Appendicitis in pregnancy is an acute or chronic inflammation of the appendix that occurs in a woman during gestation, during childbirth or immediately after them. It is manifested by sudden constant or paroxysmal pain of varying intensity in the right abdomen, fever, nausea, vomiting. It is diagnosed by physical examination, transabdominal ultrasound, laboratory blood tests, emergency diagnostic laparoscopy. The treatment is operative with the removal of the appendix and subsequent therapy to prevent complications and possible termination of pregnancy.
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Acute appendicitis is the most common abdominal surgical pathology in pregnant women. It is detected in 0.05-0.12% of women carrying a child. The incidence of inflammation of the appendicular process during pregnancy is slightly higher than in non-pregnant women. Up to 19-32% of cases of acute appendicitis occur in the 1st trimester, 44-66% — in the 2nd, 15-16% — in the 3rd, 6-8% — after the end of labor. There are sporadic cases of inflammation of the appendix in childbirth.
The relevance of considering appendicitis during gestation as a special type of disease is due to the erasure of the clinical picture and its detection at late destructive stages, when the prognosis for mother and child worsens. So, in pregnant women, the gangrenous form of inflammation is observed 5-6 times, and perforative — 4-5 times more often compared with non-pregnant women. It is destructive variants that often provoke the termination of gestation and fetal death.
Appendicitis in pregnancy occurs due to the pathological activation of mixed microflora that lives in the intestinal lumen. The causative agents of the disease are usually anaerobic non—spore-forming bacteria (cocci, bacteroids), less often – staphylococci, enterococci, E. coli. During pregnancy, there are a number of additional factors contributing to the development of appendicitis:
- Displacement of the cecum and appendix. Under the pressure of the growing uterus, the initial sections of the large intestine gradually shift upwards and outwards. As a result, the vermiform process can bend, stretch, its emptying is disrupted, and blood supply worsens. Mobility and atypical placement of the organ prevent the protective adhesive restriction of inflammation.
- Constipation. Up to two-thirds of pregnant women and every third woman in labor have difficulty emptying the intestines. This is due to the deterioration of peristalsis due to a decrease in the sensitivity of the muscle wall to stimulators of contractions and the depressing effect of progesterone. With constipation, the contents of the appendicular process stagnate, and the virulence of the intestinal flora increases.
- Reducing the acidity of gastric juice. Although pregnancy is more characterized by increased acidity, in some patients suffering from chronic hypoacid gastritis, displacement of internal organs leads to an exacerbation of the disease. Gastric juice ceases to perform a protective function, which leads to activation of the microflora of the gastrointestinal tract.
- Violation of immune reactivity. Relative physiological immunodeficiency is one of the mechanisms of protection of the fetus from rejection by the mother’s body. In addition, during pregnancy, antibodies are redistributed to ensure the humoral immunity of the child. An additional factor is the compensatory restructuring of the lymphoid tissue of the cecum.
A combination of occlusive and non-occlusive mechanisms plays a role in the development of appendicitis in pregnancy. In almost two thirds of cases, the disease begins with a violation of the outflow of the contents of the appendix due to constipation, inflection and hyperplasia of lymphoid tissue. In some pregnant women, appendicitis results from ischemia of the displaced process. The gradual stretching of the walls of the organ under the pressure of accumulated mucus, effusion and gases makes it vulnerable to damage by microorganisms living in the intestine. The situation is aggravated by blood supply disorders resulting from displacement and stretching of the organ, as well as initially high virulence of the flora against a background of decreased immunity.
Under the influence of toxins mass-produced by microorganisms, the mucous membrane of the process ulcerates (Aschoff’s primary affect). In response to the action of infectious agents, a local inflammatory reaction begins with the release of a large number of interleukins and other mediators. At first, the process of inflammation is localized in the vermiform process, but the destruction of the muscular layer leads to the rupture of the organ and the involvement of the peritoneum. A feature of appendicitis in pregnancy is a faster generalization due to the displacement of the appendix and immune disorders.
The systematization of the forms of the disease in pregnant women corresponds to the general clinical classification used by domestic abdominal surgeons. It is based on criteria for the severity of pathology, the presence of complications and features of morphological processes occurring in the appendicular process. According to the rate of development, duration and severity of symptoms, acute and chronic (primary or recurrent) appendicitis are distinguished. From a clinical point of view, it is important to take into account the morphological forms of the disease, which are actually stages of its development. There are such variants of inflammation as:
- Catarrhal. The appendix mucosa and its submucosal layer are involved in the inflammatory process. The most mild form of the disease, which lasts about 6 hours and is diagnosed in 13-15% of pregnant women.
