İsmail SERT, Cengiz AYDIN, Cem KARAALİ, Mustafa EMİROĞLU, Mehmet ÜSTÜN, Mehmet Burak ÖZTOP, İbrahim Egemen ERTAŞ

Clinical and laboratory features and treatment approaches of pregnant woman with acute appendicitis

Aim: Since it is difficult to diagnose acute appendicitis (AA) in pregnant women, the negative appendectomy and complicated appendectomy rates are higher than the normal population. However, both negative appendectomies and complicated appendicitis have negative effects on the fetus and mother. This study aims to evaluate the patients who underwent appendectomy during pregnancy according to clinical, laboratory and imaging findings. In addition, the Neutrophil-Lymphocyte ratio (NLR) and Platelet-Lymphocyte ratio (PLR) parameters, which are used in the evaluation of pregnant AA patients in the literature, will be evaluated. Material and Methods: Between January 2013 and January 2020, pregnant patients operated for AA were retrospectively analyzed. The patients were evaluated in terms of age, gestational age, clinical, laboratory and imaging findings, operation information, length of hospitalization, pathology results and complications.Results: Twelve patients were included in the study. The mean age of the patients was 29.3 ± 7.38 (min-max 17-41). Three patients were in the 1st trimester (two intrauterin and one extrauterin tubal pregnancy), seven were in the 2nd trimester, and two were in the 3rd trimester. All patients applied with abdominal pain and no appendix could be visualized in any patient on ultrasound imaging. In our study, the average of WBC (White Blood Cell), PDW (Platellet-Distribution Widht), NLR and PLR values were found to be as 13.2 (mcL), 16.9 (%), 3.4 and 79.2, respectively.Conclusion: In our study, a clear distinctive finding to be used in detecting pregnant appendicitis could not be reached. Although imaging and laboratory findings play a role in assisting the diagnosis of AA, our study has revealed that the most important criterion in the diagnosis of AA in pregnant patients is that the general surgery and gynecology team evaluate the patient together.

