Appendicitis in pregnancy
H, 29, was at 32 weeks of gestation. She was counting down the weeks for her first child to be born.
One morning, she was woken up by a severe piercing pain in her stomach. “The pain felt like I was going into labor. It was a consistent, stabbing pain on my right side," she said. She was then rushed to the emergency room of the hospital by her panicky husband straight away. On examination, H was crying in pain. Her body temperature, blood pressure and pulse rate were normal. Her uterus was soft with no signs of labour. Her right upper abdomen was very tender to touch especially when I suddenly released the pressure of my examining hand (rebound tenderness). Her right abdominal wall was very rigid and guarded as well.
The diagnosis of appendicitis was immediately suspected. Ultrasound examination showed an enlarged thickened appendix. This was confirmed by an MRI scan. She was referred immediately to the surgeon who was able to locate the inflamed appendix with laparoscope and remove it successfully without any complication to the mother and the foetus.
How common is appendicitis in pregnancy?
Appendicitis is the inflammation of appendix, which is a finger-shaped pouch that projects from the large intestine on the lower right side of the abdomen. It is the most common, non-obstetric emergency that requires surgery during pregnancy. It is seen in approximately one out of 1,500 pregnancies and commonly happens during the second or third trimester.
What are the symptoms and signs?
In the "classic" presentation of appendicitis in the non-pregnant patient, the onset of abdominal pain is the first symptom. The pain is around the umbilicus (belly-button) initially which then migrates to the right lower quadrant as the inflammatory process progresses. Nausea and vomiting, if present, follow the onset of pain. Fever may develop later.
During pregnancy, the symptoms and signs may be slightly deviated from the classic presentation especially in late pregnancy. This is because some of the symptoms like nausea and vomiting may also be present in early pregnancy. In the last trimester, the pain from appendicitis is located higher up in the upper, rather than in the lower abdomen, as the appendix is being pushed up by the enlarging uterus.
How is it diagnosed?
Besides the medical history and physical examination, blood investigations may reveal a raised white cell count and an elevated inflammation marker, C-reactive protein. Ultrasound scan may show a swollen, thickened non-mobile appendix. An MRI should be done to confirm the diagnosis to avoid an unnecessary surgery.
Early diagnosis is also important as the longer the delay, the more likely the patient may have complications, especially if the appendix ruptures. If this happens, the mother may have blood poisoning (septicemia) which can be life threatening. Premature birth and foetal demise may occur.
What is the treatment?
Surgery is the treatment of choice. If appendicitis happens in the first or second trimester, laparoscopic removal is usually done. In the last trimester, the size of the enlarged uterus may make the laparoscopic surgery difficult and conventional laparotomy may be performed. Postoperatively, the mother must be monitored carefully for premature birth.
H was lucky that the appendicitis was diagnosed early. She felt better after the surgery and was discharged 3 days after the operation. Her antenatal course remained uncomplicated and she delivered vaginally a healthy baby boy at 39 weeks of gestation.
“I feel so lucky that we have caught it(appendicitis) in time,” she said. The thought of the painful episode, however, had lingered in her mind for quite a while.