Acute appendicitis in pregnancy

Introduction to pregnancy with acute appendicitis Acute appendicitis (acuteappendicitis) is the most common surgical complication during pregnancy. The incidence of acute appendicitis in pregnant women is the same as that in non-pregnancy. It can occur in various stages of pregnancy. It is most common in the second trimester. It is difficult to diagnose acute appendicitis during pregnancy. It is faster and has many complications, so early diagnosis and timely treatment are extremely important. basic knowledge The proportion of illness: 0.006% Susceptible population: pregnant women Mode of infection: non-infectious Complications: acute diffuse peritonitis sepsis paralytic ileus

Pregnancy with acute appendicitis

(1) Causes of the disease

The cause of appendicitis is due to blockage of the appendix lumen and invasion of bacteria or acute exacerbation of chronic appendicitis. The pressure of the appendix wall after the second trimester of pregnancy forces the appendix lumen to be easily blocked, and the cecal appendix gradually increases with the palace. Upward movement also caused distortion of the appendix, adhesion, ischemia and occlusion of the lumen, resulting in a relatively increased incidence of appendicitis after the second trimester.

(two) pathogenesis

1. After the second trimester, the uterus enlarges rapidly. The cecum and appendix gradually rise from the armpit, causing the appendix to move upwards, outwards, and backwards. The position of the appendix changes, making the typical signs of appendicitis lose the clinical significance. .

2. During the pregnancy, the abdominal wall muscles are slack, the appendix is covered by the uterus and away from the abdominal wall, and the enlarged uterus raises the abdominal wall, the peritoneum of the parietal layer is opened, and the peritoneum is not easily stimulated by the inflammation appendix, so that the typical abdominal signs are not obvious.

3. The increase of steroid hormone secretion during pregnancy causes the local defense of the appendix and its self-limiting mechanism to be affected, which promotes the development of inflammation. In addition, the pelvic blood vessels are rich, and the congestion and inflammation are easy to spread with the blood. The enlarged palace body blocks the appendix and makes The omentum is relatively short and displaced. When the omentum is pushed up to the abdomen to make the position of the inflammation appendix up, the infection is easy to spread in the upper abdomen, and is not easily confined by the omentum. Therefore, appendicitis develops rapidly during pregnancy and has many complications.

Acute appendicitis can be divided into acute simple appendicitis, acute suppurative appendicitis, acute gangrenous appendicitis and appendix perforation, early appendicitis congestion and edema, inflammation is limited to the mucosa, simple appendicitis; further inflammation develops later, appendix Highly congested, swollen, obvious ulcer and mucosal necrosis in the appendix cavity, small abscess formation, acute suppurative appendicitis, partial or complete necrosis of the appendix in the late stage, dark red or black, such as combined perforation, inflammation limitation, can form the appendix Abscess around.

Pregnancy with acute appendicitis prevention

Due to changes in pregnancy, the clinical manifestations of appendicitis are not typical, and the laboratory does not help much. In order to reduce maternal and fetal mortality, such as suspected acute appendicitis, it is sometimes necessary to relax the indication for open exploration.

Pregnancy complicated with acute appendicitis complications Complications acute diffuse peritonitis sepsis paralytic ileus

Pregnancy with appendicitis due to its particularity, more likely to occur perforation of the appendix, if the inflammation spread, causing diffuse peritonitis, can lead to sepsis, paralytic ileus, portal phlebitis, multiple liver abscess and other serious consequences, to the mother Infant life is extremely dangerous.

