Appendicitis during pregnancy: signs, consequences, what to do

Inflammation of the appendix of the cecum and its prompt removal (appendectomy) are the most common reason for providing emergency surgical care to the population, part of whom are pregnant women. It is this cause in most cases that causes them to lie under the surgeon's knife to save life for themselves and their child. Can there be appendicitis in pregnancy? Of course, like any other disease.

Therefore, the pregnant woman, who is concerned about abdominal pain, must immediately contact the medical institution without delay (the account goes for hours). Consultations of a gynecologist and surgeon are mandatory in this case, it is very risky to refuse hospitalization in this case.

To alleviate pain analgesics can not in any case, only antispasmodics are allowed, for example, No-shpa. However, it is even better not to take anything, but rather to be under medical supervision.

[1], [2], [3], [4]

Epidemiology

Inflammation of the appendix rightfully belongs to the pathologies of a young age - more than seven out of ten patients operated for appendicitis were no older than 35 years. Young women operate about three times more often than men. The proportion of pregnant women among patients with appendicitis is between 0.5 and 4%. Cases of inflammation of the appendix are found in one or two women from 1000-10 000 pregnant women. Almost half of all cases occur in the second trimester of pregnancy.

[5], [6]

Causes of the appendicitis in pregnancy

Normally, the intact mucosa of the appendix is an insurmountable barrier to pathogenic and opportunistic flora. Its permeability increases with massive microbial invasion, weakening of local immunity, mechanical damage or obstruction of the lumen, leading to overflow of chyme in the appendix and stretching of its walls, ischemic processes in the blood vessels of the appendix of the cervical appendage of the cecum.

The exact causes of the inflammation of the appendix are not yet fully understood, however, the infectious theory prevails over others. In most patients, histological examination of the tissues of the remote appendix shows colonies of microbes that migrated from the intestine. Penetration of pathogenic flora with blood or lymph is extremely rare and is not considered a path of infection.

In the appendix are found a variety of microorganisms, which colonized it and caused the inflammatory process. The vast majority of detected infectious agents (more than 90% of cases) are non-spore anaerobic bacteria. Colonies of aerobic bacteria (Escherichia coli, Klebsiella, Enterococcus and others) are also found, but much less often.

In isolated cases, the source of infection may be helminths that have penetrated the appendix, which is more typical for children; cytomegalovirus, tuberculous mycobacterium, dysentery amoeba (these pathogens are often found in the inflamed appendix in AIDS patients).

Risk factors that contribute to the development of inflammation of the appendix during pregnancy:

• active growth of uterine size, contributing to the displacement of the organ, its compression and disruption of blood circulation in its vessels;
• a natural decrease in immunity during the period of gestation, reducing the ability of lymphoid tissue to kill pathogens;
• the predominant use of foods poor in food fibers (fiber), which leads to constipation and the formation of fecoliths;
• a natural change in blood composition during pregnancy, which increases the risk of thrombosis;
• anatomical features of the location of the appendix, which exacerbate the effect of the factors listed above.

[7]

Pathogenesis

The main pathogenetic link leading to the development of inflammation of the appendix is the narrowing of its lumen (about 2/3 of the cases), which disrupts the outflow of secreted mucus and contributes to the overflow of the cavity of the appendicular process. At a young age, narrowing is caused, as a rule, by an increase in lymphoid follicles. The presence of fecoliths (fecal stones) is found in more than a third of cases of inflammation of the appendix. Much less often as pathogenetic links foreign bodies, parasites, and tumors are considered. In pregnant women, in addition to the general foundations of pathogenesis, displacement, compression, or bending of the appendix may accompany the enlargement of the uterus.

So, the mucus continues to be produced, gas formation and exudation occur, and their outflow decreases or stops, which causes an increase in pressure on the walls of the process, their extension. As a consequence, the venous blood flow is disrupted, and then the arterial blood flow. In the conditions of hypoxia of the appendix wall, rapid multiplication and colonization by microbes of its internal cavity begins. The products of the vital activity of bacteria damage the epithelium, ulcers appear on the mucous membrane, the so-called primary effect of Aschoff. Immunocytes, responding to the activity of bacteria, produce anti-inflammatory mediators that limit the inflammatory process in the initial stage by appendicitis, preventing the development of the systemic process.

Further development of immunoregulators of local action promotes deepening of destructive transformations in the appendicular wall. When the muscle layer is necrotic, approximately one-half of the patients perforate the appendix wall. This is facilitated by the presence of fecal stones in it. Perforation leads to the development of complications - peritonitis or the formation of a periapendicular infiltrate.

