apendicitis gestantes

8/15/2019 Apendicitis Gestantes

1/6

Appendectomy During Pregnancy:Follow-Up of Progeny

Jacqueline J Choi, MD, Rose Mustafa, MD, Elizabeth T Lynn, MD, Celia M Divino, MD, FACS

BACKGROUND: The incidence of appendicitis in pregnant patients is 0.04% to 0.20%, making it the mostcommon nonobstetric surgical procedure in pregnancy. This study examines whether an ap-pendectomy during any stage of pregnancy affects future development of motor, sensory, andsocial skills of the progeny.

STUDY DESIGN: A prospective survey was administered to women who underwent an appendectomy during pregnancy at Mount Sinai Hospital from 2000 to 2009. The survey, which ranged from 1 to 9years postpartum, consisted of questions about motor, sensory, and social development of theirprogeny, based on established pediatric milestones. Data were collected from the medicalrecords of mother andchild. Additional follow-up was gathered from outpatient and emergency room records.

RESULTS: Fifty-two pregnant patients underwent an appendectomy during our study period. Allpregnancies continued to full term with the exception of one fetal death due to extremeprematurity. Twenty-nine patients completed the follow-up survey, making the yield re-sponse rate 55.8%. There were 7 (26.9%), 14 (48.3%), and 8 (27.6%) appendectomies inthe first, second, and third trimesters, respectively. Mean follow-up time was 47.2 months(range 13 to 117 months) after delivery. None of the children exhibited any developmentaldelay by their third year of life. Timing of the surgery (trimester) had no effect on childdevelopment.

CONCLUSIONS: Appendectomy during pregnancy is not associated with developmental delays in children,regardless of which trimester the procedure was performed. All children in this study hadnormal motor, sensory, and social development by 3 years of age. (J Am Coll Surg 2011;213:627–632. © 2011 by the American College of Surgeons)

Once regarded as high risk procedures, appendectomies inpregnant women are now performed with less hesitation.The incidence of appendicitis in pregnant patients is0.04% to 0.20%, making it the most common nonobstet-ric surgical procedure in pregnancy.1,2 Current literaturehas focused mainly on the safety of appendectomy during pregnancy based on immediate outcomes, while neglecting to examine the long-term effects on the progeny after sucha procedure. In this cohort, we focused on whether anappendectomy during any stage of pregnancy has an effect

on the child’s future development of motor, sensory, andsocial skills.

METHODS

After approval by the Institutional Review Board at TheMount Sinai Hospital, a search was done for all women who underwent an appendectomy during pregnancy at theinstitution from 2000 to 2009. Data collected included in-formation from emergency room admission, operative notes,pathology reports, progress notes, and discharge notes, as wellas any follow-up information fromoffice visits and emergency room records after the appendectomy. Obstetric notes werealso accessed regarding the pregnancy and delivery, and pedi-atric records were accessed if available.

A prospective questionnaire was also administered to allpatients to follow up on their child’s growth and develop-ment up to 9 years of age. The questionnaire was mailedout and then followed up via telephone approximately 2 weeks later. All patients were asked questions regarding their child’s motor, sensory, and social skills based on es-tablished pediatric milestones for 3 months, 6 months, 12months, 18 months, and 24 months of age (Table 1).They were also asked questions regarding physical health anddevelopment based on height, weight, and any relevant

Disclosure Information: Nothing to disclose.

Received May 25, 2011; Revised July 17, 2011; Accepted July 18, 2011.From the Division of General Surgery, Department of Surgery, The MountSinai School of Medicine, New York, NY.Correspondence address: Celia M Divino, MD, FACS, 1 Gustave L Levy Place, Box 1259, New York, NY 10029. email: [email protected]

627© 2011 by the American College of Surgeons ISSN 1072-7515/11/$36.00

Published by Elsevier Inc. doi:10.1016/j.jamcollsurg.2011.07.016

mailto:[email protected]:[email protected]:[email protected]


2/6

health issues. Patients who had children older than 2 yearsold at the time of the follow-up questionnaire were thenasked additional questions regarding health and develop-ment up to their current age.

Statistical analysis for categorical variables was per-formed with the Fisher exact test using the program R Foundation for Statistical Computing. Continuous vari-

ables were analyzed using the t -test on the program Graph-Pad Prism.

