Acute appendicitis complicating pregnancy: a 33 case series, diagnosis and management, features, maternal and neonatal outcomes

The occurrence of acute appendicitis during pregnancy may pose diagnostic and therapeutic difficulties. In fact pregnancy can make the clinical diagnosis delicate and the use of morphological examinations is still subject to controversy. The debates concerning the ideal surgical approach during pregnancy continue. On the other hand, in some cases the occurrence of acute appendicitis, especially in its complicated form, which is frequent in pregnant women, exposes to obstetrical complications and an increased risk of premature delivery We aims to describe the clinical and management features of acute appendicitis in pregnant women and the maternal and neonatal outcomes and carry out a review of the literature on this topic. It is a retrospective analysis of a series of 33 cases of appendicitis in pregnant women who were diagnosed and managed, in collaboration between the departments of General and digestive surgery, Gynecology and Obstetrics and Anaesthesia at Farhat Hached Universitary Hospital Sousse Tunisia between January 2005 and December 2015. The average age of the patients was 29 (20-40). Fourteen patients were in the first trimester, twelve in the 2nd and seven in the third trimester. The main symptom was pain in the right iliac fossa. The mean delay between consultation and surgery was 2.7 days. Twenty five patients had a preoperative ultrasound. Eight of the 33 pregnant patients presented complicated appendicitis with localized or generalized peritonitis. Thirty patients underwent laparotomic appendectomy: 28 with a Mc Burney incision and 2 with a midline incision and only three patients underwent laparoscopy. Preventive tocolysis was given to 14 patients, maternal mortality was null. Twenty four pregnancies were followed until delivery: one case of premature birth and one case of preterm labor were observed. Pregnancy makes it difficult to diagnose appendicitis, which explains the high rate of complicated acute appendicitis in our series. An early treatment improves maternal and fetal outcome.


Introduction
Acute appendicitis is the most common non-obstetrical surgical emergency during pregnancy [1]. Its incidence in pregnant women varies from 50/100 000 to 130/100 000 [2]. The association of this surgical emergency and pregnancy is a serious one that involves the maternal and fetal prognoses. Symptoms are polymorphous and misleading, causing misdiagnosis and/or diagnostic and therapeutic delay [3]. The objectives of this study were to describe the clinical, para-clinical and therapeutic features of acute appendicitis in pregnant women and the factors influencing materno-fetal outcomes.

Methods
It is a descriptive study with a retrospective analysis of a series of In comparison with the physiological hyperleukocytosis in pregnant women, leukocytosis was considered to have a white blood cell count> 12000 cells/mm 3 . The data was analyzed using SPSS 20.

Results
Of the 2982 patients who underwent surgery for acute appendicitis during the study period at the department of General and digestive surgery at Farhat Hached Universitary Hospital Sousse Tunisia, 33 cases of acute appendicitis were observed in pregnant women; leading to a prevalence in the general population of 1.1%. The mean age of our patients was 29 years, with extremes ranging from 20 to 40 years. The diagnosis of acute appendicitis was observed in the first trimester of pregnancies in 14 patients, which is twice the number of cases observed in the 3rd trimester (n = 7) (

Discussion
Acute appendicitis is the most common non-obstetrical surgical emergency during pregnancy [1,2]. It accounted for 65.6% of nontraumatic digestive emergencies in pregnant women, with a general prevalence of 0.1 to 0.2% [1]. It is higher in our series with 1.1%.

