Acute appendicitis in pregnancy, is there a role for conservative management?

Jane Tian; Tabark Altai; Shubham Bhatia; Youssef Mourad; Andrew Miele; R. Jonathan Robitsek; Katherine Mckenzie; Martine A. Louis; Nageswara R. Mandava

doi:10.18203/2349-2902.isj20240746

Authors

Jane Tian Department of Surgery, Flushing Hospital Medical Center, Flushing, New York, USA
Tabark Altai Department of Medicine, UCSF Fresno, Fresno, California, USA
Shubham Bhatia Department of Surgery, Flushing Hospital Medical Center, Flushing, New York, USA
Youssef Mourad New York Institute of Technology, New York, USA
Andrew Miele Department of Research Education and Innovation, Medisys Health Network, New York, USA
R. Jonathan Robitsek Department of Research Education and Innovation, Medisys Health Network, New York, USA; Department of Surgery, Jamaica Hospital Medical Center, Jamaica, New York, USA
Katherine Mckenzie Department of Surgery, Jamaica Hospital Medical Center, Jamaica, New York, USA
Martine A. Louis Department of Surgery, Flushing Hospital Medical Center, Flushing, New York, USA
Nageswara R. Mandava Department of Surgery, Flushing Hospital Medical Center, Flushing, New York, USA

DOI:

https://doi.org/10.18203/2349-2902.isj20240746

Keywords:

Acute appendicitis, Pregnant, Pregnancy, Surgery

Abstract

Background: Although rare, acute appendicitis is the most common general surgery problem encountered in pregnancy. A chief concern is timely and accurate diagnosis. Traditionally, delayed diagnosis of appendicitis in pregnant patients can quickly lead to appendiceal rupture associated with miscarriage, premature delivery, or even fetal loss. Hence, appendectomy has been the gold standard. However, emerging evidence suggests conservative management may be more effective than previously thought, after accounting for maternal and fetal characteristics.

Methods: This retrospective study included a sample of pregnant women diagnosed with acute appendicitis presenting for treatment to two hospitals in Queens, NY, between Jan 2012 and Dec 2021. The characteristics, presentation, and outcomes of conservatively versus surgically treated patients were compared.

Results: The cumulative incidence of acute appendicitis was 0.11% (n=44/28,000). Forty were treated surgically: 78% underwent laparoscopic appendectomy, 15% open appendectomy, and 8% underwent an initial laparoscopy which was converted to an open appendectomy. Four (14%) patients were managed conservatively with IV antibiotics. Eight percent of patients treated surgically had postoperative complications. Neither surgical nor conservatively treated groups reported any instance of mortality or fetal demise.

Conclusions: Our study adds to the literature on treatment decisions for pregnant patients with acute appendicitis. Although surgical intervention remains the gold standard, it carries the potential risk of peri- and postoperative complications. These findings suggest conservative management with antibiotics can sometimes be used without a negative impact on maternal or fetal outcomes.

Metrics

Metrics Loading ...

References

Cho I, Bae S, Jeong W, and Baek S. Single-port laparoscopic appendectomy for acute appendicitis during pregnancy. J Minimal Access Surg. 2020;17:1.

Burcu B, Ekinici O, Atak T, Eren T, Alimoglu O. Acute appendicitis in pregnancy: Case series and review. N Clin Istanbul. 2015;3(1):60-3.

Baruch Y, Canetti M, Blecher Y, Yogev Y, Grisaru D, Michaan N. The diagnostic accuracy of ultrasound in the diagnosis of acute appendicitis in pregnancy. J Maternal-Fetal Neonatal Med. 2019;33(23):3929-34.

Carstens A, Fensby L, Penninga L. Nonoperative Treatment of Appendicitis during Pregnancy in a Remote Area. Am J Perinatol. 2018;8(1):37-8.

Varadhan KK, Neal KR, Lobo DN. Safety and efficacy of antibiotics compared with appendicectomy for treatment of uncomplicated acute appendicitis: meta-analysis of randomised controlled trials. BMJ. 2012;344(5):e2156.

Di Saverio S, Sibilio A, Giorgini E, Biscardi A, Villani S, Coccolini F, et al. The NOTA Study (Non Operative Treatment for Acute Appendicitis): prospective study on the efficacy and safety of antibiotics (amoxicillin and clavulanic acid) for treating patients with right lower quadrant abdominal pain and long-term follow-up of conservatively treated suspected appendicitis. Ann Surg. 2014;260(1):109-17.

Bhandari T, Shahi S, Acharya S. Acute Appendicitis in Pregnancy and the Developing World. Int Scholarly Res Notices. 2017;2017:2636759.

Wallace CA, Petrov MS, Soybel DI. Influence of Imaging on the Negative Appendectomy Rate in Pregnancy. J Gastrointest Surg. 2008;12:46-50.

Goldberg-Stein S, Liu B, Hahn PF, Lee SI. Body CT during pregnancy: utilization trends, examination indications, and fetal radiation doses. AJR Am J Roentgenol. 2011;196(1):146-51.

Dewhurst C, Beddy P, Pedrosa I. MRI evaluation of acute appendicitis in pregnancy. J Magn Reson Imaging. 2013;37(3):566-75.

Rapp EJ, Naim F, Kadivar K, Davarpanah A, Cornfeld D. Integrating MR imaging into the clinical workup of pregnant patients suspected of having appendicitis is associated with a lower negative laparotomy rate: single-institution study. Radiology. 2013;267(1):137-44.

Nakashima M, Takeuchi M, Kawakami K. Clinical Outcomes of Acute Appendicitis During Pregnancy: Conservative Management and Appendectomy. World J Surg. 2021;45(6):1717-24.

Aggenbach L, Zeeman GG, Cantineau AEP, Hofker HS. Impact of appendicitis during pregnancy: No delay in acute diagnosis and treatment. Int J Surg. 2015;15:84-9.

Chung JC, Cho GS, Shin EJ, Kim HC, Song OP. Clinical outcomes compared between laparoscopic and open appendectomy in pregnant women. Can J Surg. 2013;56:341-6.

Walsh CA, Tang T, Walsh SR. Laparoscopic versus open appendicectomy in pregnancy: a systematic review. Int J Surg. 2008;6(4):339-44.

Jung KT, Kim SH, Kim JW, So KY. Bradycardia during laparoscopic surgery due to high flow rate of CO2 insufflation. Kor J Anesthesiol. 2013;65(3):276-7.

Ott DE. Pneumoperitoneum for Laparoscopic Surgery During Pregnancy. Non-Obstetric Surgery During Pregnancy: A Comprehensive Guide. 2019;85-97.

Pearl JP, Price RR, Tonkin AE, Richardson WS, Stefanidis D. SAGES guidelines for the use of laparoscopy during pregnancy. Surg Endosc. 2017;31(10):3767-82.

Ito K, Ito H, Whang E, Tavakklizadeh A. Appendectomy in pregnancy: evaluation of the risks of a negative appendectomy. Am J Surg. 2011;203(2):145-50.

Thompson MM, Kudla AU, Chisholm CB. Appendicitis during pregnancy with a normal MRI. West J Emerg Med. 2014;15(6):652-4.

Kozan R, Bayhan H, Soykan Y, Anadol AZ, Sare M, Aytac AB. Acute Appendicitis in Pregnancy: How to Manage? Sisli Etfal Hastan Tip Bul. 2020;54(4):457-62.