PDF

___

1. Andersen B, Nielsen T. Appendicitis in pregnancy, diagnosis, management and complications. Acta Obstet Gynecol Scand 1999;78:758-62.
2. Brown J, Wilson C, Coleman S, et al. Appendicitis in pregnancy: an ongoing diagnostic dilemma. Colorectal Dis 2009;11:116-22.
3. Petroianu A, Barroso TVV. Pathophysiology of acute appendicitis. JSM Gastroenterol Hepatol 2016;4:1062- 66
4. Lee CC, Golub R, Singer AJ, et al. H. Routine versus selective abdominal computed tomography scan in the evaluation of right lower quadrant pain: a randomized controlled trial. Acad Emerg Med 2007;14:117-22.
5. Krajewski S, Brown J, Phang PT, et al. Impact of computed tomography of the abdomen on clinical outcomes in patients with acute right lower quadrant pain: a meta-analysis. Can J Surg 2011;54:43.
6. Spalluto LB, Woodfield CA, DeBenedectis CM, et al. MR imaging evaluation of abdominal pain during pregnancy: appendicitis and other nonobstetric causes. Radiographics. 2012;32:317-34.
7. Lurie S, Rahamim E, Piper I, et al. Total and differential leukocyte counts percentiles in normal pregnancy. Eur J Obstet Gynecol Reprod Biol 2008;136:16-9.
8. Watts DH, Krohn MA, Wener MH, et al. C-reactive protein in normal pregnancy. Obstet Gynecol 1991;77:176-80.
9. McGory ML, Zingmond DS, Tillou A, et al. Negative appendectomy in pregnant women is associated with a substantial risk of fetal loss. J Am Coll Surg 2007;205:534-40.
10. Masselli G, Derme M, Laghi F, et al. Evaluating the Acute Abdomen in the Pregnant Patient. Radiol Clin North Am 2015;53:1309-25.
11. Basaran A, Basaran M. Diagnosis of acute appendicitis during pregnancy: a systematic review. Obstet Gynecol Surv 2009;64:481-8.
12. Long SS, Long C, Lai H, et al. Imaging strategies for right lower quadrant pain in pregnancy. AJR Am J Roentgenol 2011;196:4-12.
13. Poortman P, Oostvogel HJ, Bosma E, et al. Improving diagnosis of acute appendicitis: results of a diagnostic pathway with standard use of ultrasonography followed by selective use of CT. J Am Coll Surg 2009;208:434-41.
14. Yu C-H, Weng S-F, Ho C-H, et al. Pregnancy outcomes following nonobstetric surgery during gestation: a nationwide population-based case-control study in Taiwan. BMC Pregnancy Childbirth 2018;18:460.
15. Reitman E, Flood P. Anaesthetic considerations for non-obstetric surgery during pregnancy. Br J Anaesth 2011;107:i72-i8.
16. Zhang Y, Zhao Y-y, Jie Q, et al. Diagnosis of appendicitis during pregnancy and perinatal outcome in the late pregnancy. Chin Med J 2009;122:521-4.
17. Tracey M, Fletcher HS, Hollenbeck JI, et al. A. Appendicitis in pregnancy/discussion. The American Surgeon. 2000;66:555.
18. Coleman MT, Trianfo VA, Rund DA. Nonobstetric emergencies in pregnancy: trauma and surgical conditions. Am J Obstet Gynecol 1997;177:497-502.
19. Yagci MA, Sezer A, Hatipoglu AR, et al. Acute appendicitis in pregnancy. Dicle Med J 2010;37:134.
20. Tiryaki C, Haksal MC, Turgut HT, et al. Acute appendicitis during pregnancy: clinical experience. Kocaeli Medical Journal 2014;3:1-5.
21. Cobben LP, Groot I, Haans L, et al. MRI for clinically suspected appendicitis during pregnancy. AJR Am J Roentgenol 2004;183:671-5.
22. Pedrosa I, Levine D, Eyvazzadeh AD, et al. MR imaging evaluation of acute appendicitis in pregnancy. Radiology 2006;238:891-9.
23. Khandelwal A, Fasih N, Kielar A. Imaging of acute abdomen in pregnancy. Radiol Clin North Am 2013;51:1005-22.
24. Garcia EM, Camacho MA, Karolyi DR, et al. ACR appropriateness criteria right lower quadrant painsuspected appendicitis. J Am Coll Radiol 2018;15:373- 87.
25. Masselli G, Brunelli R, Monti R, et al. Imaging for acute pelvic pain in pregnancy. Insights Imaging 2014;5:165-81.
26. Timins J. Pregnancy and medical radiation: part I. Journal of Women's Imaging 2002;4:31-2.
27. Hurwitz LM, Yoshizumi T, Reiman RE, et al. Radiation dose to the fetus from body MDCT during early gestation. AJR Am J Roentgenol 2006;186:871-6.
28. J Damilakis, K Perisinakis, A Voloudaki, et al. Estimation of fetal radiation dose from computed tomography scanning in late pregnancy: depth-dose data from routine examinations. Invest Radiol 2000;35:527-33.
29. Neto F, Amorim MMRd, Nóbrega BMSV. Acute appendicitis in pregnancy: literature review. Rev Assoc Med Bras 2015;61:170-7.
30. Baskiran A, Ince V, Cicek E, et al. Efficacy of laboratory tests and ultrasonography in the diagnosis of acute appendicitis in gravid patients according to the stages of pregnancy. Ulus Travma Acil Cerrahi Derg 2018;24:333-6.
31. Yazar FM, Bakacak M, Emre A, et al. Predictive role of neutrophil-to-lymphocyte and platelet-to-lymphocyte ratios for diagnosis of acute appendicitis during pregnancy. Kaohsiung J Med Sci 2015;31:591-6.