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RCOG World Congress 2023
June 12 - 14, 2023 | London, UK
EP.0337
Case report: acute gangrenous appendicitis complicating pregnancy in the third trimester
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Hot Topics (Emerging research/issues) in Obstetrics
Objective:
•Acute appendicitis during pregnancy is the most common non-obstetric emergency requiring surgical intervention, with an incidence of 1 in 800-1500 pregnancies.
Case report:
• A healthy 33-year-old 33+6 weeks pregnant woman presented with acute right-sided abdominal pain and threatened pre-term labour.
•Her abdomen was soft with tenderness in the right iliac fossa and right renal angle with regular palpable contractions.
•Speculum examination revealed a long and closed cervix with a positive Actim Partus test.
•Blood tests showed leukocytosis of 26.4x109/L (4.0-11.0), a C-reactive protein (CRP) level of 41 mg/L (<5.0), and a lactate level of 1.3 mmol/L (0.5-2.2).
•Pelvic ultrasound did not visualize her appendix, and no surrounding free fluid was found. MRI showed no signs or secondary features of appendicitis.
•The surgical team recommended conservative management, as she was hemodynamically stable with reassuring imaging findings.
•Broad-spectrum antibiotics, tocolysis, and antenatal steroids were administered.
•The patient then developed persistent right iliac fossa pain and a tender abdomen with peritonism on the following day.
•An emergency open laparotomy, caesarean section, and appendectomy were performed at 34 weeks gestation.
•Perforated gangrenous appendicitis with purulent exudate was identified during the laparotomy.
•The patient developed postoperative pneumonia and pericardial effusion, which were managed by the medical team. She recovered and was discharged home on day five.
Discussion:
•The diagnosis of acute appendicitis remains challenging during pregnancy due to changes in the anatomical location of the appendix related to the enlarged uterus and physiological mild leukocytosis.
•Presenting symptoms, such as abdominal pain, nausea, and vomiting, can be difficult to differentiate from common pregnancy-related symptoms.
•The perforation rate occurs in 43% of pregnant patients whose surgical treatment is delayed for 24 hours.
•In this case, surgical management of acute appendicitis was delayed due to reassuring ultrasound and MRI findings, leading to complications, including perforation of the gangrenous appendix and preterm delivery.
Conclusion:
•Acute appendicitis should be diagnosed promptly, and early surgical intervention reduces maternal and neonatal complications.