- Phlegmonous. The inflammation spreads to the muscle layer and the serous membrane. The prognosis of appendicitis becomes more serious. Appendix phlegmon is observed in 70-72% of cases and lasts from 6 to 24 hours.
- Gangrenous. It is characterized by partial or complete destruction of the appendicular process. Prognostically, the most unfavorable form of the disease. It is detected in 12-17% of patients 24-72 hours after the onset of inflammation.
The comparative increase in destructive phlegmonous and gangrenous forms of appendicitis in the gestational period in relation to the main population is associated with later seeking medical help with erased clinical symptoms. For a more accurate prediction and choice of surgical tactics during pregnancy, it is reasonable to isolate complicated variants of inflammation, in which periappendicular and other abdominal abscesses form, peritonitis, periappendicitis, pileflebitis, abdominal sepsis develop.
In the first trimester, the signs of the disease are almost the same as outside the pregnancy period. The patient usually feels a sudden cutting pain on the right in the iliac region, which is permanent or paroxysmal, can radiate to the lower abdomen and lower back. Sometimes pain first occurs in the epigastrium and only then moves to a typical place. Nausea, vomiting, a one-time disorder of the stool, bloating, hyperthermia, tension of the abdominal muscles, a feeling of lack of air are possible. A late referral to a specialist may be due to the explanation of dyspeptic disorders by early toxicosis, and pelvic pain — the threat of miscarriage.
The specificity of the manifestations of the disease in the II-III trimesters is associated with the displaced location of the appendix, less pronounced pain syndrome and stretching of the muscles of the anterior abdominal wall, complicating the detection of symptoms of peritoneal irritation. Pain syndrome is more often moderate, most patients associate it with developing pregnancy. Usually the pain is localized in the right side of the abdomen closer to the subcostal region.
There is a subfebrile temperature, sometimes nausea and single vomiting occur. The tension of the stretched muscles is hardly caught. Of all the peritoneal symptoms, the symptoms of Obraztsov (increased soreness in the right iliac region when lifting the straightened right leg) and Bartomier-Michelson (increased pain when palpating the cecum in the position of a pregnant woman on the left side) are more pronounced. In general, unlike appendicitis in non-pregnant women, the clinical picture is more often atypical, which complicates diagnosis.
In childbirth, pathology is extremely rare, characterized by an unfavorable course. The pain syndrome characteristic of appendicitis and the tension of the abdominal muscles are masked by contractions. Inflammation of the appendix can be suspected by hyperthermia, weakening or discoordination of labor, preservation and even intensification of pain in the right half of the abdomen in the intercapular period. After childbirth, there is usually a typical course of appendicitis with the occurrence of pain, nausea, vomiting and fever. However, muscle tension is less pronounced, since the abdominal muscles have not yet fully recovered their tone after pregnancy.
Untimely diagnosis of acute appendicitis and delay in removing the inflamed appendix lead to perforation of the process and the development of complicated forms of the disease — peritonitis with severe intoxication, pileflebitis, abdominal abscesses, septic shock. Irritation of the pregnant uterus with inflammatory metabolites and formed adhesions, fever, increased intra-abdominal pressure, instrumental injuries, psychoemotional stress in 2.7-3.2% of cases provoke miscarriage in early gestational terms and premature birth — in late.
After appendectomy, the risk of detachment of the normally located placenta, intrauterine infection of the fetus, the development of chorioamnionitis, fetal hypoxia, labor anomalies, hypotonic bleeding during childbirth and the postpartum period increases. The death of a child with uncomplicated forms of appendicitis, according to various obstetricians and gynecologists, is observed in 2-7% of cases, with rupture of the process it increases to 28-30%, and with peritonitis it reaches 90%. Maternal mortality in acute inflammation of the appendix is 1.1%, which is 4 times more than in patients without pregnancy.
