Pregnancy and Appendicitis. Clinical picture
Appendicitis is an inflammation of vermiform appendix of the caecum. Its frequency at pregnancy makes up 0.7-1.4 %. Lethality of pregnant from appendicitis for the recent 40 years has decreased from 3. 9 to 1.1 %; however it is higher than in nonpregnant women.
Simple forms of acute appendicitis in pregnant women are encountered on average in 63 %, destructive forms — in 37 % of cases. The recurrent attacks of appendicitis are 3 times more frequent in the first half of pregnancy than in the second one and during labor.
Appendicitis complicates the course of pregnancy. In its second half there is no encapsulation of periappendiceal exudate at perforation of appendix, diffuse peritonitis develops. Commissures formed with uterus cause activation of contractile activity of the uterus that results in abortion at 2.7-3.2 % of women.
Clinical picture. The attack of appendicitis begins with an acute abdominal pain. The pain is localized in the field of belly-button, spreads to the whole abdomen, and later passes to the right ileal area. From the 5th month of pregnancy appendix with the caecum is pushed off by the uterus upwards and backwards. It changes the localization of pains. The sharpest morbidity can be not in the right ileal area (McBurney sign), but higher, in the hypochondrium. Pain during pregnancy is not so intensive as in nonpregnant patients. Patients quite often account for occurrence of pains in the abdomen by pregnancy, that is why they address a doctor late and it leads to late hospitalization and operation.
It is difficult to distinguish acute appendicitis during labor from labor pains; the muscle strain of the abdominal wall is weakly expressed. In this case it is necessary to pay attention to local morbidity, Sitcovsky’s symptom, and Bartomier-Michelson’s symptom, neutrophilic leukocytosis. Pain is followed by nausea; vomiting is possible. Temperature increases up to 38º С and over, but can remain normal. Pulse rate during the first day is accelerated up to 90-100 per minute. The tongue at first is slightly coated and wet, then becomes dry.
The protective strain of abdomen muscles on palpation of pregnant is poorly expressed, as the abdominal wall is overdistended, and appendix is located behind the uterus. Rovsing’s sign (intensification of pains in the field of caecum at pressure exerted over the left ileal area) and Sitcovsky’s sign (intensification of pains in the patient’s position on the left side) are not always of importance. The Bartomier-Michelson’s sign is frequently clearly marked, i.e. intensification of pain on palpation of the patient in position on the right side, when appendix is pressed down by uterus, but not on the left side, as in nonpregnant. The sign of irritative peritoneum (Shchotkin-Blumberg symptom) occurs early, its range of definition corresponds to spread of inflammatory reaction in the abdominal cavity. On blood analysis every 3-4 hours leukocytosis can increase up to 9x109/l — 12.0x109/l; from the second day erythrocyte sedimentation rate (ESR) also increases.
Acute appendicitis should be differentiated from early gestosis, renal colic, pyelonephritis, cholecystitis, pancreatitis, acute gastritis, ectopic pregnancy, pneumonia and torsion of cystic pedicle. With the purpose of differential diagnosis the following should be researched: Pasternatsky’s sign (negative at appendicitis), urine (it should not contain any pathological elements), feces (character of stool); auscultation of the lungs is made (in doubtful cases roentgenoscopy should be performed); the pregnant is necessarily examined bimanually, chromocystoscopy is carried out (at renal colic the indigo carmine is not excreted from the blocked ureter).
During the first half of pregnancy an increased temperature, nausea and vomiting charactristic of early toxicosis can be also signs of acute appendicitis. In the second half of pregnancy, when appendix is located high, appendicitis is especially difficult to differentiate from right-side pyelonephritis. The onset of the disease is different: appendicitis always begins with pains, then temperature rises and vomiting occurs; pyelonephritis begins with chill, vomiting, fever, and only after that pains occur.
Treatment is the same as without pregnancy: diagnosis serves the indication to obligatory operation. Simultaneously medicines should be administered to prevent abortion. When the clinical picture of appendicitis is not clear enough, a case monitoring for not more than 3 hours is possible.
During this time it is necessary to take differential-diagnostic measures. In case of confirmation of the diagnosis or impossibility to exclude it the operation is necessary.
Similar to non-pregnancy, at noncomplicated acute appendicitis appendectomy should be performed, and the wound sutured tightly. If the access to the appendix is complicated due to enlarged uterus, the woman should be turned to the left side. Any complication of appendicitis (periappendiceal abscess, peritonitis of any spread) is the indication to a good drainage of the abdominal cavity with the subsequent active aspiration and introduction of antibiotics into the abdominal cavity. Subsequent extent of treatment is defined by spread of the process: in pregnant, as well as in nonpregnant, acute appendicitis can be complicated by periappendiceal mass (periappendiceal abscess, local, diffuse or general peritonitis that determines surgical approach, treatment and prognosis.
After the operation the treatment preventing miscarriage is continued, including suppositories with papaverine, injections of magnesium sulfate, no-spa, vitamin Е, in the II-III trimester — partusisten intravenously. The incidence of abortions after the operation ranges within the limits of 0.9-3.8 %. If operation and postoperative period have passed without complications and signs of threatening abortion are not present, the woman is allowed to get up on the 4-5th day, but not on the 2-3rd day as in non-pregnancy.
The development of labor soon after appendectomy is undesirable. Contractions of the uterine musculature, changes of uterine configuration after birth disturb the process of exudate encapsulation, leading to development of generalized peritonitis. The question on volume of operation in these cases is decided individually. At diffuse purulent peritonitis caused by a phlegmonous or gangrenous appendicitis, a delivery is made by cesarean section with subsequent amputation or extirpation of the uterus. After that the appendix is removed, the abdominal cavity is drained. In other cases extraperitoneal cesarean section is made with preservation of uterus at proceeding treatment of peritonitis. At last, the treatment of peritonitis on a background of proceeding pregnancy is possible at its small term with the purpose of not so much to preserve pregnancy (further, after convalescence the abortion is possible), as to preserve a reproductive function. At term or almost term pregnancy (36-40 wk) in view of inevitability of labor on a background of peritonitis the operation is started with cesarean section, then after suturing of uterus and peritonization of the suture, appendectomy and treatment of peritonitis are provided.
Periappendiceal mass is treated conservatively at the surgical department up to its resorption or abscess formation. If resorption of periappendiceal mass takes place, appendectomy should be made in 6 months.
Pregnant women, who had appenectomy, should undergo abortion not earlier than 2-3 weeks after the operation at noncomplicated course of postoperative period.
Date added: 2022-12-25; views: 200;