Appendicitis in pregnancy

Abdominal surgery during pregnancy is not without risk. However, because undue delay in operating on a pregnant woman who has acute appendicitis can have fatal consequences, a reasonable suspicion of acute appendicitis de¬ mands immediate surgical intervention. The inevitable removal of a number of normal appendices is preferable to a single unnecessary maternal death.1 During a 9-year period, 1964 to 1972, 25 pregnant patients had their appendices removed at the Ottawa Civic Hospital. The gross and histologic diagnosis was acute appendicitis in 20

aborted and two went into premature labour. One of the premature infants survived. The fetal loss associated with acute appendicitis was 15%. Early diagnosis and operation is essential.
Resume: L'appendicite durant la grossesse Au cours d'une periode de 9 ans, 25 appendectomies survenues pendant la grossesse ont ete pratiques dans un seul hdpital. Dans  Abdominal surgery during pregnancy is not without risk. However, because undue delay in operating on a pregnant woman who has acute appendicitis can have fatal consequences, a reasonable suspicion of acute appendicitis de¬ mands immediate surgical intervention.
The inevitable removal of a number of normal appendices is preferable to a single unnecessary maternal death. 1 During a 9-year period, 1964 to 1972, 25  (38.3°C) and the lowest 99°F (37.2°C). No patient was dehydrated. In 10 patients the leukocyte count was between 8000 and 10 000/mm3, in 13 it was between 10 000 and 15 000 and in 2 it was between 15 000 and 20 000. No abnormalities were re¬ ported in the differential count. The normal leukocyte count in pregnancy varies between 8000 and 12 000/mm3.

Operation and results
All 25 patients underwent surgery within 18 hours of hospitalization, and 18 of these within 12 hours. Two pa¬ tients in the 2nd trimester delivered prematurely, at 30 and 31 weeks' ges¬ tation respectively: one patient deliv¬ ered 4 weeks and the other 10 weeks after operation; one baby was stillborn, the other survived. Two patients aborted at 2 and 4 weeks, respectively, after operation, one at 12 weeks' and the other at 19 weeks' gestation. The two patients with fibrosis obliterans and the three with normal appendices recovered satisfactorily and went on to deliver healthy infants at term.
Progesterone and antimicrobials were used infrequently and their usefulness could not be assessed.