In the pathogenesis of non-occlusive forms of the disease, primary ischemia of the appendix is considered because of insufficient arterial blood flow to meet the needs of the process. Changing the composition of the blood during pregnancy - an increase in the thrombus-forming component fits perfectly into the picture of thrombosis feeding the organ of the vessels.

The pathogenesis of the development of acute inflammation of the appendix is also considered as a consequence of an allergic reaction in the appendix of an immediate or delayed form. Their local manifestations in the form of constriction of vessels and disturbance of the structure of the wall of the appendix allow the pathogens from the intestine to affect its tissues and migrate with the lymphatic drainage. The response to the introduction and development of pathogenic microorganisms is edema of the mucous membrane, which causes a decrease in the volume of the cavity and the diameter of the lumen of the appendix, the tissues of which undergo ischemia, hypoxia and purulent necrotic transformations.

The consequence of the further course of the inflammatory process is the development of complications. When the whole thickness of the appendix wall is affected, the adjacent part of the peritoneum and nearby organs are involved.

If one of the most important peritoneal abilities works, to protect themselves from spilled peritonitis by means of dissociation of purulent exudate due to closely related inflammatory organs, a periapendicular infiltrate is formed (the inflamed appendix as a case covers the connection of the joint organs and tissues in the area of local inflammation). This conglomerate protects the focus of inflammation from the rest of the peritoneum. After a certain period of time, the infiltrate dissolves or the inflammatory process develops with the formation of an abscess.

Progress of the disease without connecting the mechanism of delimitation leads to the development of diffuse peritonitis.

With thrombosis of vessels and ischemia of the appendicular shell, the gradual dying of the tissues ends with gangrene, extending to the mesentery loop, where the veins are also thrombosed and ascending septic thrombophlebitis reaching the portal vein and its branches (pylephlebitis). This complication is extremely rare (5 out of 10,000 cases of appendicitis), however, is one of the most formidable.

[8], [9], [10], [11]

Symptoms of the appendicitis in pregnancy

The symptomatology of appendicitis inflammation in women bearing a baby varies, sometimes very significantly, because of the physiological, hormonal and metabolic rearrangements occurring in the body during this period. The main symptom of inflammation is pain, which starts suddenly and does not allow you to forget about yourself. In the first trimester, when the growing uterus does not yet have a significant effect on the location of the abdominal organs, the localization of pain is normal. The first signs are felt in the upper part of the abdomen above the navel or just the stomach hurts without specific localization. Abdominal discomfort is accompanied by swelling and bursting of the abdomen, the gases go off badly or do not go away at all. Pain in appendicitis during pregnancy can be intense or moderate, persistent or paroxysmal. After a short period of time, pain migrates to the appendicular appendix. The classical version is on the right in the lower quadrant of the abdomen. Appendicitis in early pregnancy is symptomatically similar to that of other patients.

With the growth of the uterus, the cecum and its process are shifted upward, the abdominal wall is raised and moved away from the appendix. In this regard, women in the second half of pregnancy usually complain of pain on the right opposite the navel, and sometimes above under the ribs. With a high location of the appendix, symptoms resembling gastritis may appear.

Probable and pain in the zone of the waist, reminiscent of the kidney. With pelvic localization of the appendix, a clinic resembling cystitis can be observed - rapid urine excretion in small portions, pain radiating to the bladder, perineum and right leg.

It is worth paying attention to the fact that for inflammation of the appendix, a characteristic feature is the intensification of painful sensations when coughing, walking, shaking, turning on any side. Appendicitis in late pregnancy more than half of patients is not manifested by the musculature of the anterior wall of the peritoneum because of its progressive relaxation; in others, this tension is very weak and practically not felt. Other symptoms of irritation of the anterior abdominal wall may also be absent.

Pain in the initial stage of appendicitis in most cases is characterized by moderation. This corresponds to a superficial or catarrhal process, when only the mucosa of the appendix is involved. Usually this stage corresponds to the first six to twelve hours from the onset of the onset of the pain syndrome.

When filling the appendix with pus (phlegmonous appendicitis) and stretching it due to it, the pain syndrome becomes intense. The nature of pain can change to cramping, pulsating. At this stage, the submucosal and part of the muscular layer is already involved in the process. In time this corresponds to the second half of the first day after the onset of the first symptoms (12-24 hours).

Gangrenous changes, which usually occur on the second day (24-48 hours from the onset of pain) lead to the death of nerve endings, and the pain for some time abates (imaginary improvement). Then there is a sharp increase in it, it can be a sign of the perforation of the appendage and the onset of inflammation of the peritoneum - a very dangerous condition for the pregnant woman and the fetus.

