APPENDIX

                                                      APPENDIX

       

     Appendicitis is the most common non- obstetric surgical complication and the most common gastrointestinal disorder  requiring  surgery during pregnancy. It accounts  for 25 percent of surgeries for non- obstetric  indications in  pregnancy and complicates every  1 in 1500 to 2000 pregnancies. The incidence of perforated  appendicitis in pregnant women is 43 percent compared to 4-9 percent in the non- obstetric  population.  This increased  incidence may be due to delay in diagnosis and reluctance to operate in pregnancy. Maternal and fetal morbidity and  mortality correlate with perforation and  its associated complications. Uncomplicated appendicitis has a 3-5 percent  fetal loss rate with negligible maternal mortality. Appendix perforation, however, is associated with a 20-35 percent fetal loss rate and 4 percent maternal mortality. Appendix  perforation , however , is associated  with  a 20-35 percent  fetal  loss rate and 4 percent  maternal  mortality. Maternal  mortality rates have  dropped  significantly in the  recent  years with prompt surgical  intervention , newer antibiotics and  surgical  techniques. 

      The preterm contractions  caused  by  uterine irritation from perforation peritonitis result in preterm delivery in 5-14 percent. This incidence is similar between  open  and laparoscopy. In the  first trimester the  appendix remains in its  normal anatomic  position. The appendix  undergoes progressive displacement cephalad  and laterally with advancing pregnancy. After 24 weeks gestation, the  appendix is shifted superiorly  above the right iliac crest , and the tip of the appendix is rotated  medially toward the uterus. By  late pregnancy, the appendix may be closer to the gallbladder than MCBurney's point, occupying the right upper quadrant . This change may alter the location of the pain, making diagnosis difficult. As the  peritoneum is displaced  from the appendix  and cecum by the growing uterus, the increased separation of  the visceral  and parietal peritoneum  decreases  the somatic  sensation of pain and compromises the ability to  localize pain  on examination. The enlarging uterus interfere with the ability  of the omentum and bowel to wall off the inflamed appendix.  Diffuse peritonitis from perforation is  facilitated by this inability of the omentum to isolate the infection. The appendix  returns  to its normal  position by the tenth postpartum day. However, modern clinical experience does not confirm this assertion, with recent studies demonstrating  that the most frequent  location of pain  remains in the right lower quadrant, regardless of trimester. 

               

     Symptoms of appendicitis often  are confused with normal  pregnancy related conditions, particularly in the third trimester. Pain in the right lower quadrant is the most  common and reliable symptom  of appendicitis along with the usual features of appendicitis. Rectal  and pelvic tenderness may not be present when the appendix  is displaced by the uterine enlargement. Leukkocytosis is normal in pregnancy  and so not a good  indicator. Ultrasound Scan is useful  in the first  and second trimester. MRI is safe in pregnancy . CT  Scan should be reserved for cases where Ultrasound and MRI are non- diagnostic. Despite reluctance to operate on a pregnant patient, immediate surgical  intervention is indicated when a  diagnosis of appendicitis is made. The choice of surgical procedure is  based on uterine size and experience  of the  surgeon.  The only indication  of delay  is active labor, and in these  cases the surgery is performed immediate  postpartum.

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      Diagnostic and operative  laparoscopy  is reasonable  before 20 weeks gestation  and is as safe as open surgery. When  performing  laparoscopy  open entry(Hassan)  is preferable to avoid inadvertent veress or trocar  entry into uterus. Trocar placement  needs to be changed according  to the  size of the uterus. Beyond the late second trimester, laparoscopy  becomes more technically challenging . Appendicitis is confirmed in 36-50  percent of cases. Accuracy of diagnosis  in the  first trimester is greater.  A higher false positive rate is acceptable  in pregnant women, because  any delay in diagnosis may compromise maternal and fetal  well - being .