RESULTS

There were 52 pregnant patients who underwent an appen-dectomy during our study period. All pregnancies contin-ued to full term with the exception of one fetal death due toextreme prematurity. Twenty-nine patients completed thefollow-up survey (55.8% response rate). Patient character-istics are outlined in Table 2. Mean follow-up time was47.2 months (range 13 to 117 months) after delivery.

The average age of surveyed patients was 30.9 years(range 20 to 42 years) and the average gestational age attime of appendectomy was 20.0 (range 5.0 to 35.5) weeks.There were 7 (26.9%), 14 (48.3%), and 8 (27.6%) appen-dectomies in the first, second, and third trimesters, respec-tively. There were 23 (79.3%) cases performed laparoscopi-cally, 5 (17.2%) cases performed as open procedures, and 1(3.4%) requiring conversion from laparoscopic to open.Four (13.8%) patients had complicated cases of appendi-citis with either gangrene or perforation, and 24 (82.8%)patients had cases of catarrhal or suppurative appendicitis.There was 1 (3.4%) case that proved to be negative forappendicitis on pathologic examination and was attributedto renal colic. All patients underwent appendectomy withgeneral anesthesia and received prophylactic antibiotictreatment. Antibiotics administered included cefezolin,unasyn, cefotetan, clindamycin, and metronidazole, whichare all FDA category B drugs for pregnancy. The meanlength of time under anesthesia was 92.1 minutes. Thepreoperative diagnosis of appendicitis was made based onclinical presentation with confirmation with radiographicimaging. All patients underwent abdominal ultrasound, which is the preferred method of imaging due to a lack of ionizing radiation. However, 11 (37.9%) had additionalCT scans performed because of inconclusive ultrasoundfindings. The average hospital length of stay after appen-dectomy was 2.5 days (range 1 to 6 days). Uterine contrac-tions developed in 2 patients (6.9%), 1 in each of thesecond and third trimesters, but both were resolved with

tocolytics. Postoperative complications were otherwiselimited to 1patient with postoperative fever.The mean gestational age at delivery was 39.3 weeks

(range 36.3 to 41.4 weeks). The most common complica-tion of pregnancy was a positive test for Group B Strepto-coccus, which was present in 6 (20.7%) mothers. There was also 1 patient who developed gestational diabetes, 1 who had first trimester bleeding, and 1 who required a cerclage due to an incompetent cervix.

There were 23 (79.3%) vaginal deliveries, 4 (13.8%)scheduled cesareans, and 2 (6.9%) emergent cesareans.

Table 1. Developmental Milestones

Age/skills Milestones

3 mo

Motor skills Lift head while lying on stomach

Follow moving objects with eyes

Sensory skills Recognize bottle or breast

Turn to sound of human voice

Language/social skills Make cooing, gurgling sounds

Smile when smiled at

6 mo

Motor skills Reach and grasp for objects

Sit in high chair

Sensory/thinking skills Open mouth for spoon

Language/social skills Recognize familiar faces

Laugh and squeal with delight

12 mo

Motor skills Grasp small objects with thumb andindex finger

Crawl on hands and knees

Walk while holding onto walls/furniture

Sensory/thinking skills Copy sounds and actions

Attempt simple goals (see and crawltoward a toy)

Language/social skills Say first word

Recognize family members’ names

Raise arms when wanting to bepicked up

18 mo

Motor skills Scribble with crayons

Walk without helpSensory/thinking skills Identify objects in picture book

Look for objects out of sight

Language/social skills Says 8–10 words (“hi, bye, mama,dada,” etc)

Recognize self in mirrors or pictures

24 mo

Motor skills Feed self with spoon

Take steps backwards

Sensory/thinking skills Take things apart

Point to 5–6 body parts

Language/social skills Speak in 2–3 word sentences (“I wantcookie”, etc)

Take turns in play with otherchildren

628 Choi et al Appendectomy in Pregnancy: Progeny J Am Coll Surg


3/6

The emergent cesareans were due to arrested descent and

breech position. One vaginal delivery required vacuumassistance (3.4%). The average Apgar scores for all de-liveries were 8.93 and 9.00 at 1 and 5 minutes, respec-tively. Mean birth weight was 3,361.3 g and mean length was 49.9 cm. There were no multiple births. The mostcommon complication of delivery was chorioamnioitis, which developed in 2 patients (6.9%) and was resolved with antibiotics without further incident. There werealso 1 case each of fetal bradycardia, thin meconium,and maternal fever.

