Editing Appendicitis (section)

== '''Appendicitis in pregnancy''' ==

* Most common surgical     pathology of pregnancy - 1/1500 confirmed appendicitis
* Progresses more quickly -     immunosuppression of pregnancy
* Atypical presentation in     40-50% of patients
** Emesis, migratory RIF pain,      rebound tenderness, elevated Alvarado score were all useful indicators
*** Nausea/vomiting common in       pregnancy
*** Mild leucocytosis is normal       in pregnancy
*** Mild elevation in CRP is       normal in pregnancy
** One study from AJ Surgery      reported a sensitivity of 100% in 164 patients for left shift and      neutrophils >70%
** Uncommon in first and third      trimester - 50% of cases occur in second trimester
** DDx UTI/pyelo,      hydronephrosis, degenerative uterine fibroids, ligamentous pain, ectopic      ruptured, ovarian torsion (most common in first trimester), ovarian      hyperstimulation syndrome
* Differential diagnosis
** Ectopic
** Torsion
** Ovarian cyst accident
** Placental abruption      (generalised pain, PV bleeding)
** Uterine rupture (previous      surgery)
** Pre-eclampsia/HELLP (usually      RUQ pain)
* Routine imaging is     recommended
** Use USS/MRI (without      contrast) to diagnose
** USS is most useful in first      trimester - after that, very rarely able to see it, and se/sp <70%
** MRI:
*** Use T2 phase - will be       darkish tubular structure
*** Gradient Echo phase or DWI       are the other useful phases
*** Should be able to see       oedema and stranding if it's present
*** On DWI, inflammation shows       as quite bright
*** Don't mistake the ureter       and ovarian vein lying on top of psoas for the appendix
*** MRI sensitivity 92% (maybe       a bit more)
* Can potentially use low-dose     CT, but, uh, hmm
** Theoretically 1 in 500      fetuses will develop cancer because of this dose, and riskiest time is      between 8 to 15 weeks
** However in one study it      reduced the negative appendicectomy rate from 32% (with USS) to 8%
* Management
** Unwell patients with O+G dx      excluded can be taken to OT without confirmatory imaging
** Well and likely appendicitis      with O+G dx excluded can also go to OT without imaging confirmation if      there are delays - constantly reassess timing
** If well, and      unlikely/possible appendicitis, image
** Laparoscopic is the      preferred technique, but open can be used
** Cut-down 2cm above uterine      fundus is a safe way to do it
** Lowest effective intra-abdo      pressure
** Minimise head down
** Indomethacin PR if suggested      by O+G
* Prognosis
** Uncomplicated appendicitis      a/w 3-5% fetal loss
** Complicated appendicitis      leads to pre-term labour in 11% and fetal loss in 36%
** Negative appendicectomy also      likely leads to risk of pre-term labour and fetal loss, although this      risk may be overstated

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