Constant completely moderate nausea and lack of appetite can begin and up to pain, however, a pregnant woman, especially with early toxicosis, this condition is unlikely to alert. But in conjunction with the pain, it must already be made to consult a doctor.

Severe nausea and one-two-time vomiting begins after the onset of pain and is the body's response to pain. Vomiting masses with inflammation of the appendix contain bile, if it is not, it is most likely that vomiting is caused by another cause (exacerbation of cholecystitis, a violation of the outflow of bile). If the patient has multiple emetic urges and permission does not bring relief, this is a bad sign of a complicated appendicitis. And vomiting before the onset of pain calls into question the diagnosis of appendicitis.

The lack of appetite almost always accompanies the inflammation of the appendix. Also, the constant symptoms include delayed bowel movements due to intestinal paresis.

Much less often there is a loose stool or cutting (pulling) pain in the rectum and vain desires for defecation, not accompanied by emptying of the intestine. This symptomatology is typical for the medial or pelvic location of the appendix.

Patients with appendicitis often complain of dryness of the oral mucosa. They have a white coating on the tongue and a characteristic blush.

Subfebrile in the first day is observed in about half of patients, the temperature above 38 ℃ is a sign of complication of the appendix inflammation or the development of intestinal infection.

[12], [13], [14]

Stages

The stages of classical development of acute appendicitis at a young age are often accompanied by the following order of appearance of symptoms:

• discomfort in the abdomen, swelling, indeterminate pain over the navel or near it;
• absence of appetite, nausea, vomiting no more than once or twice;
• migration of pain to the right lower quadrant of the abdomen (in the second half of the pregnancy the pain is usually localized on the right, but somewhat higher);
• the tension of the peritoneal musculature in the right ileum (in pregnant women, especially in the second half of pregnancy, this symptom is weak or not expressed at all);
• subfebrile temperature (may not be);
• high level of leukocytes in a general blood test.

In surgery, the following types of inflammation of the appendix of the cecum are common: acute and chronic. The second type is treated as a consequence of the first, resulting in recovery without surgery, however, counting on the process's timing is not worth it. The cold form of appendicitis after the first attack is called residual, after two or more exacerbations - recurrent. The existence of the primary chronic form of the disease raises doubts in most practicing surgeons who consider such a conclusion as a diagnostic error.

Acute appendicitis in pregnancy is characterized by the expressed above described symptoms and is divided into uncomplicated and complicated. The most mild form is superficial or catarrhal appendicitis. Uncomplicated forms also include purulent (phlegmonous) appendicitis and not perforated gangrenous. The main symptoms that are recommended to pay attention are the suddenness of the onset of the attack, pain in the right side of the abdomen and a painful reaction to palpation in this place.

Inflammation of the appendix of the caecum can be complicated by perforation, infiltration, peritonitis, abscesses of various locations, sepsis and pylephlebitis. In this case, the symptomatology is much harder - pulse and breathing becomes more frequent, it becomes superficial, because with deep inhalation pain increases. There are other signs of systemic intoxication. Since it is complications, and not an operation to remove an inflamed appendix, that pose a real threat to the life of the child and mother, then the doctor's appointment at the first alarming signs, early diagnosis and surgery allows saving the life of the child and causing minimal damage to the health of both.

Chronic appendicitis during pregnancy is often exacerbated. Usually, during a period of exacerbation, the patients complain of pains concentrated in the right side of the abdomen, radiating in the leg from the same side, and also - pains can be felt in the epigastric zone. Pregnant worried about the symptoms of colitis - frequent constipation, occasionally alternating with diarrhea.

[15], [16]

Complications and consequences

Since any intervention, much less an operation under anesthesia, is associated with a certain risk during pregnancy, then the decision to conduct it should be considered, since an unnecessary operation can have negative consequences for the child. However, long-term follow-up of a pregnant woman with symptoms of appendicitis is also undesirable, as it leads to complications of the disease and an increase in the volume of the operation.

Especially insidious gangrenous appendicitis, in which necrosis destroys the nerve endings of the body, and the pain for a while ceases, which can cause the future mother to announce an improvement in well-being and refuse surgical treatment. The lost time will turn into a perforation of the appendix and further aggravate the situation. With complications in the form of diffuse peritonitis, the probability of abortion is high.

Peritonitis often turns into sepsis, which is fatal.

The triggered appendicitis is complicated by the formation of retroperitoneal phlegmon, abscesses of various localizations in the cavity of the peritoneum.

Very rarely, inflammation of the appendix can be complicated by septic thrombophlebitis of the portal vein and its branches. Rapid progression of the complication leads to the development of hepatic-renal dysfunction and patient's death, slow - allows to take measures to save the patient. In this case, completely remove the mesentery of the process of the cecum. However, pregnancy can not be maintained.

