Feasibilty of early surgical intervention for acute appendicitis in gravid patients

Abstract

Background: Acute appendicitis is the most common surgical non-obstetric pathology during pregnancy. Unnecessary hesitation and hence delay in surgical intervention for acute appendicitis in pregnancy is common. In this background, while attempting early suspicion and surgical intervention (appendectomy) in our patients, we encountered no mortality and no significant morbidity in the in immediate postoperative period. Materials and Methods: This prospective study was carried over a period of 3.5 years from June 2012 to November 2015, in the department of surgery, GMC (Government Medical College) Srinagar. Patients included were only those who had features of acute appendicitis on clinical grounds and/or imaging studies (ultrasound). Objective: Our aim was to study the feasibility of early suspicion and surgical intervention in patients with features of acute appendicitis in pregnancy. Results: The mean age of the patients was 28.84 years, ranging from 21 to 38 years. The mean gestational age of our patient cohort was 17.4 weeks (6-35 weeks). Majority of the patients presented in the 2nd trimester (55.9%) followed by 1st trimester (29.4%). The Alvarado score of the patients ranged from 5 to 9 (mean 6.76). WBC (white blood cell count) of our patients ranged from 5800 to 22400 (average 14150). Neutrophill count ranged from 64.4% to 92.2% (mean 79.20%). USG diagonosed 20 patients as acute appendicitis (58.82%) and 14 patients as negative for appendicitis (41.2%) with a sensitivity of 60.6% and specificity of 71.42 %. Intraoperatively 31 patients (22 inflamed and 9 perforated) had features of acute appendicitis, one had early lump formation, and two had grossly normal appendix. All patients were followed up strictly for 2 months postoperatively and no obstetrical complication was recorded. Conclusion: Diagnosis of acute appendicitis in pregnancy can be difficult; however, surgical intervention should be performed with any suspicion. Fetal morbidity and mortality are high in the presence of perforation and generalized peritonitis. For minimizing the unnecessary delay in diagnosis and surgery, high clinical suspicion can only be supplemented and not replaced by imaging studies. Ultrasound is not only safe in pregnancy but also easily available and affordable. The decision to perform laparotomy should be based on clinical findings and diagnostic imaging. Delays over 24 hours for intervention increase the risk of perforation. We noted no immediate fetal or other major complications in our patients, hence we recommend early surgical intervention in patients with suspicion of acute appendicitis in pregnancy. There is also need for some unequivocal diagnostic scoring system which should be highly predictive of acute appendicitis in pregnancy, early in the course of disease before giving way to complications.