Appendicitis during pregnancy: signs, consequences, what to do

Inflammation of the appendix of the cecum and its surgical removal (appendectomy) are the most common reason for emergency surgical care in the population, part of which are pregnant women. It is this reason that in most cases makes them go under the surgeon's knife to save their own lives and those of their child. Can appendicitis occur during pregnancy? Of course, like any other disease.

Therefore, a pregnant woman who is bothered by abdominal pain should immediately (every hour counts) contact a medical institution. Consultations with a gynecologist and surgeon are mandatory in this case; refusing hospitalization in this case is very risky.

You should never relieve your pain with analgesics, only antispasmodics are allowed, for example, No-shpa. However, it is even better not to take anything, but to get under medical supervision as soon as possible.

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Epidemiology

Inflammation of the appendix rightfully belongs to the pathologies of young age - more than seven out of ten patients operated on for appendicitis were under 35 years old. Young women are operated on approximately three times more often than men. The proportion of pregnant women among patients with appendicitis is from 0.5 to 4%. Cases of inflammation of the vermiform appendix occur in one or two women out of 1000-10,000 pregnant women. Almost half of all cases occur in the second trimester of pregnancy.

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Causes appendicitis in pregnancy

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

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

A variety of microorganisms are found in the appendix, colonizing it and causing the inflammatory process. The vast majority of infectious agents found (more than 90% of cases) are non-spore-forming anaerobic bacteria. Colonies of aerobic bacteria (E. coli, Klebsiella, enterococci, etc.) are also found, but much less frequently.

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

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

• active growth of the uterus, which contributes to the displacement of the organ, its compression and disruption of blood circulation in its vessels;
• a natural decrease in immunity during pregnancy, which reduces the ability of lymphoid tissue to destroy pathogenic organisms;
• predominant consumption of foods poor in dietary fiber, which leads to constipation and the formation of fecal calculi;
• a natural change in blood composition during pregnancy that increases the risk of blood clots;
• anatomical features of the location of the appendix, which aggravate the effect of the factors listed above.

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Pathogenesis

The main pathogenetic link leading to the development of appendicitis is the narrowing of its lumen (approximately 2/3 of cases), which disrupts the outflow of secreted mucus and contributes to the overflow of the cavity of the appendicular process. In young people, the narrowing is usually caused by an increase in lymphoid follicles. The presence of fecoliths (fecal stones) is detected in more than a third of cases of appendicitis. Much less often, foreign bodies, parasites, and tumors are considered as pathogenetic links. In pregnant women, in addition to the general principles of pathogenesis, displacement, compression, or bending of the vermiform appendix may occur due to an increase in the size of the uterus.

Thus, 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 appendix, their stretching. As a result, venous blood flow is disrupted, and then arterial. Under conditions of hypoxia, the walls of the appendix begin to rapidly multiply and colonize its internal cavity with microbes. The products of bacterial activity damage the epithelium, ulcers appear on the mucous membrane, the so-called primary Aschoff effect. Immunocytes, responding to the activity of bacteria, produce anti-inflammatory mediators that limit the inflammatory process at the initial stage of the appendix, preventing the development of a systemic process.

Further development of local immunoregulators contributes to the deepening of destructive transformations in the appendicular wall. When the muscular layer necrotizes, the wall of the appendix is perforated in about half of the patients. This is facilitated by the presence of fecal stones in it. Perforation leads to the development of complications - peritonitis or the formation of a periappendicular infiltrate.

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

The pathogenesis of acute inflammation of the appendix is also considered as a consequence of an allergic reaction in the appendix of immediate or delayed form. Their local manifestations in the form of vasoconstriction and disruption of the structure of the wall of the appendix allow pathogens from the intestine to affect its tissues and migrate with the lymph flow. 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 entire thickness of the appendix wall is affected, the adjacent part of the peritoneum and nearby organs are involved.

If one of the most important abilities of the peritoneum is triggered - to protect itself from diffuse peritonitis by separating the purulent exudate at the expense of nearby organs affected by inflammation, a periappendicular infiltrate is formed (the inflamed appendix, like a case, covers the connection of organs and tissues fused together, located in the area of local inflammation). This conglomerate protects the inflammation site from the rest of the peritoneum. After a certain period of time, the infiltrate is absorbed or the inflammatory process develops with the formation of an abscess.

The progression of the disease without the involvement of the limitation mechanism leads to the development of diffuse peritonitis.

In case of vascular thrombosis and ischemia of the appendicular membrane, gradual tissue death ends with gangrene, spreading to the mesenteric loop, where veins also become thrombosed and ascending septic thrombophlebitis develops, reaching the portal vein and its branches (pylephlebitis). This complication is extremely rare (5 out of 10,000 cases of appendicitis), however, it is one of the most formidable.