Andersson et al found an inversely proportional relationship
between appendicitis and pregnancy and it was mostly in the 3rd trimester [4], unlike our own findings were most patients were diagnosed during the 1 st and 2 nd trimester of pregnancy. Andersson et al concluded that pregnancy protects against appendicitis [4].
However, other studies, like ours, have shown that the association of appendicitis and pregnancy is more frequent during the 1 st and 2 nd trimester [5] and rare in the last weeks of pregnancy [6]. And a recent review of the literature found an incidence of acute appendicitis slightly elevated in the 2 nd trimester of pregnancy [5], which is concordant with our results (42.4% of our patients were in their first trimester, which was twice as many as in the third trimester). The clinical and radiological diagnosis of acute appendicitis during pregnancy is challenging [7]. The pros and cons of this diagnosis must be weighed because excessive intraoperative pelvic manipulations increase the risk of threat of premature delivery and neglected appendicitis exposes to the risk of serious materno-fetal complications. In the first trimester, the semiology of appendicitis is no different from that observed in non-pregnant [8].
Abdominal pain is the most constant sign. Since 1932, Baer et al.
demonstrated that the appendix and the caecum moved during the pregnancy progressively and laterally in a counter-clockwise direction outside the pelvis [9]. Subsequently, this theory was called into question. In fact, Mourad et al [10] found that in the majority of pregnant women, pain was located in the RIF and this is regardless of the term of pregnancy. The same results were confirmed by the studies of Yilmaz and Melnick [11] and our own results: RIF was the predominant site of pain (78.8% of our patients) regardless of the term of pregnancy. Other functional signs are common during pregnancy, which deprives them of their diagnostic interest [1]. As with all acute appendicitis, fever is not constant or specific [11,12]. Therefore its presence most often in favor of a complicated appendicitis [2].
Of eight patients in our series with a fever, seven had a complicated acute appendicitis. The higher incidence of complicated appendicitis in pregnant women is not only due to the delay in diagnosis and/or in management but also to some patho-physiological changes. In fact, pregnancy puts the woman in a state of relative immune suppression that alters the normal inflammatory response. On the other side, pregnancy may result in a hyper-vascularization of the appendix that promotes early lymphatic dissemination, and uterine contractions hamper peripheral appendicular adherence. Moreover, pregnancy makes the abdominal palpation signs difficult to appreciate given the increase in the uterine volume [8]. As the pregnancy progresses, abdominal sensation and defense are less evident because of the laxity of the abdominal wall and the increase in the space between the abdominal wall and the appendix [12][13][14].
The abdominal contracture, master symptom in case of appendicular peritonitis is often inconstant. The uterine contraction rapidly evolving in contracture causes suspicion of an obstetrical complication and may lead to premature delivery [15]. The patient that had a Caesarean section for suspicion of acute fetal suffering in our series illustrates this notion. "The American College of Radiologists (ACR) Appropriateness Criteria 2011" considered abdominal ultrasound, the initial imaging of choice, in front of any suspicion of acute appendicitis in pregnant women [16]. It is also of interest to eliminate an associated adnexal or obstetrical pathology, to document the pregnancy by specifying the age gestation and the fetal vitality. However, the false negative rate by ultrasound that is variable in the literature puts these recommendations into question [17,18]. Our study as well as several recent studies have also shown a low ultrasound sensitivity varying from 36 to 46% [17,18].
These results are explained according to some authors, by the fact that the ultrasounds are "operator dependent". The pregnant uterus, in our cases, impeded the visualization of the appendix in the 3 rd trimester and some authors suggest that abdominal CT can be of help. Indeed, it has a sensitivity ranging from 77% to 98% and a specificity of 83% to 100% in the diagnosis of acute appendicitis [19,20]. Its superiority to abdominal ultrasound is proved by a large meta-analysis [21]. The strong reluctance to use CT during pregnancy is mainly due to the teratogenic risks of ionizing radiation especially during the organogenesis period. Surgical complications may occur in the form of deep peritoneal abscess, or parietal suppuration, which remains the most frequent [1] and its frequency ranged from 8% to 15% [11]. In our study no

Competing interests
The authors declare no competing interests.

Authors' contributions
Mohamed Amine El Ghali did collection of data, writing of the manuscipt and the opinion of the surgeon. Ons Kaabia did writing of the manuscipt and the opinion of the obstrics. Zaineb Ben Mefteh did collection of data and writing of the manuscript. Maha Jgham did writing of the manuscript. Amel Tej did writing of the manuscipt: pediatrics and neonalt opinion. Asma Sghayer did collection of data.
Amine gouidar did collection of data. Afra Brahim did writing of the manuscipt: opinion of anatshisist. Rafik Ghrissi did revision of the manuscript. Rached letaief did revision of the manuscript. All the authors have read and agreed to the final manuscript.