Appendicitis, an inflammation of the appendix, is the most common non-obstetric surgical emergency during gestation. The condition affects approximately 1 in 1,500 pregnant women, with the highest incidence observed during the second trimester. While the idea of undergoing surgery while pregnant may cause apprehension, an appendectomy is frequently required to protect both the pregnant individual and the fetus. Prompt surgical removal of the inflamed appendix is supported by medical consensus, as the benefits far outweigh the risks associated with the procedure.
Why Immediate Surgery is Essential
A delay in treatment for appendicitis can rapidly lead to severe, life-threatening complications for the pregnant individual and the fetus. If the inflamed appendix is not removed quickly, it can rupture, releasing infectious material into the abdominal cavity. This progression increases the risk of developing peritonitis, a widespread infection of the abdominal lining, and systemic sepsis.
Pregnant patients face a higher rate of appendiceal perforation, sometimes reaching 55%, compared to the general population. Perforation dramatically increases the risk of inducing preterm labor. Untreated infection and inflammation can also lead to fetal distress and, in severe cases, fetal demise. Therefore, emergency surgery is recommended regardless of the gestational age to minimize these catastrophic outcomes.
Identifying Appendicitis in Pregnancy
Diagnosing appendicitis in a pregnant patient presents a unique challenge because many classic symptoms overlap with the normal physiological changes of pregnancy. Nausea, vomiting, and an elevated white blood cell count (leukocytosis) are common in both early pregnancy and appendicitis. A white blood cell count as high as 16,900 cells per cubic millimeter can be a normal finding in the third trimester, making this traditional indicator less reliable.
The growing uterus physically displaces the appendix, particularly after the first trimester, moving it away from the typical lower right quadrant pain location. Pain may instead present higher up in the abdomen or on the flank, confusing the clinical picture. Physicians rely on a careful physical examination combined with specific imaging modalities to confirm the diagnosis.
Ultrasound is the preferred initial imaging technique because it avoids exposing the fetus to radiation. If the ultrasound is inconclusive, Magnetic Resonance Imaging (MRI) is utilized as the next step, offering high accuracy without ionizing radiation exposure. Computed Tomography (CT) scans are generally reserved as a last resort due to radiation concerns, though low-dose protocols can be employed when other imaging is unavailable or indeterminate.
Adapting the Appendectomy Procedure
Once the diagnosis is confirmed, an appendectomy is performed immediately. The second trimester is generally considered the optimal time for non-obstetric surgery, but the surgical approach must be adapted to accommodate the pregnant uterus. This often requires a multidisciplinary team of surgeons and obstetricians. Laparoscopic appendectomy (LA), a minimally invasive technique, is frequently preferred, offering advantages like a shorter hospital stay and less post-operative pain.
During a laparoscopic procedure, the surgeon must use a modified technique, including maintaining a lower insufflation pressure of carbon dioxide (typically 10 to 12 mmHg) to create space. The placement of the surgical ports is adjusted higher and more laterally as the pregnancy progresses to avoid puncturing the uterus. For patients in the late second or third trimester, or in cases of a severe, perforated appendix, an open appendectomy (laparotomy) may be necessary to ensure clear visualization and control of the infection. Regardless of the method, the patient is positioned with a slight left tilt to prevent the uterus from compressing the vena cava.
Fetal and Maternal Monitoring After Surgery
The post-operative recovery period focuses on maternal healing and minimizing obstetric complications. Continuous fetal monitoring for contractions and fetal heart rate is standard practice immediately following the procedure. This surveillance helps the medical team quickly identify any signs of uterine irritability or fetal distress triggered by the surgery or anesthesia.
If uterine contractions begin, medications known as tocolytics may be administered to suppress preterm labor. The hospital stay is often brief, especially following a laparoscopic procedure, allowing for a faster return to normal activity.