Pregnancy with acute appendicitis symptoms Common symptoms Appendice around the appendix Abdominal rebound tenderness Abdominal pain Right lower quadrant tenderness Appendice Perforation Diarrhea Peritonitis Nausea Approximate pregnancy reaction

Symptom

(1) Abdominal pain: The inherent rule of metastatic abdominal pain in most pregnant women with acute appendicitis is unchanged. Abdominal pain often begins under the xiphoid process and extends to the umbilical cord. After several hours or ten hours, it is transferred to the right side. In the lower abdomen, some patients have atypical symptoms. In the early pregnancy, the symptoms of appendicitis are similar to those in non-pregnancy. In the middle and late pregnancy, the position of the appendix changes due to the increase of the uterus in the pregnancy. The painful part of the pregnant woman can reach the right subcostal area or In the right posterior lumbar region, the pain may be lighter than during non-pregnancy.

(2) Other symptoms: may have nausea, vomiting, diarrhea and other symptoms, some patients may be accompanied by fever, general malaise or fatigue.

2. Signs

The tenderness point of appendicitis during pregnancy can continue to move up with the increase of uterus. In early pregnancy, at the point of the right lower abdomen, there is tenderness and rebound tenderness, accompanied by muscle tension, such as gangrene or perforation of the appendix, which can form around the appendix. Abscess or diffuse suppurative peritonitis, corresponding signs, the middle and late pregnancy, tenderness points can be high, abdominal rebound pain and muscle tension are not obvious, such as accompanied by abscess around the appendix, can touch the mass, accompanied by tenderness, Since the tenderness area can be masked by the factor palace, the following methods can be used to assist in the diagnosis:

1Bryan test: It can be used as a reliable sign to distinguish between appendicitis and uterine diseases. The specific method is to take the right lateral position of the patient, and the pregnant uterus moves to the right side to cause pain, which may cause pain and non-uterine diseases.

2Aldel test: the patient is supine, the examiner puts his finger on the most obvious tender point in the appendix area, and then the patient is placed in the left lateral position. After the uterus falls to the left side, if the tenderness is relieved or disappears, the pain comes from the uterus, such as tenderness. More obvious than in the supine position, the possibility of lesions in the appendix itself is greater.

Examination of pregnancy with acute appendicitis

White blood cell count normal white blood cells in pregnancy (6 ~ 16) × 10 ⁹ / L, can be as high as (20 ~ 30) × 10 ⁹ / L during childbirth, so white blood cell count is not helpful for diagnosis, such as white blood cells continue 18 × 10 ⁹ / L or counting in the normal range but the classification has a nuclear left shift also makes sense.

Ultrasound examination can be found that the enlarged appendix has a multi-layered tubular structure with the same accuracy as non-pregnancy, and is convenient and safe. However, the diagnosis is better in the first half of pregnancy, and the uterus is enlarged in the third trimester, and the cecal movement makes the examination difficult.

Laparoscopy for patients with suspected appendicitis can be used for diagnosis and differential diagnosis, but also feasible treatment. Foreign literature reports that non-pregnant women with suspected appendicitis are common and safe, but for appendicitis during pregnancy, most people It is considered that laparoscopic surgery is feasible without simple perforation or abscess formation in patients with simple appendicitis or suppurative appendicitis before the second trimester. It can be used for differential diagnosis, but the operation time should not be too long, so as to avoid harm to mother and baby. Too large, difficult to expose, it is not suitable for mother and child.

CT and X-ray should be carefully selected for the diagnosis and differential diagnosis of appendicitis during pregnancy.