Timely operation is much safer. Pregnant women, whom she was held before the onset of complications, recover quickly and often give birth on their own. When performing diagnostic or operative laparotomy, the future mother will be prescribed a course of antibiotic therapy to prevent infection and development of peritonitis.

Complications of the operation performed are uncomfortable sensations when the surgical suture is cut from appendicitis during pregnancy.

After the operation, there may be proliferation of fibrous tissues - adhesions from appendicitis during pregnancy. Their formation directly depends on the volume of the operation, with a clean operation without infectious complications or laparotomy, adhesions usually do not form. In the case of extensive interventions, the likelihood of adhesions increases to 60-80%. If you pull the seam after appendicitis during pregnancy, this symptom may indicate a high probability of adhesions.

A rare, but possible consequence of an operation performed in the first trimester of pregnancy is fetal death. However, a much higher probability of his death as a result of perforation of the appendix and septic peritonitis.

Operations in the second and third trimester can provoke premature birth, however, in most cases, timely interventions for apendectomy in a future mother end safely for her and the baby. Postoperative complications usually develop in the first week more often with advanced stages. Occasionally, surgical treatment is complicated by premature detachment of the normally located placenta. There may be inflammation of the amniotic membranes (chorioamnionitis) or intrauterine infection of the fetus, requiring special therapeutic measures. The rest of the period until the birth of a woman who has undergone apendectomy is under the close attention of doctors, the purpose of which is her successful delivery in due time.

[17],

Diagnostics of the appendicitis in pregnancy

Establish an accurate diagnosis of the inflammatory process that occurs in the appendix, only according to clinical symptoms and complaints of the future mother is quite difficult. The symptomatology of an acute abdomen is similar to many physiological manifestations of pregnancy. The diagnostic features are determined by the period of bearing of the child, the location of the process of the cecum and the stage of development of the inflammatory process, the suspicion of which arises when the patient complains of a sudden onset and not passing, often increasing, pain in the right side of the abdomen.

In the first months of pregnancy, the diagnosis of appendicitis in women bearing a baby does not differ from the generally accepted one. As the uterus grows, the same diagnostic measures are carried out - physical methods, analyzes, instrumental research, but the results are analyzed taking into account the gestational age and its possible impact.

Pregnant women are characterized by various complaints related to the functioning of the stomach and intestines, discomfort in the area of these organs, nausea and vomiting due to the high level of sex hormones, so they are taken into account, but they do not represent a diagnostic value.

In addition, during pregnancy, the blood formula changes somewhat - it does not cause surprise that the level of leukocytes exceeds the norm, anemia, distortion of the inflammatory response. Nevertheless, the patient is given a blood test, the white blood cell count in pregnant women usually exceeds 15 × 10⁹g / l.

Analyze the composition of urine under a microscope, in which erythrocytes, leukocytes and bacteria are sometimes found in the urine, indicating the pathology of the urinary organs. When appendicitis, urine microscopy is usually recorded within the normal range.

Approximately to the fourth-fifth month of gestation, the location of the process of the cecum changes because of the displacement of its growing uterus. The musculature of the abdomen is stretched and relaxed, so the symptoms of irritation of the peritoneum are not indicative. During the examination, attention is drawn to the sudden onset of pain in the right side of the abdomen, increased pain when turning from left to right, and preserving the localization of the most severe pain when turning in the opposite direction. More than a third of patients show a frequent pulse, about a fifth - a high temperature. Complaints about frequent constipation and the intake of laxatives, attacks of appendicitis in the anamnesis (even before the onset of pregnancy) are taken into account.

For visualization of the appendix and differentiation with other pathologies, instrumental diagnostics - ultrasound and magnetic resonance imaging - is used. Radiography to pregnant women is not indicated. The most informative method of diagnosis is laparoscopy, which allows you to see the appendix on the camera screen and other organs of the peritoneum. The diagnostic measure often turns into the process of removing the process of the cecum.

According to the collected history, differential diagnosis is carried out. Other diseases that cause symptoms of an acute abdomen, such as apoplexy of the ovary, torsion of the leg of the ovarian cyst, pyelitis, infringement of the stone in the bile ducts, perforation of the stomach ulcer, intestinal obstruction are excluded. In the first trimester, it is vital to distinguish between conditions such as right ectopic pregnancy and appendicitis requiring emergency surgery and having similar symptoms. With ectopic pregnancy, the pain syndrome is usually more pronounced up to shock, symptoms of internal hemorrhage appear, the character of the pain radiating to the scapula, paroxysmal, and also the palpation of the abdomen is less painful. Pain in inflammation of the appendix is more moderate, does not radiate and is permanent in nature. Supplement the symptoms of the data analysis and instrumental examination.

