Appendicitis During Pregnancy Does Not Always Require Surgery

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We have discussed appendicitis in the past on The Pulse, and, if you are like most people, you may have the idea that when appendicitis is acute (severe with a sudden onset) it’s an emergency that always requires surgery. It certainly is always an emergency, but the past few years have seen an accumulation of evidence that many people with acute appendicitis do just fine if they are treated non-operatively, which means a regimen of antibiotics. The rationale for this is that appendicitis —meaning an inflamed appendix (a sac-like appendage of the colon, the large intestine)— results from the appendix becoming infected infected with bacteria. The idea that an inflamed appendix must always be removed dates back to the late 19th century, when surgeons began performing appendectomies routinely as a way to prevent death of a patient that would result if a swollen appendix perforated, causing a very serious condition called peritonitis, or if an abscess developed without peritonitis. In those days, there were no antibiotics, nor would there be for most of a century the particular types of antibiotics that must be given to have a good chance of defeating appendicitis without operating. The situation is analogous to tonsillitis. In the past, many more children had their tonsils removed than needed to have them removed in the mid to late 20th century when appropriate antibiotics were available and used frequently. Today tonsillectomies are still performed, but the threshold for performing them is a little stricter than it was 50 years ago.

Similarly, what the evidence is showing today is that cases of acute appendicitis without complications, meaning simple, acute appendicitis, can be treated with certain regimens of antibiotics, with a success rate of about 70 percent. This means that in about 70 percent of people who receive the right kind of antibiotics on the correct schedule to treat uncomplicated appendicitis, the appendicitis will not recur. The success rate varies among people of different ages and situations, but pregnant women fit into the picture. Non-operative treatment is possible and may succeed, and, even if the appendicitis does recur, it may not recur until long after pregnancy. Many years ago, when the antibiotic treatment was first developed, it had consist of only intravenous antibiotic treatment for many days. Now, however, the non-operative, medical strategy has progressed to the point that there is good success with regimens that require intravenous antibiotics only initially and then you go home with antibiotics that you take as pills. This is particularly good news for pregnancy, because, while appendicitis is usually a very straightforward diagnosis, pregnancy is one of the situations that complicates the diagnosis.

We said that above that the non-operative option applies only to simple, meaning uncomplicated, cases of appendicitis. We need to discuss what the possible complications would be that change the situation from one in which you can discuss two treatment options with your surgeon and obstetrician and select either surgical or medical treatment to a situation in which you must have surgery to remove your appendix. First, though, let’s go through more detail on what appendicitis actually is. Appendicitis means inflammation of the vermiform appendix. Symptoms of acute appendicitis include abdominal pain. In non-pregnant women, the pain typically begins gradually around the navel (dull, periumbilical pain) and over a period of 12-48 hours moves to the right side of the lower abdomen, but pain is often less severe when appendicitis occurs during pregnancy. Also, the location and movement of the pain can be very different during pregnancy since the pressure from the growing womb pushes the appendix into different areas of the abdomen, and the location changes as pregnancy progresses. In particular, growth of the uterus shuffles the internal organs, pushing the appendix upward, toward the end of the second trimester so appendicitis pain is often in the upper right part of the abdomen during pregnancy. Along with modifying the pain during pregnancy, the relocation of internal organs also changes the usual signs that surgeons can expect to find when examining the abdomen for possible appendicitis. Apart from pain, symptoms of appendicitis also include nausea, anorexia (lack of appetite), vomiting, fever, increase in urination, and painful urination.

In assessing patients for possible appendicitis, doctors will order blood tests to see if the number of white blood cells in the blood is elevated. This test is not so useful for diagnosis of appendicitis during pregnancy since the white blood cell count typically rises in pregnant women anyway. Therefore, what usually leads to a diagnosis of appendicitis in pregnancy is abdominal ultrasound examination, revealing that the appendix is swollen. If the ultrasound imaging does not give a clear result, doctors will order magnetic resonance imaging (MRI) of the abdomen to get a better look inside. Actually, neither ultrasound, nor MRI, is the best way to image the appendix in order, not only to confirm that it is inflamed, but also to assess complications, which, as we noted above, make all the difference in determining whether or not non-operative treatment could be an option. The best imaging is actually computed tomography (CT). Doctors try to avoid this during pregnancy, because it exposes your abdomen to ionizing radiation, but actually for appendicitis it only needs to be low dose abdominal CT, so there actually is controversy over the benefits versus the drawbacks, and it’s possible that the attitude will change soon.

Complications of appendicitis that must be ruled out, if you are to avoid surgery are:

  • Perforation, meaning a hole opens in the appendix, which can allow the infection to spread through the abdomen and pelvis. This can lead to an abscess, to peritonitis, or to sepsis.
  • An abscess on or near the appendix, or elsewhere in the abdomen: this is basically, a swollen accumulation of pus.
  • Evidence of a possible tumor in or near the appendix.
  • An appendicolith: This is a calcified deposit within the appendix and here is where abdominal CT comes in very handy, because it is particularly good and revealing calcified structures. It does this better than MRI and ultrasound.

Getting the diagnosis correct is important, not only because of the need to reveal complications making surgery necessary, but also because, if appendicitis is diagnosed falsely, then surgery will be performed for nothing. That is certainly something you’d want to avoid as it would put the fetus at unnecessary risk. Even so, appendectomy is a very routine and safe operation, so you should not be distressed in the event that you do need surgery. Usually, the procedure is performed laparoscopically, meaning that just a few very tiny incisions are made in your abdomen and the appendix is pulled from your body through a narrow tube. Recovery is fairly rapid, so if you are struck with a case of uncomplicated appendicitis when you are not pregnant, or even when you are pregnant, you may very well decide to have the surgery, even if it’s an uncomplicated case, since the success rate of non-operative treatment is significantly below 100 percent, and by having your appendix removed, you won’t have to think about appendicitis again.

David Warmflash
Dr. David Warmflash is a science communicator and physician with a research background in astrobiology and space medicine. He has completed research fellowships at NASA Johnson Space Center, the University of Pennsylvania, and Brandeis University. Since 2002, he has been collaborating with The Planetary Society on experiments helping us to understand the effects of deep space radiation on life forms, and since 2011 has worked nearly full time in medical writing and science journalism. His focus area includes the emergence of new biotechnologies and their impact on biomedicine, public health, and society.

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