Diagnosis and diagnosis of pregnancy complicated with acute appendicitis

diagnosis

Due to the anatomical and physiological characteristics of the appendix during pregnancy, the symptoms of abdominal pain can be atypical at the time of onset, and the abdominal signs are not obvious, which makes it difficult to diagnose and differentially diagnose early and late acute appendicitis in pregnancy. Mourad et al. (2000) reported that during early pregnancy The pre-diagnosis rate is up to 77%, but only 57% in the middle and late pregnancy. About 20% of pregnant women are diagnosed when the perforation of the appendix or concurrent peritonitis is performed. The course of appendicitis in pregnancy is developing rapidly, the perforation of appendix and the incidence of peritonitis Obviously higher than non-pregnancy, perforation rate and necrosis rate in late pregnancy are significantly higher than early and mid-pregnancy. The literature reports that the perforation rate of appendectomy in non-pregnancy is about 15%, early pregnancy, mid-term reaches 31%, and late pregnancy can rise to 69. %, therefore, early diagnosis of appendicitis during pregnancy is the key, the diagnosis should pay attention to detailed history, the symptoms and signs of appendicitis in the early pregnancy are the same as the general patients, but the digestive symptoms caused by appendicitis should be differentiated from pregnancy reaction, pregnancy reaction It is more obvious on an empty stomach and has no symptoms of abdominal pain. The symptoms of abdominal pain and tenderness at the appendix are often in the middle and late pregnancy. High; perinatal period should pay attention to the symptoms and abdominal pain and uterine pain phase difference.

Differential diagnosis

When clinicians diagnose patients with acute abdominal pain during pregnancy, they must master the clinical manifestations of appendicitis during pregnancy, and with gynecological diseases such as premature delivery, uterine contraction pain at the time of labor, attachment torsion, corpus luteum rupture, ectopic pregnancy, Placental abruption, uterine fibroid degeneration, round ligament syndrome, etc.; pregnant women with upper gastrointestinal symptoms and upper abdominal pain must be differentiated from upper abdominal surgery, such as acute gastroenteritis, cholecystitis, cholelithiasis, Pancreatitis, intestinal obstruction, right ureteral calculi, mesenteric lymphadenitis, etc.

Ovarian tumor pedicle torsion

More common in early pregnancy, mid-term and postpartum, often have a history of lower abdominal mass, manifested as sudden, persistent lower abdominal pain, such as tumor blood supply obstruction, tumor necrosis, may have localized peritonitis, double examination, can Touching the cystic or cystic mass, there is tenderness, B-ultrasound can be clearly diagnosed.

2. Ectopic pregnancy rupture

Should be differentiated from acute appendicitis in early pregnancy, patients with a small amount of irregular vaginal bleeding after menopause, persistent lower abdominal pain and anal bulge, double examination, cervical pain, post-palat can be full, tender, right attachment The area can touch the mass, and the B-ultrasound shows that there is a liquid dark area in the pelvic cavity. If the posterior iliac puncture is not coagulated, the diagnosis can be confirmed.

3. Right acute pyelonephritis

Rapid onset, general high fever after chills, pain begins in the lumbar flank, along the ureter to the bladder area, accompanied by urinary pain, frequent urination, urgency and other bladder irritation symptoms, check the right kidney area slamming pain, There were tenderness in the upper ureteral point and the rib waist point, no peritoneal irritation, and a large number of pus cells and white blood cell casts were observed under conventional urinary microscope.

4. Right ureteral calculi

The colic is severe, the pain is in the lumbar flank, and the inner thigh and the external genitalia are radiated. The laboratory can check the red blood cells in the urine, and the X-ray or B-ultrasound can show the urinary calculi.

5. biliary colic

More common in acute cholecystitis and cholelithiasis, pain is more common in the right upper abdomen under the costal margin, paroxysmal cramps, multiple nights, can be sent to the right shoulder, right shoulder squat or right waist, 80% of patients may have chills, fever , nausea, vomiting, or obstructive jaundice, X-ray, B-ultrasound or gallbladder angiography can help diagnose.

6. Acute perforation of upper gastrointestinal ulcer

Often there is a history of ulcers, usually full abdominal pain, check the abdominal muscle tension, tenderness and rebound tenderness, X-ray standing examination more than the underarm free gas, can help diagnose.

7. Placental abruption

Should be differentiated from acute appendicitis in the third trimester of pregnancy, placental abruption often has a history of pregnancy-induced hypertension and trauma, severe abdominal pain, check the uterus hard, stiff contraction, fetal heart slow or disappear, maternal can have acute blood loss and shock symptoms, abdominal B-ultrasound The hematoma after the placenta is displayed, and the diagnosis can be confirmed.

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