[18], [19], [20]

Treatment of the appendicitis in pregnancy

A pregnant woman with a sudden deterioration in the state of health and the appearance of symptoms similar to the signs of appendicitis (pain on the right side of the abdomen and others) requires an obligatory thorough examination, and as soon as possible. This is not the case when you can wait until "it passes by itself". Diagnosis of appendicitis in pregnant women presents certain difficulties and time works against the patient and her child. Do not doubt if appendicitis is removed during pregnancy. This condition is not a contraindication to appendectomy. And its volume and, consequently, the consequences depend on the stage of the development of the inflammatory process, it will be done.

A very common misconception is that the fetus dies or abnormally develops if the mothers perform general anesthesia. In fact, the risk of developmental abnormalities in the child as a result of the mother of surgical intervention suffered by the mother under anesthesia is negligible. The frequency of birth of children with malformations in mothers who underwent anesthesia surgery is comparable to the frequency of such events in women who were not operated on.

When the diagnosis is acute, as well as chronic appendicitis in the acute stage, an emergency surgery to remove appendicitis during pregnancy is mandatory. If possible, try to resort to the laparoscopic method as the least traumatic. Through a small hole in the peritoneal wall, a thin fiber optic telescopic tube (laparoscope) is inserted that translates the image of the internal organs onto the screen. Through other holes-punctures, micromanipulators are injected into the abdominal cavity filled with carbon dioxide, where the inflammation of the cecum takes place under the control of the laparoscope. This method minimizes tissue trauma, blood loss, no adhesions and an impressive scar. The recovery period in comparison with the open operation is reduced.

In the classical operation, an incision (up to 10 cm) is made in the wall of the abdominal cavity, through which the appendix is removed. If necessary, ensure the outflow of exudate, leave small holes through which the drainage tubes are withdrawn. Surgical treatment with phlegmonous appendicitis, peritonitis and other complications involves pre- and postoperative antibiotic therapy (usually cephalosporin series and aminoglycosides). At pure operations antibacterial preparations are not applied.

In the framework of therapeutic and preventive measures of premature delivery, pregnant patients are prescribed medications that reduce the muscular tone of the uterus and have a sedative effect, for example, magnesium sulfate or suppositories with papaverine. Physiotherapy in the form of endonasal administration of thiamine hydrochloride (vitamin B1). It is recommended that the post-operative diet be followed, drugs that improve bowel function may be prescribed. Pregnant after surgery recommended longer-term bed rest than usual patients.

After discharge from the surgical department of pregnant women who have undergone appendectomy, they are put on dispensary records on the threat of premature birth. The future child is considered to be in utero infected, so closely monitor its development, the condition of the amniotic membrane and the placenta. With symptoms of fetal hypoxia or other complications of pregnancy, the future mother is referred to a hospital and a number of necessary therapeutic measures are taken.

If the term of childbirth came up in the early postoperative period, prophylaxis is carried out against the divergence of the sutures (tight bandaging of the abdomen). Give birth to full-fledged anesthesia, spasmolytics are widely used. In the process of delivery, continuous therapy is performed to compensate for oxygen deficiency in the fetus. To reduce pressure on the peritoneal wall (prevention of discrepancies in postoperative sutures), an episiotomy is performed to accelerate the process of labor.

In any case (even after a long time), postoperative parturient women are conducted with great care, suggesting possible complications.

Prevention

Since the exact causes of inflammation of the appendix are not yet completely clear, preventive measures to prevent the onset of the inflammatory process are difficult to determine.

The main recommendation is a full-fledged healthy diet, including many vegetables, fruits, whole-wheat bread, bran, porridge. These foods are rich in vitamins and trace elements, support the immune system in tone. They are also rich in dietary fiber, helping to establish peristalsis of the intestine and preventing constipation. The feasible motor activity, walking outdoors will also contribute to these goals.

Spanish researchers recently found out that in about 40% of cases of appendectomy patients had eaten fried sunflower seeds or chips the day before. So our grandmothers were not so wrong when they forbade eating many seeds, threatening with a subsequent attack of appendicitis.

[21], [22], [23],

Forecast

With timely access to a doctor uncomplicated appendicitis in pregnant women is operated successfully, subsequent births also take place without negative consequences for the mother and child.

The prognosis of appendicitis with complications depends on the degree of severity and prevalence in the peritoneum of the inflammatory process.

[24], [25], [26], [27],