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Symptoms appendicitis in pregnancy

The symptoms of appendicitis in women carrying a child change, sometimes very significantly, due to physiological, hormonal and metabolic changes occurring in the body during this period. The main symptom of inflammation is pain that begins suddenly and does not allow you to forget about it. 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 abdomen above the navel or just a stomach ache without a specific location. Abdominal discomfort is accompanied by bloating and distension of the abdomen, gases are released poorly or do not leave at all. Pain in appendicitis during pregnancy can be intense or moderate, constant or paroxysmal. After a short period of time, the pain migrates to the area of the appendicular process. The classic version is on the right in the lower quadrant of the abdomen. Appendicitis during early pregnancy is practically no different in symptoms from that in other patients.

As the uterus grows, the cecum and its appendix move upward, the abdominal wall rises and moves 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 higher under the ribs. If the appendix is located high, symptoms resembling gastritis may appear.

Pain in the lumbar region, reminiscent of renal pain, is also likely. If the appendix is located in the pelvis, clinical symptoms reminiscent of cystitis may be observed - frequent urination in small portions, pain radiating to the bladder, perineum and right leg.

It is worth paying attention to the fact that a characteristic feature of appendicitis is an increase in pain when coughing, walking, shaking, turning to either side. Appendicitis in the late stages of pregnancy in more than half of patients does not manifest itself as tension in the muscles of the anterior abdominal wall due to its progressive relaxation, in the rest this tension is very weak and is practically not felt. Other symptoms of irritation of the anterior abdominal wall may also be absent.

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

When the appendix is filled with pus (phlegmonous appendicitis) and stretched as a result, the pain syndrome becomes intense. The nature of the pain may change to cramping, pulsating. At this stage, the submucosal and part of the muscular layer are already involved in the process. In terms of time, this corresponds to the second half of the first day from the moment the first symptoms appear (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 subsides for some time (apparent improvement). Then it sharply increases, this may be a sign of perforation of the appendix and the onset of peritoneal inflammation - a very dangerous condition for a pregnant woman and fetus.

Constant, quite moderate nausea and loss of appetite may begin before pain, however, a pregnant woman, especially with early toxicosis, is unlikely to be alarmed by such a condition. But in combination with pain, it should already make you see a doctor.

Severe nausea and vomiting once or twice begin after the pain appears and are the body's response to pain. Vomiting during appendicitis contains bile, if it is not present, then most likely the vomiting is caused by another reason (exacerbation of cholecystitis, obstruction of bile outflow). If the patient has multiple vomiting urges and resolution does not bring relief, this is a bad sign of complicated appendicitis. And vomiting before the onset of pain casts doubt on the diagnosis of appendicitis.

Lack of appetite almost always accompanies appendicitis. Also, delayed bowel movements due to intestinal paresis are considered constant symptoms.

Much less common are loose stools or cutting (pulling) pains in the rectum and futile urges to defecate, not accompanied by bowel movement. Such symptoms are typical for a 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 temperature in the first day is observed in approximately half of patients; a temperature above 38℃ is a sign of a complication of appendicitis or the development of an intestinal infection.

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Stages

The stages of classical development of acute appendicitis in young people are most often accompanied by the following order of appearance of symptoms:

• abdominal discomfort, bloating, vague pain above or near the navel;
• lack 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 pregnancy, pain is usually localized on the right, but slightly higher);
• tension of the abdominal muscles in the right iliac region (in pregnant women, especially in the second half of pregnancy, this symptom is weakly expressed or not expressed at all);
• subfebrile temperature (may not be present);
• high level of leukocytes in a general blood test.

In surgery, it is customary to distinguish the following types of appendicitis: acute and chronic. The second type is interpreted as a consequence of the first, which ended in recovery without surgical intervention, however, one should not count on the chronicity of the process. The cold form of appendicitis after the first attack is called residual, after two or more exacerbations - recurrent. The existence of a primary chronic form of the disease raises doubts among most practicing surgeons, who consider such a conclusion a diagnostic error.

Acute appendicitis during pregnancy is characterized by the pronounced symptoms described above and is divided into uncomplicated and complicated. The mildest form is superficial or catarrhal appendicitis. Uncomplicated forms also include purulent (phlegmonous) appendicitis and non-perforated gangrenous appendicitis. The main symptoms that are recommended to pay attention to are the sudden onset of an attack, pain in the right half of the abdomen and a painful reaction to palpation in this area.

Inflammation of the appendix of the cecum can be complicated by perforation, infiltrate formation, peritonitis, abscesses of various localizations, sepsis and pylephlebitis. In this case, the symptoms are much more severe - the pulse and breathing quicken, it becomes superficial, since the pain intensifies with a deep breath. Other signs of systemic intoxication appear. Since it is the complications, and not the operation to remove the inflamed appendix, that pose a real threat to the life of the child and mother, then contacting a doctor at the first alarming signs, early diagnosis and surgery allows you to save the life of the child and cause minimal damage to the health of both.