The correct diagnosis of appendicitis at the prehospital stage is established only in 42.9% of cases of the disease, in other patients the threat of termination of pregnancy is assumed. Late diagnosis and untimely operation worsen the prognosis of inflammation. Physical examination in pregnant women is less informative. When using traditional methods of diagnosis in patients with possible appendicitis, it is necessary to take into account a number of features due to the specifics of the gestational period:
- Blood test. The diagnostic value of laboratory diagnostics of appendicitis in pregnancy is low. The increase in ESR and leukocytosis characteristic of the disease can be observed during the physiological course of gestation. It is recommended to evaluate the results obtained in dynamics. The probable inflammation of the appendix is indicated by a rapid increase in inflammatory changes in the blood.
- Ultrasound of the abdominal cavity. Normally, the vermiform process is not visualized. In appendicitis, it is defined as a hyperechoic non-perestalting formation with a diameter of 6.0-10.0 mm with a thickened wall emanating from the cecum. The sensitivity of the method reaches 67-90%. If necessary, ultrasound is supplemented with dopplerometry, which allows you to detect an area of inflammation in the abdominal cavity.
- Diagnostic laparoscopy. Although using an endoscope, the appendix can be fully visualized in 93% of cases, there are a number of limitations for using the method. Usually, the procedure is prescribed for atypical course of inflammation up to 16-18 weeks of pregnancy, as well as after childbirth. In the second half of gestation, an enlarged uterus prevents an effective examination of the appendix and the dome of the cecum.
Taking into account clinical data and research results, acute appendicitis that occurred during pregnancy can be detected in time in 57.0-83.5% of cases. Depending on the gestational timing, differential diagnosis of appendicitis is carried out with early toxicosis, the threat of miscarriage, ectopic pregnancy, pyelitis of pregnant women, torsion of the leg of the ovarian cyst, acute gastritis, perforation of gastric or duodenal ulcers, cholecystitis, pancreatitis, renal colic, pyelonephritis. A surgeon must be connected to the management of a pregnant woman with suspected inflammation of the appendix. According to the indications, the patient is consulted by a gastroenterologist, hepatologist, urologist, nephrologist, anesthesiologist-resuscitator.
Treatment of appendicitis in pregnancy
If signs of inflammation of the appendicular process are detected in a pregnant woman, urgent hospitalization and appendectomy are indicated, regardless of the gestational age. The duration of observation of the patient should not exceed 2 hours, during which it is necessary to conduct a differential diagnosis and determine the volume of surgical intervention. The main therapeutic goals for appendicitis in a pregnant woman are:
Appendectomy. Laparoscopic surgery is preferred before the 18-week period and after delivery. In other cases, laparotomy is performed through a lower median incision or a modified access corresponding to the presumed location of the displaced caecum with an appendicular process. During appendectomy, it is necessary to create conditions for a thorough revision of the abdominal cavity and its drainage according to indications. If appendicitis is diagnosed in childbirth, with normal labor and catarrhal or phlegmonous inflammation of the appendix, intervention is carried out at the end of labor with a shortening of the period of exile. The presence of a gangrenous or perforating process clinic serves as an indication for simultaneous cesarean section and removal of an inflamed appendix.
Prevention of complications and termination of pregnancy. To eliminate postoperative intestinal paresis, pregnant women who have undergone appendectomy are prohibited from prescribing proserin, hypertensive enemas, hyperosmotic sodium chloride solution, which can provoke contractions of the myometrium. Usually, diathermy of the solar plexus is used to restore intestinal peristalsis in the early stages of gestation, and in the later stages — the lumbar region. In the 1st trimester of pregnancy, antispasmodics are used for preventive purposes, progestins— if necessary, and tocolytics in 2-3 trimesters. Antibacterial drugs are indicated to prevent infectious and inflammatory complications. The volume of antibiotic therapy after surgery is determined by the prevalence of the process.
Prognosis and prevention
The prognosis of appendicitis depends on the time of its detection, the gestation period, the speed of decision-making on the operation and the correctness of pregnancy support in the postoperative period. The later treatment is started, the higher the probability of losing a child and complicated appendicitis. With an increase in the gestational period, the probability of a fatal outcome in a pregnant woman increases, after 20 weeks, the frequency of termination of gestation increases by 5 times.
Although the primary prevention of appendicitis has not been developed in detail, during pregnancy it is recommended to correct the diet to ensure good digestion and prevent possible constipation, compliance with the diet with the exception of overeating, sufficient motor activity, timely treatment of chronic gastrointestinal diseases. In case of sudden appearance of any unusual abdominal pain, an urgent consultation of a specialist in abdominal surgery or obstetrics and gynecology is necessary for early diagnosis of the disease and prevention of complications.