Twenty-one of the surveyed mothers did not report any

delayed deviation from the established pediatric milestones.The remaining 8 children all caught up to normal rates of development and exhibited no signs of delay by their thirdyear of life. At thetime of follow-up,additional questions wereasked regarding subsequent development or academic perfor-mance in school if applicable. There were no reports of any motor, sensory, or social developmental delay.

On analysis of children who exhibited developmentalvariations compared with those who met all milestones attheir designated age, there were no significant differences

Table 2. Patient Characteristics

Patient characteristics

All surveyed

(n 29)

On-time

development

(n 21)

Variations in

development

(n 8) p Value

Mean age at appendectomy, y 30.9 30.7 31.3 0.848

Race, n (%)

Caucasian 20 (69.0) 13 (61.9) 7 (87.5) 0.810 African American 1(3.4) 1 (4.8) 0 (0.0)

Hispanic 7 (24.1) 6 (28.6) 1 (12.5)

Asian 1 (3.4) 1 (4.8) 0 (0.0)

Mean gestational age at appointment, wk 20.0 20.6 18.6 0.542

Trimester, n (%)

First 7 (26.9) 5 (23.8) 2 (25.0) 0.982

Second 14 (48.3) 10 (47.6) 4 (50.0)

Third 8 (27.6) 6 (28.6) 2 (25.0)

Procedure, n (%)

Open 5 (17.2) 2 (9.6) 3 (37.5) 0.082

Laparoscopic 23 (79.3) 19 (90.5) 4 (50.0)

Converted 1 (3.4) 0 (0.0) 1 (12.5)Mean time under anesthesia, min 92.1 90.2 97.0 0.612

Pathology, n (%) 1.000

Gangrenous/perforated 4 (13.8) 3 (14.3) 1 (12.5)

Acute 24 (82.8) 17 (81.0) 7 (87.5)

Negative/normal 1 (3.4) 1 (4.8) 0 (0.0)

Mean length of stay, d 2.5 2.5 2.5 0.971

Received CT scan, n (%) 11 (37.9) 7 (33.3) 4 (50) 0.433

Mean total gestational age, wk 39.3 39.2 39.4 0.679

Delivery, n (%) 0.647

Normal spontaneous vaginal delivery 23 (79.3) 16 (76.2) 7 (87.5)

Scheduled cesarean section 4 (13.8) 4 (19.0) 0 (0.0)

Emergent cesarean section 2 (6.9) 1 (4.8) 1 (12.5)Forceps/vacuum assistance, n (%) 1 (3.4) 0 (0.0) 1 (12.5) 0.276

Epidural, n (%) 24 (82.8) 18 (85.7) 6 (75) 0.597

Mean birth weight, g 3,361.3 3298.5 3541.0 0.429

Mean birth length, cm 49.9 49.4 51.4 0.544

Mean Apgar score, min

1 8.93 8.95 8.75 0.118

5 9.00 9.00 8.88 1.000

Mean follow-up time, mo 47.2 49.3 42.0 0.528

629Vol. 213, No. 5, November 2011 Choi et al Appendectomy in Pregnancy: Progeny


4/6

found between maternal age (p 0.848) or demographics(p 0.810). It made no difference in which trimester theappendectomy was performed (p 0.982), or whether it was performed as an open or laparoscopic procedure (p

0.082). Additionally, there were no differences in the 2groups based on pathology for gangrenous or perforatedappendices compared with uncomplicated, nonperforatedappendices (p 1.00). There were no differences whetherthe mode of delivery was a natural spontaneous vaginaldelivery or a cesarean section (p 0.647). Mean birth weight (p 0.429), length (p 0.544), and Apgar scoresat 1 and 5 minutes (p 0.118 and p 1.00, respectively) were not predictive of developmental variations in thisstudy (Table 2).

When comparing the progeny by trimester of appendec-tomy, there were no significant differences in any of thepreviously examined variables. Trimester of surgery was notindicative of developmental delay (p 0.864) (Table 3).

