Appendicitis during pregnancy

Abstract

We read with interest the recent study by Mourad et al (Mourad J, Elliott JP, Erickson L, Lisboa L. Appendicitis in pregnancy: New information that contradicts long-held clinical beliefs. Am J Obstet Gynecol 2000;182:1027-9). The study examined 66,993 deliveries, 67 of which (0.1%) were complicated by a preoperative diagnosis of probable appendicitis. The diagnosis was histologically verified in 45 cases, and the appendix was ruptured in 8 cases. Reported complications after appendectomy were preterm contractions in 23 patients and an additional 3 cases of documented cervical change. One delivery occurred in the postoperative period because of abruptio placentae. Mourad et al wrote, “It is necessary to avoid unacceptable delay [before appendectomy], with the possibility of increased morbidity and mortality rates.” First, we are concerned about the inclusion of patients in the study, because it appears that only women with a delivery after appendectomy were examined. What about women with an appendectomy during pregnancy that ended in an abortion? For evaluation of all maternal and fetal complications after appendectomy, these women should be included. Second, it would have been interesting to know the delay from time of onset of symptoms to the appendectomy in relation to maternal and fetal complications.1Hée P Viktrup L. The diagnosis of appendicitis during pregnancy and maternal and fetal outcome after appendectomy.Int J Gynaecol Obstet. 1999; 65: 129-135Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar In a recent study of 117 appendectomies during pregnancy, 50% of the patients had appendicitis and 21 had a perforated appendix.1Hée P Viktrup L. The diagnosis of appendicitis during pregnancy and maternal and fetal outcome after appendectomy.Int J Gynaecol Obstet. 1999; 65: 129-135Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar The obstetric complications were few and appeared only in the group of women with a normal appendix and first after discharge from the hospital.1Hée P Viktrup L. The diagnosis of appendicitis during pregnancy and maternal and fetal outcome after appendectomy.Int J Gynaecol Obstet. 1999; 65: 129-135Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar No significant delay was observed in the group of women with perforated appendicitis. Even after perforated appendicitis during pregnancy, intraperitoneal adhesions or infertility 4 to 9 years after the appendectomy seems insignificant.2Viktrup L Hée P. Fertility and long-term complications four to nine years after appendectomy during pregnancy.Acta Obstet Gynecol Scand. 1998; 77: 746-750Crossref PubMed Scopus (12) Google Scholar Third, it would be of interest to know the interval between the appendectomy and potential complications. We agree with Mazze and Källén3Mazze RI Källén B. Appendectomy during pregnancy: a Swedish registry study of 778 cases.Obstet Gynecol. 1991; 77: 835-840PubMed Google Scholar that if there is an effect of the surgical trauma on the fetal, placental, and uterine elements it should have ceased in uncomplicated cases by approximately 1 week after appendectomy.1Hée P Viktrup L. The diagnosis of appendicitis during pregnancy and maternal and fetal outcome after appendectomy.Int J Gynaecol Obstet. 1999; 65: 129-135Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar Finally, although leukocytosis may be more pronounced in pregnant women with appendicitis than in those with a normal appendix,1Hée P Viktrup L. The diagnosis of appendicitis during pregnancy and maternal and fetal outcome after appendectomy.Int J Gynaecol Obstet. 1999; 65: 129-135Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar this is only a weak indicator of a correct preoperative diagnosis.1Hée P Viktrup L. The diagnosis of appendicitis during pregnancy and maternal and fetal outcome after appendectomy.Int J Gynaecol Obstet. 1999; 65: 129-135Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar We agree with Mourad et al that pain in the right lower quadrant seems to be the most common presenting symptom, regardless of gestational age or the pathologic state of the appendix.1Hée P Viktrup L. The diagnosis of appendicitis during pregnancy and maternal and fetal outcome after appendectomy.Int J Gynaecol Obstet. 1999; 65: 129-135Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar 6/8/112864