Management of a Walled-off Perforated Appendix in a 39^th Week Gestational Pregnancy: A Case Report

Aazim Arif^1, , Cilia Nazef¹, Karolain Garcia¹, Aman Kataria², Alexander Baradei³ and Kristy Crawford D.O.^{4, 5}

¹Florida State University College of Medicine, Fort Pierce Campus, Fort Pierce, FL

²Florida State University College of Medicine, Orlando Campus, Orlando, FL

³Florida State University College of Medicine, Sarasota Campus, Sarasota, FL

⁴Clinical Assistant and Professor at Florida State University College of Medicine, Fort Pierce Campus, FL

⁵Department of Obstetrics and Gynecology, Indian River Medical Center, Vero Beach, FL

Cite this paper

Aazim Arif, Cilia Nazef, Karolain Garcia, Aman Kataria, Alexander Baradei and Kristy Crawford D.O.. Management of a Walled-off Perforated Appendix in a 39^th Week Gestational Pregnancy: A Case Report. American Journal of Medical Case Reports. 2019; 7(5):87-89. doi: 10.12691/AJMCR-7-5-3

Abstract

Background: One of the most common surgical problems that requires emergent intervention during pregnancy is acute appendicitis [1]. The incidence of appendicitis during pregnancy is 1 in 766 births, with 16% of the diagnoses occurring within the third trimester [1,2]. Acute appendicitis, with subsequent wall-off perforation, can pose a great risk to both the mother and the fetus. Thus, it is extremely important to recognize and correctly diagnose acute appendicitis, in all trimesters of pregnancy. Case Presentation: This case report discusses a 30-year-old G1P0 with a gestation age of 39.6 who presented to the hospital with complaint of flank pain that waxed and waned. The medical team consisting of labor and delivery nurses, obgyn attending physician and a general surgery attending. Possible etiologies for such presentation including UTI, nephrolithiasis, pyelonephritis, uterine abruption, uterine rupture or musculoskeletal causes were all effectively ruled out. MRI was then performed and suggested appendicitis with associated appendicolith. The risk of perforation and potential complication was discussed amongst the patient, obstetrician and general surgeon. The patient was given an active participation in the decision making and ultimately decided that she would like to proceed with cesarean and appendectomy. Conclusions: Given the nonclassical presentation of acute appendicitis in pregnancy, a closer evaluation for the underlying etiology is warranted. Acute appendicitis in pregnancy should not be excluded based on clinical evaluation alone, as there is great risk posed to the mother and fetus if missed. Imaging should be performed if no other underlying etiology can account for the clinical features. Any diagnostic uncertainty may delay surgical intervention resulting in risk of maternal morbidity and potential fetal mortality. In term patients, expeditious delivery followed by appendectomy may be warranted.

Keywords

pregnancy, acute appendicitis, management

Copyright

This work is licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/

References

[1]	Tamir, I. L., Bongard, F. S., & Klein, S. R. (1990). Acute appendicitis in the pregnant patient. Am J Surg, 160(6), 571-575; discussion 575-576.
[2]	Weingold, A. B. (1983). Appendicitis in pregnancy. Clin Obstet Gynecol, 26(4), 801-809.
[3]	Snyder, M. J., Guthrie, M., & Cagle, S. (2018). Acute Appendicitis: Efficient Diagnosis and Management. Am Fam Physician, 98(1), 25-33.
[4]	Segev, L., Segev, Y., Rayman, S., Nissan, A., & Sadot, E. (2017). Acute Appendicitis During Pregnancy: Different from the Nonpregnant State? World J Surg, 41(1), 75-81.
[5]	Arer, I. M., Alemdaroglu, S., Yesilagac, H., & Yabanoglu, H. (2016). Acute appendicitis during pregnancy: case series of 20 pregnant women. Ulus Travma Acil Cerrahi Derg, 22(6), 545-548.
[6]	Zingone, F., Sultan, A. A., Humes, D. J., & West, J. (2015). Risk of acute appendicitis in and around pregnancy: a population-based cohort study from England. Ann Surg, 261(2), 332-337.
[7]	Smith, M. P., Katz, D. S., Lalani, T., Carucci, L. R., Cash, B. D., Kim, D. H., . . . Rosen, M. P. (2015). ACR Appropriateness Criteria(R) Right Lower Quadrant Pain--Suspected Appendicitis. Ultrasound Q, 31(2), 85-91.
[8]	Long, S. S., Long, C., Lai, H., & Macura, K. J. (2011). Imaging strategies for right lower quadrant pain in pregnancy. AJR Am J Roentgenol, 196(1), 4-12.
[9]	Hurwitz, L. M., Yoshizumi, T., Reiman, R. E., Goodman, P. C., Paulson, E. K., Frush, D. P., . . . Barnes, L. (2006). Radiation dose to the fetus from body MDCT during early gestation. AJR Am J Roentgenol, 186(3), 871-876.
[10]	Bickell, N. A., Aufses, A. H., Jr., Rojas, M., & Bodian, C. (2006). How time affects the risk of rupture in appendicitis. J Am Coll Surg, 202(3), 401-406.
[11]	Yilmaz, H. G., Akgun, Y., Bac, B., & Celik, Y. (2007). Acute appendicitis in pregnancy--risk factors associated with principal outcomes: a case control study. Int J Surg, 5(3), 192-197.
[12]	Mazze, R. I., & Kallen, B. (1991). Appendectomy during pregnancy: a Swedish registry study of 778 cases. Obstet Gynecol, 77(6), 835-840.
[13]	House, J. B., Bourne, C. L., Seymour, H. M., & Brewer, K. L. (2014). Location of the Appendix in the Gravid Patient. The Journal of Emergency Medicine, 46(5), 741-744.
[14]	Halvorsen, A. C., Brandt, B., & Andreasen, J. J. (1994). [Appendicitis in pregnancy. Complications and treatment]. Ugeskr Laeger, 156(9), 1308-1310.