Acute appendicitis in pregnancy

Abstract

Akutni apendicitis je najčešći neopstetrički uzrok akutnog abdomena u trudnoći. Javlja se u 1/500-2000 trudnoća i obuhvaća 25% operativnih indikacija za akutni abdomen u trudnoći. Čini se da je apendicitis češći u drugom tromjesečju trudnoće, s incidencijom od 35-50%, međutim nema dokazanih podataka da trudnoća utječe na cjelokupnu učestalost apendicitisa. Ne postoji niti jedan posve pouzdan znak ili simptom koji bi mogao pomoći u dijagnosticiranju apendicitisa u trudnoći, a neki od klasičnih znakova nisu se pokazali od kliničke važnosti prilikom dijagnosticiranja akutnog apendicitisa u trudnoći. Konstantna bol u trbuhu je najčešći, a bol u donjem desnom kvadrantu (prisutna u 75-84% bolesnica) je najpouzdaniji simptom. Nakon provedenih dijagnostičkih postupaka u bolnici i potvrđene dijagnoze akutnog apendicitisa, liječenje je uvijek kirurško uklanjanje apendiksa. Operacije se mogu izvesti na nekoliko različitih načina, a jednostavno ih možemo podijeliti na otvorene (laparotomije) i laparoskopske postupke. Sve izvađene biološke uzorke treba poslati na patohistološki pregled, jer se i u populaciji trudnih bolesnica može naći i druga patologija osim apendicitisa. Neke od potencijalnih prednosti laparoskopske apendektomije u trudnih bolesnica uključuju: smanjenu fetalnu depresiju zbog smanjenih zahtjeva za postoperativnim opioidima, manji rizik od komplikacija i smanjenu postoperativnu hipoventilaciju majke. Danas je kombinirana stopa pobačaja i fetalnog mortaliteta vezana za akutni apendicitis u trudnoći u opadanju; kada apendiks nije perforiran stopa je 0-5%, a kada je apendiks perforiran, smrtnost fetusa raste do 20-36%. Ukupan mortalitet majki je manji od 1%. Rijedak je u prvom tromjesečju, a povećava se s napredovanjem gestacijske dobi te je povezan je s odgađanjem operacije više od 24 sata po pojavi simptoma i perforacijom apendiksa.Acute appendicitis is the most common non-obstetric cause of acute abdomen in pregnancy. It is present in 1/500-2.000 pregnancies and amounts 25% of operative indications for the acute abdomen in pregnancy. Appendicitis seems to be more common in the second trimester of pregnancy with incidence of 35-50%, however there are no proven data that pregnancy affects the overall incidence of appendicitis. There is not one, completely reliable sign or symptom that could help diagnose appendicitis in pregnancy, and some of the classic signs have not been shown to be of clinical significance in diagnosing an acute appendicitis in pregnancy. Constant abdominal pain is the most common symptom and pain in the right lower quadrant (present in 75-84 % of patients) is the most reliable symptom. Once investigations have been carried out in hospital and the diagnosis of acute appendicitis has been confirmed, management is always surgical removal of the inflamed appendix. This can be performed in several different procedures simply divided into laparotomy or laparoscopy procedures. All the extracted specimens should be sent to pathohistological examination because in the pregnant patient group other pathologies besides appendicitis could be found. Potential advantages of laparoscopic appendectomy in pregnant patients include decreased fetal depression due to lessened postoperative narcotic requirements, lower risks of wound complications and diminished postoperative maternal hypoventilation. Today, combined miscarriage/fetal mortality is declining; when the appendix is not perforated is 0-5%, and when the appendix is perforated, the fetal mortality rises to 20-36%. Overall, maternal mortality is less than 1%. It is rare in the first trimester, it increases with advancing gestational age, and is associated with: a delay in surgery of more than 24 hours after onset of symptoms and appendiceal perforation