Uniformed Services University of the Health Sciences, San Antonio, TX (Drs. Stull and Hale); Uniformed Services University of the Health Sciences, Bethesda, MD (Dr. Servey) jessica.servey@usuhs.edu
The authors reported no potential conflict of interest relevant to this article.
The views expressed here are those of the authors and do not reflect the official views or policy of the Department of Defense or the US government.
The most common nonobstetric surgical intervention during pregnancy is appendectomy, at a rate of 6.3/10,000 person-years, which increases to 9.9/10,000 in the postpartum period.37 Two large population studies demonstrate the rate of appendicitis varies over the course of pregnancy, with the lowest rates in the third trimester,38,39 and a significant rebound lasting for 2 years postpartum.39Peritonitis, septic shock, pneumonia, postoperative infection, and longer hospital stays occur more frequently in pregnant women than in nonpregnant women with appendicitis.40 Fetal loss is higher in the first trimester.32
In pregnancy, the most predictive sign of appendicitis is a white blood cell count > 18,000.
In a 14-year review of 63,145 appendicitis cases, an increased risk of fetal loss and maternal death was noted across ages and ethnicities, with the largest risk of maternal death occurring in Hispanics and fetal death in non-Hispanic Blacks.41 In a large study of 1018 adverse events after appendectomy or cholecystectomy, the 3 most common events were preterm delivery (35.4%), preterm labor without preterm delivery (26.4%), and miscarriage (25.7%).42 The surgery itself was not a major risk factor for adverse events. Major risk factors included cervical incompetence (odds ratio [OR] = 24.3), preterm labor in current pregnancy (OR = 18.3), and presence of vulvovaginitis (OR = 5.2).42
Nonoperative management in pregnancy is not recommended; only 1 prospective trial has been done, with 20 patients, showing a 25% failure rate.43 Two meta-analyses published in 2019 highlight the potential increase of fetal loss with laparoscopic approaches to appendectomy.44,45 However, recently published literature demonstrates no significant maternal-fetal morbidity. Current guidelines of the Society of American Gastrointestinal and Endoscopic Surgeons agree that laparoscopy is the operative choice in pregnancy.36
Children
Acute appendicitis is the most common surgical emergency in children.4 Physical exam findings and laboratory results are not classic in this population, obtaining an accurate history can be challenging, and results of clinical scoring systems can be inconclusive.4 Additional serum biomarkers, procalcitonin and calprotectin, are gaining evidence for use in improving scoring systems to refine low-risk groups. Unavailability of timely, reliable biomarker testing in rural practice locations limits definitive recommendations at this time.46 ACR recommends no imaging in a pediatric patient whose risk of having appendicitis is low based on any of several scoring systems.47 For those assessed as having higher risk, US is the recommended initial modality,with CT with IV contrast or MRI without contrast equally recommended if the US is equivocal.47
Despite promising data from trials of nonoperative treatment for adults with appendicitis, no definitive evidence and recommendations are available for children.
Despite promising data from trials of nonoperative treatment for adults with appendicitis, no definitive evidence and recommendations are available for children. Two systematic reviews show nonoperative treatment is safe, with an efficacy rate of 76% to 82% at long-term follow-up,48,49 although the success of antibiotic regimens varies. Within the nonoperative treatment group, 16% of patients had appendectomy during the follow-up period, which varied from 8 weeks to 4 years.48 A randomized controlled trial is needed for final guidance.