Chronic appendicitis often worsens during pregnancy. Usually, during the period of exacerbation, patients complain of pain concentrated in the right side of the abdomen, radiating to the leg on the same side, and pain can also be felt in the epigastric region. The pregnant woman is bothered by symptoms of colitis - frequent constipation, occasionally interspersed with diarrhea.

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Complications and consequences

Since any intervention, and especially an operation under anesthesia, is associated with a certain risk during pregnancy, the decision to perform it should be thoughtful, since an unnecessary operation can have negative consequences for the child. At the same time, long-term observation of a pregnant woman with symptoms of appendicitis is also undesirable, since it leads to complications of the disease and an increase in the volume of the operation.

Gangrenous appendicitis is especially insidious, in which necrosis destroys the nerve endings of the organ, and the pain subsides for a while, which can force the expectant mother to announce an improvement in her health and refuse surgical treatment. The lost time will result in perforation of the vermiform appendix and further aggravate the situation. In case of complications in the form of diffuse peritonitis, there is a high probability of termination of pregnancy.

Peritonitis often turns into sepsis, which can be fatal.

Advanced appendicitis is complicated by the formation of retroperitoneal phlegmon and abscesses of various localizations in the peritoneal cavity.

Very rarely, appendicitis can be complicated by septic thrombophlebitis of the portal vein and its branches. Rapid progression of the complication leads to the development of liver-renal dysfunction and death of the patient, slow progression allows taking measures to save the patient. In this case, the mesentery of the appendix of the cecum is completely removed. However, the pregnancy cannot be saved.

A timely operation is much safer. Pregnant women who have it performed before complications develop recover quickly and often give birth on their own. When performing a diagnostic or surgical laparotomy, the expectant mother will be prescribed a course of antibiotic therapy to prevent infection and the development of peritonitis.

A complication of the operation is discomfort when the surgical suture from appendicitis during pregnancy heals.

After the operation, fibrous tissue growths may form - 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 probability of adhesions increases to 60-80%. If the suture is pulled after appendicitis during pregnancy, such a symptom may indicate a high probability of adhesions.

A rare but possible consequence of surgery performed in the first trimester of pregnancy is fetal death. However, a much greater probability of death is due to perforation of the appendix and septic peritonitis.

Surgeries in the second and third trimesters can provoke premature birth, however, in most cases, timely interventions regarding appendectomy in the expectant mother end well for her and the child. Postoperative complications usually develop in the first week, more often at advanced stages. Occasionally, surgical treatment is complicated by premature detachment of a normally located placenta. Inflammation of the amniotic membranes (chorioamnionitis) or intrauterine infection of the fetus may occur, requiring special therapeutic measures. For the entire remaining period before delivery, a woman who has undergone appendectomy is under the close attention of doctors, the goal of which is her successful delivery on time.

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Diagnostics appendicitis in pregnancy

It is quite difficult to establish an accurate diagnosis of the inflammatory process occurring in the appendix based only on the clinical symptoms and complaints of the expectant mother. The symptoms of acute abdomen overlap with many physiological manifestations of pregnancy. The diagnostic features are determined by the period of gestation, the location of the appendix of the cecum and the stage of development of the inflammatory process, suspicions of which arise when the patient complains of sudden and persistent, often increasing, pain in the right side of the abdomen.

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

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

In addition, during pregnancy, the blood formula changes somewhat - it is not surprising that the level of leukocytes exceeds the norm, anemia, and distortion of the inflammatory response. Nevertheless, patients undergo blood tests, the content of leukocytes in pregnant women usually exceeds 15×10⁹g/l.

The composition of urine is analyzed under a microscope, which sometimes reveals erythrocytes, leukocytes and bacteria in the urine, indicating pathologies of the urinary organs. In appendicitis, urine microscopy indicators are usually recorded within normal limits.

Around the fourth or fifth month of gestation, the location of the appendix changes due to its displacement by the growing uterus. The abdominal muscles are stretched and relaxed, so symptoms of peritoneal irritation are not indicative. During examination, attention is paid to the sudden onset of pain in the right side of the abdomen, increased pain when turning from left to right, and preservation of the location of the most severe pain when turning in the opposite direction. More than a third of patients have a rapid pulse, and about a fifth have a high temperature. Complaints of frequent constipation and taking laxatives, attacks of appendicitis in the anamnesis (even before pregnancy) are taken into account.

To visualize the appendix and differentiate it from other pathologies, instrumental diagnostics are used - ultrasound and magnetic resonance imaging. X-rays are not indicated for pregnant women. The most informative diagnostic method is laparoscopy, which allows you to see the appendix and other organs of the peritoneum on the camera screen. The diagnostic procedure often turns into the process of removing the appendix of the cecum.