There were no significant aberrations or differences inphysical growth and development reported in any of thechildren. Two of the children were diagnosed with torticol-lis shortly after birth, the etiology of which remains unclear.However, neither of these 2 children exhibited any devia-tions of normal development according to the establishedpediatric milestones.

There was 1 fetal death in our study, which occurred at25 weeks gestational age. The mother presented with ele-vated fever, leukocytosis, and severe right lower quadrant

Table 3. Characteristics by Trimester

Patient characteristics

Trimester 1

(n 7)

Trimester 2

(n 14)

Trimester 3

(n 8) p Value

Mean age at appendectomy, y 32.1 30.6 30.3 0.844

Race, n (%)

Caucasian 5 (71.4) 9 (64.3) 6 (75.0) 1.00

African American 0 (0.0) 1 (7.1) 0 (0.0)Hispanic 2 (28.6) 3 (21.4) 2 (25.0)

Asian 0 (0.0) 1 (7.1) 0 (0.0)

Procedure, n (%)

Open 0 (0.0) 2 (14.3) 3 (37.5) 0.194

Laproscopic 6 (85.7) 12 (85.7) 5 (62.5)

Converted 1 (14.3) 0 (0.0) 0 (0.0)

Pathology, n (%) 0.662

Gangrenous or perforated 0 (0.0) 3 (21.4) 1 (12.5)

Acute 7 (100) 10 (71.4) 7 (87.5)

Negative/normal 0 (0.0) 1 (7.1) 0 (0.0)

Mean length of stay, d 2.6 2.29 2.75 0.796

Received CT scan, n (%) 2 (28.6) 5 (35.7) 4 (50.0) 0.610Mean total gestational age, wk 39.5 39.5 38.7 0.164

Delivery, n (%) 0.415

Normal spontaneous vaginal delivery 7 (100) 10 (71.4) 6 (75.0)

Scheduled cesarean section 0 (0.0) 2 (14.3) 2 (25.0)

Emergent cesarean section 0 (0.0) 2 (14.3) 0 (0.0)

Forceps/vacuum assistance, n (%) 1 (14.3) 0 (0.0) 0 (0.0) 0.500

Epidural, n (%) 7 (100) 11 (78.6) 6 (75.0) 0.782

Mean birth weight, g 3,473.7 3,432.6 3,122.6 0.133

Mean birth length, cm 51.0 51.6 45.8 0.167

Mean Apgar score, min

1 9.00 8.86 9.00 0.341

5 9.00 9.00 9.00 1.000Mean follow-up time, mo 42.3 45.1 55.4 0.604

Met all developmental milestones, n (%) 5 (71.4) 10 (71.4) 6 (75) 0.864

Motor skills variation, n (%) 2 (28.6) 1 (7.1) 1 (12.5) 0.606

Sensory variation, n (%) 1 (14.3) 0 (0.0) 0 (0.0)

Speech variation, n (%) 1 (14.3) 4 (28.6) 2 (25.0)



5/6

pain for a perforated gangrenous appendicitis. Placentalabruption occurred before the patient was taken to theoperating room. An emergency cesarean section was per-formed with a concomitant appendectomy, but the infantdied 2 days after delivery due to extreme prematurity. Themother made a complete recovery after a course of IV antibiotics.

DISCUSSION

Studies report appendicitis to be the most common non-obstetric surgical emergency during pregnancy, with an es-timated incidence of 0.04% to 0.2%.1,2 It is generally agreed that the performance of any operation during preg-nancy carries a risk of premature labor averaging 15% to40%.3 However, it is not necessarily the surgery itself thatcarries the highest risk, but the underlying pathology. Out-comes are greatly correlated with prompt diagnosis andtimely treatment.3 A delay in diagnosis, and therefore a delay in surgery, correlate with advanced disease with anincreased risk of perforation. Reports indicate that the fetalmortality after appendectomy in pregnant women rangesfrom 1% to 5% for nonperforated and perforated appen-dices, respectively.2 These statistics make appendicitis a topdiagnostic differential for pregnant patients with com-plaints of abdominal pain despite the trimester of theirgravid uterus.

