Delayed diagnosis of acute appendicitis in the first trimester of pregnancy leading to adverse pregnancy and maternal outcomes: a case report and literature review

Abstract

Acute appendicitis is the most common non-gynaecological surgical emergency occurring in pregnancy. However, its diagnosis can be challenging owing to similarities in symptoms with pregnancy and unreliability of clinical predictive scoring systems. We present a case of a woman who presented with equivocal symptoms in early pregnancy, which eventually turned out to be gangrenous appendicitis. The case is presented to illustrate the attendant diagnostic dilemmas in these rare cases. We report on a 28-year-old female patient who presented with vomiting, generalised weakness and vague abdominal discomfort progressing to spontaneous miscarriage and dramatic onset of septic shock within 2 days of her admission. Ultrasound scan revealed significant ascites. At laparotomy, gangrenous appendicitis in association with 1500mls of purulent exudate was noted. Appendicectomy was performed followed by saline peritoneal lavage and exploration. The patient had a prolonged postoperative recovery but did well and was subsequently discharged. Acute appendicitis is the commonest non-gynaecological surgical emergency complicating pregnancy with an incidence of 1 in 800-1500 pregnancies. Appendiceal luminal obstruction due to lymphoid hyperplasia or faecolith has been implicated. The absence of typical features and the similarity with symptoms of pregnancy frequently confound the diagnosis. Appendicitis in pregnancy has a diverse spectrum of presentation and infrequently occurs. A high index of suspicion should be maintained in patients with vague abdominal symptoms.