Discussion
From 1964 to 1972, 34 270 babies were born at the Ottawa Civic Hospital and there were 20 cases of acute ap¬ pendicitis in the mothers, an incidence of 1 in 1713 . less than the generally reported 1 in 1000 but consistent with the incidence of appendicitis in the nonpregnant population. Sixty percent of CMA JOURNAL/MAY 17, 1975/VOL. 112 1187 our patients were in the 1St trimester, 30% in the 2nd and 10% in the 3rd. Although the incidence is low, acute appendicitis is the most common condition leading to an intra-abdominal operation for a nonobstetric problem in pregnancy.
The prognosis for acute appendicitis in pregnancy is graver than in the nonpregnant state. The more intense degree of inflammation leads quickly to perforation and spread of infection. This is influenced by the vascularity of the pelvis in pregnancy and the increased lymphatic drainage. The natural defence mechanism by which the omentum isolates the diseased appendix from the rest of the abdomen is not always effective because of the displacement of the appendix upwards, laterally and posteriorly by the expanding uterus. 2 The clinical picture of appendicitis in pregnancy varies with the progressive increase in the size of the uterus and the displacement of the appendix. In the 1st trimester the clinical picture is identical to that in the nonpregnant state, with pain, vomiting and localized tenderness at McBurney's point. As pregnancy progresses, the appendix is pushed further upwards and laterally, with axial rotation,3 so that near the end of the 3rd trimester the pain and tenderness may be localized as far up as the right costal margin or the right costovertebral angle, as was found in four patients in the survey by Thomford, Patti and Teteris.4 When the tenderness is in this area, pyelitis, peptic ulcer and gallbladder disease must be considered. By the 28th week of gestation the appendix is at the level of the iliac crest.
Early in pregnancy, hyperemesis gravidarum, ectopic pregnancy, renal calculi and salpingitis are possible diagnoses. The normal leukocytosis, raised erythrocyte sedimentation rate and abdominal discomfort in normal pregnancy adds to the confusion, as does the presence of leukocytes in the urine.
With uterine enlargement and stretching of the anterior abdominal wall, not only is the site of pain changed but also the character may be modified. Later in pregnancy the differential diagnosis includes pre-eclampsia, concealed accidental hemorrhage, ruptured ovarian cyst, pyelitis, uterine injury and degenerating uterine leiomyoma.
During labour the clinical picture is difficult to assess, but, unlike the pain of labour, which is intermittent, the pain of appendicitis is persistent. Alders' test5 may be useful in differentiating pain of extrauterine origin from that of intrauterine origin in the pregnant patient. While the examining fingers are on the area of maxi-mal tenderness the patient is turned on her side so that the abdominal wall is vertical to the table. If of uterine origin, the pain will diminish or will disappear entirely as the uterus falls away from the examining fingers.
Because one expects to find the appendix in the area of maximal tenderness the incision is made near this point. It is important that minimal manipulation be exerted on the pregnant uterus for fear of stimulating premature labour. However, if labour does begin in late pregnancy after appendectomy, it is usually uneventful. Although Cesarean section at the time of appendectomy has been performed successfully by Meiling,6 most authors condemn this procedure, stressing the high morbidity and mortality as a result of the infected intra-abdominal hematomas, uterine infection and septicemia that may follow. Postoperatively the patient should be given antimicrobials.
Pushed away by the enlarging uterus, the omentum is not able to localize an appendiceal abscess, so that the uterus itself becomes the medial wall of the abscess. This irritant may precipitate premature labour. With expulsion of the uterine contents and reduction in the size of the uterus, the abscess disintegrates and the contents are disseminated throughout the abdominal cavity, leading to general peritonitis. In this situation it may be wise to wash out the peritoneal cavity and to use antimicrobials locally. Peritonitis is more common in appendicitis in pregnancy and increases in frequency as gestation advances. The normal Braxton Hicks contractions contribute to dissemination of infection. When the appendix has perforated, the complications include abscess or fistula formation, wound infection and phlebitis.
Abortion, premature labour and stillbirth are common complications. Hoffman and Suzuki7 found that fetal loss was 11% with the disease limited to the appendix and 35% when peritonitis was present. Parker8 found a maternal mortality of 5.8%, predominantly in late pregnancy, mortality being greatest in labour. ALDOMET* (methyldopa, MSD Std.) IndIcatIons: Sustained moderate through severe hypertension. Dosage Summary: Start usually with 250mg two or three times daily during the first 48 hours; thereafter ad1ustat intervals of not less than two days according to the patients response. Maximal daily dosage is 3.0 g of methyldopa. In the presence of impaired renal function smaller doses may be needed. Syncope in older patients has been related to sn increased sensitivity in tho.e patients with advanced arteriosclerotic vascular disease slid may be avoided by reducing the dose. Tolerance may occur occasionally between the second and third month after initialing therapy. Effectiveness can frequently be restored by increasing the dose or adding a thiazide. Contralndlcations: Active hepatic disease such as acute hepatitis and active cirrhosis; known sensitivity to methyldopa; unsuitable in mild or labile hypertension responsive to mild sedation or thiazides alone; pheochromocytoma; pregnancy. Use cautiously it there is a history of liver disease or dysfunction. Precautions: Acquired hemolytic anemia has occurred rarely. Hemoglobin and/or hematocrit determinations should be performed when anemia is suspected. If anemia is present, determine if hemolysis is present. Discontinue methyldopa on evidence of hemolytic anemia. Prompt remission usually results on discontinuation alone or the nitration of adrenocortical steroids. Rarely, however, fatalities have occurred. A positive direct Coombatest has been reported in some patients on continued therapywith methyldopa, the exact mechanism and significance of which is not established. Incidence has varied from 10 to 20%. If a positive teal is to develop it usually does within 12 months following start of therapy. Reversal of positive test occurs within weeks to months after discontinuation of the dwg. Prior knowledge of this reaction will aid in cross matching blood for transfusion. This may result in incompatible minor cross match. If the indirect Coombs test ix negative, transfusion with otherwise compatible blood may be carried out. If positive, advisability of transfusion should be determined by a hematologist or expert in transfusion problems.
Reversible leukopenia with primary eftect on granulocytex has been seen rarely. Rare cases of clinical agranulocytoxis have been reported. Granulocyte and leukocyte counts returned promptly to normal on discontinuance of drug. Occasionally fever has occurred within the first three weeks of therapy, sometimes associated with eosinophilia or abnormalities in one or more liver function tests. Jaundice, with or without fever, may occur also, with onset usuallywithin first 2 or 3 months of therapy. Rare cases of fatal hepetic necrosis have been reported. Liver biopsies in several patients with liver dysfunction showed a microscopic focal -necrosis compatible with drug hypersensitivity. Determine liver function, leukocyte and differential blood counts at intervals during the first six to twelve weeks of therapy orwhenever unexplained fever may occur. Occasional drug related fever and abnormal liver function studies with aundice and hepatocellular damage, (see PRECAUTIONS) and a rise in BUN. Rarely, skin rash, sore tongue or black tongue, pancreatitis and inflammation of the salivary glands. Endocrine and Metabolic: Rarely, breast enlargement, lactation, impotence, decreased libido; weight gain and edema which may be relieved by administering a thiazide diuretic. If edema progresses or signs of pulmonary congestion appear, discontinue drug. MisceUaneous: Occasionally nasal stuftineas, mild arthralgia and myalgia; rarely, darkening of urine after voiding. Detailed Information available on request. How Supplied: Tablets ALDOMET are yellow, film-coated, biconvex shaped tablets, supplied as follows: Ca 8737each tablet containing 125mg of methyldopa, marked MSD l3Son one side, supplied in bottles of 100 and 500. Ca 3290each tablet containing 250mg of methyldopa, marked MSD 401 on one side, supplied in bottles of 50 and 500. Ca 8733-each tablet containing 500 mg of methyldopa, marked MSD 516 on one side, supplied in boftlex of 50 and 250. Also available: Ca 3293 -Injection ALDOMET Ester hydrochloride, a clear colourless solution containing 250 mg methyldopate hydrochloride per 5 ml, supplied in 5 ml ampoules.