Diagnosing acute appendicitis in pregnancy can be clin-ically challenging due to the anatomic and physiologicchanges that the body undergoes. The classic sign of rightlower quadrant pain may be displaced by a gravid uterus,and other symptoms such as nausea, vomiting, and fevermay be dismissed as side effects of pregnancy. Similarly,leukocytosis may be masked because white blood cell countis normally elevated during pregnancy.4

In the appropriate setting, with high clinical suspicion,ultrasound has been the primary imaging modality to con-firm appendicitis because of a lack of radiation exposure,bedside availability, and with a sensitivity and specificity of 85% and 92%, respectively.5 In cases where ultrasonogra-phy is nondiagnostic, a CT scan, with 92% sensitivity and99% specificity, is performed.6 Although concern for thepossibility of teratogenic effects of radiation may arise, re-ports have shown that radiation doses the fetus is exposedto from institutional CT protocols are below levels thoughtto induce neurologic detriment to the fetus.7,8

Multiple studies have shown that there is no differencein terms of risk between performing an open vs a laparo-scopic appendectomy.3, 9,10 In a long-term follow-up study on 11 patients, Rizzo11 demonstrated that the minimally invasive approach of laparoscopic surgery in pregnancy issafe and efficacious, without any long-term effects to the

mother, fetus, or resulting child. Laparoscopy offers multi-ple advantages that encompass a reduction in postoperativepain, rapid recovery, fewer pulmonary complications, andconsequently, a shorter hospital stay. Still, there are knowncardiovascular effects of pneumoperitoneum created by

laparoscopic operations, such as the increase in arterial vas-cular resistance due to increased intra-abdominal pressure.This can lead to unfavorable respiratory effects, which canultimately result in hypoxemia and exacerbated fetal acido-sis if not monitored.12 However, hemodynamic changesduring laparoscopic surgery in pregnancy are similar tothose observed in the nonpregnant state, and the occur-rence of a miscarriage, premature labor, or fetal death ap-pears to be related to the underlying pathology, indepen-dent of the operative intervention.13 A study evaluating risks of general anesthesia for appendectomy in pregnant vsnonpregnant women showed that there are no significant

differences in the rate of congenital anomalies.14

Any po-tential effects of surgical trauma that might occur to thefetus should be evident immediately and cease approxi-mately 1 week after appendectomy.15,16

Antibiotics that are contraindicated in pregnancy are nottypically administered for routine prophylaxis in appen-dectomies. All patients in this study received antibiotics atthe time of surgery, and all antibiotics administered wereclassified as FDA category B drugs, indicating that there isno evidence to show fetal harm. Metronidazole use in preg-nant patients is still considered controversial and clinicalopinion recommends against its use during the first trimes-

ter of pregnancy. However, studies have shown that there isno increase in teratogenic risk when used in recommendeddoses regardless of trimester.17,18 Andersen and Nielsen19

also recommended that prophylactic antibiotic treatmentstill be given to pregnant patients in appendectomies.

Developmental guidelines have been established by the American Academy of Pediatrics by examining the pres-ence of motor, sensory, and social skills in children at spe-cific ages and indicating the 50th percentile to define “nor-mal development.”20 Evaluation of these milestones hasbeen widely implemented in the pediatric setting to assessfor developmental delay and implement early interventionif necessary.

The limitation of the milestone concept is that by using the 50th percentile as a point estimate of normal develop-ment, it does not take into consideration a normal range.There is no standardized way to evaluate children whoseskill level is delayed slightly off the mean, but may stillexhibit appropriate development for their age. So theremay be a higher reported incidence of developmental delay,causing unnecessary alarm among parents. Studies recom-mending evaluation based on 10th, 50th, and 90th percen-

631Vol. 213, No. 5, November 2011 Choi et al Appendectomy in Pregnancy: Progeny


6/6

tiles establish a more accurate guide to include the varia-tions in “normal” child development.21

In conclusion, this study demonstrates that appendec-tomy during pregnancy is not associated with long-termdevelopmental delays in children up to 9 years old, regard-

less of trimester in which the procedure was performed.Children may demonstrate acquisition of developmentalskills at varying rates. However, all children in this study had normal motor, sensory, and social development by 3years of age. A larger study evaluating child developmentbased on a normal range would be recommended to draw more definitive conclusions.

