92.2% (mean 79.20%). Similar results were observed in other study by Kapan et al.[14]

USG diagnosed twenty patients as acute appendicitis (58.82%) and 14 patients as negative for appendicitis (41.2%) with a sensitivity of 60.6% and specificity of 71.42%. In other studies, sensitivity of USG ranged from 67% to 100% and specificity ranged from 83% to 96%.[19]

Isoxuprine drip was continued for 3 days as a precautionary measure to stall preterm labor with close monitoring of pulse and blood pressure. Drip was monitored with care as isoxuprine causes tachycardia and hypotension.

Intraoperatively, 31 patients (22 inflamed and 9 perforated) had features of acute appendicitis, one had lump formation, and two had grossly normal appendix. Among the two grossly normal appendices, one had acute appendicitis on HPE. Rest all patients had acute appendicitis on HPE.

Time in hours between onset of symptom and surgery ranged from 5 to 48 (mean, 15.4).

The mean operation time was 55 min (45–115 min). The mean hospital stay was 2.5 days (2–5 days). Similar results were observed in the study by Kapan et al.[14]

Wound site infection developed in three of the nine patients with perforated appendicitis. The nature of the drain was feculent in one patient with intraoperative finding of appendicular lump which subsided completely by 15th postoperative day.

All patients were followed up strictly for 2 months postoperatively and no obstetrical complication was recorded. Four patients delivered successfully (two caesarean and two vaginal) during this short course of follow-up. No case of fetal mortality was also encountered in the study done by Kapan et al.[14]


  Conclusion Top


Acute appendicitis in pregnancy is an important issue. Slight reluctance to surgical intervention in pregnancy is observed both on the patient as well as the surgeon side. The reason for this is undue fear of fetal compromise due to surgical intervention. Diagnosis of acute appendicitis in pregnancy can be difficult; however, surgical intervention should be performed with any suspicion. Fetal morbidity and mortality are high in the presence of perforation and generalized peritonitis. Diagnostic difficulties arise because of displacement of vermiform appendix with advancing pregnancy and also presentation of acute appendicitis often resembles the nonspecific symptoms of pregnancy itself. For minimizing the unnecessary delay in diagnosis and surgery, high clinical suspicion can only be supplemented and not replaced by imaging studies. Ultrasound is not only safe in pregnancy but also easily available and affordable. Appendicitis is diagnosed if a noncompressible tubular structure is displayed in the lower right quadrant, with a maximum diameter >6 mm. If clinical and ultrasound findings are inconclusive, magnetic resonance imaging can be thought of, when available. The decision to perform laparotomy should be based on clinical findings and diagnostic imaging. Delays over 24 h for intervention increase the risk of perforation and thus leading to further complications. Delay usually arises because of nonfamiliarity of general surgeons with pregnant patients. We noted no immediate fetal or other major complications in our patients. Hence, we recommend early surgical intervention in patients with suspicion of acute appendicitis in pregnancy. There is also need for some unequivocal diagnostic scoring system which should be highly predictive of acute appendicitis in pregnancy, early in the course of disease before giving way to complications. This will definitely help in overcoming the unnecessary delay in diagnosis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Horowitz MD, Gomez GA, Santiesteban R, Burkett G. Acute appendicitis during pregnancy. Diagnosis and management. Arch Surg 1985;120:1362-7.  Back to cited text no. 1
    
2.
Wittich AC, DeSantis RA, Lockrow EG. Appendectomy during pregnancy: A survey of two army medical activities. Mil Med 1999;164:671-4.  Back to cited text no. 2
    
3.
Mazze RI, Källén B. Appendectomy during pregnancy: A Swedish registry study of 778 cases. Obstet Gynecol 1991;77:835-40.  Back to cited text no. 3
    
4.
Fallon WF Jr., Newman JS, Fallon GL, Malangoni MA. The surgical management of intra-abdominal inflammatory conditions during pregnancy. Surg Clin North Am 1995;75:15-31.  Back to cited text no. 4
    
5.
Tarraza HM, Moore RD. Gynecologic causes of the acute abdomen and the acute abdomen in pregnancy. Surg Clin North Am 1997;77:1371-94.  Back to cited text no. 5
    
6.
Wijesuriya LI. Imaging as an aid to the diagnosis of acute appendicitis. Malays Fam Physician 2007;2:106-9.  Back to cited text no. 6
    
7.
Guttman R, Goldman RD, Koren G. Appendicitis during pregnancy. Can Fam Physician 2004;50:355-7.  Back to cited text no. 7
    
8.
Borst AR. Acute appendicitis: Pregnancy complicates this diagnosis. JAAPA 2007;20:36-8, 41.  Back to cited text no. 8
    
9.
Humes DJ, Simpson J. Acute appendicitis. BMJ 2006;333:530-4.  Back to cited text no. 9
    
10.
Turhan AN, Kapan S. Akut apandisit. In: Ertekin C, Güloǧlu R, Taviloǧlu K, editors. Acil Cerrahi. İstanbul: Nobel Tıp Kitabevleri; 2009. p. 301-16.  Back to cited text no. 10
    
11.
Kilpatrick CC, Monga M. Approach to the acute abdomen in pregnancy. Obstet Gynecol Clin North Am 2007;34:389-402, x.  Back to cited text no. 11
    
12.
Brown JJ, Wilson C, Coleman S, Joypaul BV. Appendicitis in pregnancy: An ongoing diagnostic dilemma. Colorectal Dis 2009;11:116-22.  Back to cited text no. 12
    
13.
Coleman MT, Trianfo VA, Rund DA. Nonobstetric emergencies in pregnancy: Trauma and surgical conditions. Am J Obstet Gynecol 1997;177:497-502.  Back to cited text no. 13
    
14.
Kapan S, Bozkurt MA, Turhan AN, Gönenç M, Alis H. Management of acute appendicitis in pregnancy. Ulus Travma Acil Cerrahi Derg 2013;19:20-4.  Back to cited text no. 14
    
15.
Firstenberg MS, Malangoni MA. Gastrointestinal surgery during pregnancy. Gastroenterol Clin North Am 1998;64:7-11.  Back to cited text no. 15
    
16.
Phophrom J, Trivej T. The modified Alvarado score versus the Alvarado score for the diagnosis acute appendicitis. Thia J Surg 2005;26:69-72.  Back to cited text no. 16
    
17.
Memon ZA, Irfan S, Fatima K, Iqbal MS, Sami W. Acute appendicitis: Diagnostic accuracy of Alvarado scoring system. Asian J Surg 2013;36:144-9.  Back to cited text no. 17
    
18.
Shrivastava UK, Gupta A, Sharma D. Evaluation of the Alvarado score in the diagnosis of acute appendicitis. Trop Gastroenterol 2004;25:184-6.  Back to cited text no. 18
    
19.
Williams R, Shaw J. Ultrasound scanning in the diagnosis of acute appendicitis in pregnancy. Emerg Med J 2007;24:359-60.  Back to cited text no. 19
    


    Figures

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    Tables

  [Table 1], [Table 2]



 

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