Based on the collected anamnesis, differential diagnostics is performed. Other diseases causing symptoms of acute abdomen are excluded - ovarian apoplexy, torsion of the ovarian cyst pedicle, pyelitis, strangulation of a stone in the bile ducts, perforation of a gastric ulcer, intestinal obstruction. In the first trimester, it is vital to distinguish between conditions such as right-sided ectopic pregnancy and appendicitis, which require emergency surgical intervention and have similar symptoms. In case of ectopic pregnancy, the pain syndrome is usually expressed more clearly up to shock, symptoms of internal hemorrhage appear, the nature of the pain radiating to the scapula is different, paroxysmal, and palpation of the abdomen is less painful. Pain with inflammation of the appendix is more moderate, does not radiate and is constant. The symptoms are supplemented by data from tests and instrumental examination.

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Treatment appendicitis in pregnancy

A pregnant woman with a sudden deterioration in health and the appearance of symptoms similar to signs of appendicitis (pain on the right side of the abdomen, etc.) needs a thorough examination, and as soon as possible. This is not the case when you can wait until it “goes away on its own.” Diagnosis of appendicitis in pregnant women presents certain difficulties and time works against the patient and her child. There is no need to doubt whether appendicitis is removed during pregnancy. This condition is not a contraindication to appendectomy. And its volume and, therefore, the consequences depend on the stage of the inflammatory process at which it is performed.

A common misconception is that the fetus dies or develops abnormally if the mother undergoes general anesthesia. In fact, the risk of a fetus developing anomalies as a result of a pregnant mother undergoing surgery under anesthesia is extremely small. The incidence of birth defects in mothers who have undergone surgery under anesthesia is comparable to the incidence of such events in women who have not undergone surgery.

In the case of acute and chronic appendicitis in the acute stage, an emergency operation to remove appendicitis during pregnancy is mandatory. If possible, they try to resort to the laparoscopic method as the least traumatic. A thin fiber-optic telescopic tube (laparoscope) is inserted through a small opening in the peritoneal wall, transmitting an image of the internal organs to the screen. Micromanipulators are inserted through other puncture holes into the abdominal cavity filled with carbon dioxide, where the inflamed appendix of the cecum is removed under the control of the laparoscope. This method minimizes tissue trauma, blood loss, there are no adhesions and an impressive scar. The recovery period is reduced compared to an open operation.

In a classic operation, an incision (up to 10 cm) is made in the abdominal wall, through which the appendix is removed. If it is necessary to ensure the outflow of exudate, small openings are left through which drainage tubes are brought out. Surgical treatment for phlegmonous appendicitis, peritonitis and other complications involves pre- and postoperative antibiotic therapy (usually cephalosporins and aminoglycosides). Antibacterial drugs are not used in clean operations.

As part of the treatment and prevention of premature delivery, pregnant patients are prescribed medications that reduce the muscle tone of the uterus and have a sedative effect, such as magnesium sulfate or suppositories with papaverine. Physiotherapy in the form of endonasal administration of thiamine hydrochloride (vitamin B1). A postoperative diet is recommended, and medications that improve bowel function may be prescribed. Pregnant women are recommended to stay in bed longer than normal patients after surgery.

After discharge home from the surgical department, pregnant women who have undergone appendectomy are registered for the risk of premature birth. The unborn child is considered to be intrauterinely infected, so its development, the condition of the amniotic membrane and placenta are closely monitored. If symptoms of fetal hypoxia or other pregnancy complications occur, the expectant mother is sent to the hospital and a number of necessary therapeutic measures are taken.

If the due date is early in the postoperative period, prophylaxis against suture divergence is carried out (tight abdominal bandaging). The woman in labor is given full anesthesia, and antispasmodics are widely used. During the delivery, continuous therapy is carried out to compensate for the oxygen deficiency in the fetus. To reduce the pressure on the peritoneal wall (prevention of postoperative suture divergence) in order to speed up the labor process, an episiotomy is performed.

In any case (even after a long period of time), postoperative women in labor are treated with great caution, anticipating possible complications.

Prevention

Since the exact causes of appendicitis are not yet entirely clear, it is difficult to determine preventive measures to prevent the occurrence of the inflammatory process.

The main recommendation is a complete healthy diet, including lots of vegetables, fruits, whole grain bread, bran, cereals. These products are rich in vitamins and microelements, and keep the immune system in good shape. They are also rich in dietary fiber, which helps to improve intestinal peristalsis and prevent constipation. Moderate physical activity and walks in the fresh air will also contribute to these goals.

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

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Forecast

If a doctor is consulted in a timely manner, uncomplicated appendicitis in pregnant women can be operated successfully, and subsequent births also occur without negative consequences for the mother and child.

The prognosis for complicated appendicitis depends on the severity and prevalence of the inflammatory process in the peritoneum.

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