Author Contributions

Study conception and design: Choi, Lynn, Divino Acquisition of data: Choi, Mustafa, Lynn, Divino

Analysis and interpretation of data: Choi, DivinoDrafting of manuscript: Choi, Mustafa, Lynn, DivinoCritical revision: Choi, Divino

REFERENCES

1. Yilmaz HG, Akgun Y, Bac B, Celik Y. Acute appendicitis inpregnancy–risk factors associated with principal outcomes: a case control study. Int J Surg 2007;5:192–197.

2. Zhang Y, Zhao YY, Qiao J, Ye RH. Diagnosis of appendicitisduring pregnancy and perinatal outcome in the late pregnancy.Chin Med J (Engl) 2009;122:521–524.

3. Sadot E,Telem DA, Arora M, et al.Laparoscopy: a safe approachto appendicitis during pregnancy. Surg Endosc 2010;24:383–389.

4. Musselman RC, Nunnelee JD, Ware DB. Appendicitis during pregnancy. Clin Excell Nurse Pract 1998;2:338–342.

5. Orr RK, Porter D, Hartman D. Ultrasonography to evaluateadults for appendicitis: decision making based on meta-analysisand probabilistic reasoning. Acad Emerg Med 1995;2:644–650.

6. Lazarus E, Mayo-SmithWW, Mainiero MB, Spencer PK. CT inthe evaluation of nontraumatic abdominal pain in pregnant

women. Radiology 2007;244:784–790.

7. Butala P, Greenstein AJ, Sur MD, et al. Surgical management of acute right lower-quadrant pain in pregnancy: a prospective co-hort study. J Am Coll Surg 2010;211:490–494.

8. Binnebosel M, Otto J, Stumpf M, et al. [Acute appendicitis.Modern diagnostics–surgical ultrasound]. Chirurg 2009;80:579–587.

9. Lyass S, Pikarsky A, Eisenberg VH, et al. Is laparoscopic appen-dectomy safe in pregnant women? Surg Endosc 2001;15:377–379.

10. Moreno-Sanz C, Pascual-Pedreno A, Picazo-Yeste J, et al. [Lapa-roscopic appendicectomy and pregnancy. Personal experienceand review of the literature]. Cir Esp 2005;78:371–376.

11. Rizzo AG. Laparoscopic surgery in pregnancy: long-termfollow-up. J Laparoendosc Adv Surg Tech A 2003;13:11–15.

12. Amos JD, Schorr SJ, Norman PF, et al. Laparoscopic surgery during pregnancy. Am J Surg 1996;171:435–437.

13. Al-Fozan H, Tulandi T. Safety and risks of laparoscopy in preg-nancy. Curr Opin Obstet Gynecol 2002;14:375–379.

14. Duncan PG, Pope WD, Cohen MM, Greer N. Fetal risk of anesthesia and surgery during pregnancy. Anesthesiology 1986;64:790–794.

15. Hee P, Viktrup L. The diagnosis of appendicitis during preg-nancy and maternal and fetal outcome after appendectomy. Int

J Gynaecol Obstet 1999;65:129–135.16. Mazze RI, Kallen B. Appendectomy during pregnancy: a Swed-

ish registry study of 778 cases. Obstet Gynecol 1991;77:835–840.

17. Diav-Citrin O, Shechtman S, GotteinerT, et al. Pregnancy out-come after gestational exposure to metronidazole: a prospectivecontrolled cohort study. Teratology 2001;63:186–192.

18. Burtin P, Taddio A, Ariburnu O, et al.Safety of metronidazole inpregnancy: a meta-analysis. Am J Obstet Gynecol 1995;172:525–529.

19. Andersen B, Nielsen TF. Appendicitis in pregnancy: diagnosis,management and complications. Acta Obstet Gynecol Scand

1999;78:758–762.20. Council on Children With Disabilities; Section on Develop-mental Behavioral Pediatrics; Bright Futures Steering Commit-tee; Medical Home Initiatives for Children With Special NeedsProject Advisory Committee. Identifying infants and young children with developmental disorders in the medical home: analgorithm for developmental surveillance and screening. Pediat-rics 2006;118:405–420.

21. Sices L. Use of developmental milestones in pediatric residency training and practice: time to rethink the meaning of the mean.

J Dev Behav Pediatr 2007;28:47–52.


apendicitis gestantes

Documents