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The small bowel has diminished motility during pregnancy. Using a nonabsorbable carbohydrate, Lawson (1985) showed that small bowel mean transit times were 99, 125, and 137 minutes in each trimester, compared with 75 minutes when nonpregnant. In a study cited by Everson (1992), mean transit time for a mercury-filled balloon from the stomach to the cecum was 58 hours in term pregnant women compared with 52 hours in nonpregnant women.
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Muscular relaxation of the colon is accompanied by increased absorption of water and sodium that predisposes to constipation. This complaint is reported by almost 40 percent of women at some time during pregnancy (Everson, 1992). Such symptoms are usually only mildly bothersome, and preventive measures include a high-fiber diet and bulk-forming laxatives. Wald (2003) has reviewed treatment options. We have encountered several pregnant women who developed megacolon from impacted stool. These women almost invariably had chronically abused stimulatory laxatives.
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The estimated monthly prevalence of diarrhea among adults is 3 to 7 percent (DuPont, 2014). Diarrhea can be classified as acute (<2 weeks), persistent (2 to 4 weeks), and chronic (>4 weeks). Most cases of acute diarrhea are caused by infectious agents, and a third result from foodborne pathogens. The large variety of viruses, bacteria, helminths, and protozoa that cause diarrhea in adults inevitably also afflict pregnant women. Some of these are discussed in Chapter 64. Evaluation of acute diarrhea depends on its severity and duration. Some indications for evaluation include profuse watery diarrhea with dehydration, grossly bloody stools, fever >38ºC, duration >48 hours without improvement, recent antimicrobial use, and diarrhea in the immunocompromised patient (Camilleri, 2015; DuPont, 2014). Cases of moderately severe diarrhea with fecal leukocytes or gross blood may best be treated with empirical antibiotics rather than evaluation. Some features of the more common acute diarrheal syndromes and their treatment are shown in Table 54-4.
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The mainstay of treatment is intravenous hydration using normal saline or Ringer lactate with potassium supplementation in amounts to restore maternal blood volume and to ensure uteroplacental perfusion. Vital signs and urine output are monitored for signs of sepsis syndrome. For moderately severe nonfebrile illness without bloody diarrhea, antimobility agents such as loperamide (Imodium) may be useful. Bismuth subsalicylate (Pepto-Bismol) may also alleviate symptoms.
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Judicious use of antimicrobial agents is warranted. For moderate to severely ill women, some recommend empirical treatment with ciprofloxacin, 500 mg twice daily for 3 to 5 days. Specific pathogens are treated as needed when identified (see Table 54-4). Syndromes for which treatment is usually unnecessary include those caused by Escherichia coli, staphylococcal species, Bacillus cereus, and Norwalk-like virus. Severe illness caused by Salmonella spp is treated with ciprofloxacin or trimethoprim-sulfamethoxazole; by Campylobacter spp with azithromycin; by Clostridium difficile with oral metronidazole or vancomycin; and by Giardia spp and Entamoeba histolytica with metronidazole (DuPont, 2014; Rocha-Castro, 2016).
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Clostridium Difficile Infection
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This anaerobic gram-positive bacillus is transmitted by the fecal-oral route. It is the most frequent nosocomial infection in the United States. In 2011, 453,000 cases of C difficile and 29,000 associated deaths were reported by the Centers for Disease Control and Prevention (CDC) (Lessa, 2015). The most important risk factor is antibiotic use, and the highest risk is with aminopenicillins, clindamycin, cephalosporins, and fluoroquinolones. Other risk factors include inflammatory bowel disease, immunosuppression, advanced age, and gastrointestinal surgery. Most cases are hospital-acquired, however, community-acquired cases are becoming common (Leffler, 2015). With severe colitis, the infection-related mortality rate is 5 percent.
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Diagnosis is by enzyme immunoassay for toxins in the stool, or by DNA-based tests that identify toxin genes. Only patients with diarrhea should be tested, and posttreatment testing is not recommended. Prevention is by soap-and-water hand washing, and infected individuals are isolated. Treatment is oral vancomycin or metronidazole. The risk of recurrence after an initial episode is 20 percent. Fecal microbial transplantation may become standard for recurrent clostridial colitis.
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Inflammatory Bowel Disease
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Two presumably noninfectious forms of intestinal inflammation are ulcerative colitis and Crohn disease. Differentiation between these is important because treatment differs. That said, they both share common features, and sometimes are indistinguishable if Crohn disease involves the colon. The salient clinical and laboratory features shown in Table 54-5 permit a reasonably confident diagnostic differentiation in most cases. The etiopathogenesis is enigmatic in both, but a genetic predisposition is suspected. Inflammation is thought to result from dysregulated mucosal immune function in response to commensal microbiota, with or without an autoimmune component (Friedman, 2015).
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This is a mucosal disorder with inflammation confined to the superficial luminal layers of the colon. It typically begins at the rectum and extends proximally for a variable distance. In approximately 40 percent of cases, disease is confined to the rectum and rectosigmoid, but 20 percent have pancolitis. For unknown reasons, prior appendectomy protects against development of ulcerative colitis (Friedman, 2015). Endoscopic findings include mucosal granularity and friability that is interspersed with mucosal ulcerations and a mucopurulent exudate (Fig. 54-2).
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Major symptoms of ulcerative colitis include diarrhea, rectal bleeding, tenesmus, and abdominal cramps. The disease can be acute or intermittent and is characterized by exacerbations and remissions. Toxic megacolon and catastrophic hemorrhage are particularly dangerous complications that may necessitate colectomy. Extraintestinal manifestations include arthritis, uveitis, and erythema nodosum. Another serious problem is that the risk of colon cancer approaches 1 percent per year. With either ulcerative colitis or Crohn disease, there is also concern for possible increased risks for venous thromboembolism (Kappelman, 2011; Novacek, 2010).
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Also known as regional enteritis, Crohn ileitis, and granulomatous colitis, Crohn disease has more protean manifestations than ulcerative colitis. It involves not only the bowel mucosa but also the deeper layers, and sometimes involvement is transmural (see Fig. 54-2). Lesions can be seen throughout the entire gastrointestinal tract, from the mouth to the anus, but it typically is segmental (Friedman, 2015). Approximately 30 percent of patients have small-bowel involvement, 25 percent have isolated colonic involvement, and 40 percent have both, usually with the terminal ileum and colon involved. Perianal fistulas and abscesses develop in a third of those with colonic involvement.
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Symptoms depend on which bowel segment(s) is involved. Thus, complaints may include lower-right-sided cramping abdominal pain, diarrhea, weight loss, low-grade fever, and obstructive symptoms. The disease is chronic with exacerbations and remissions, and importantly, it cannot be cured medically or surgically. Approximately a third of patients require surgery within the first year after diagnosis, and thereafter, 5 percent per year. Reactive arthritis is common, and the gastrointestinal cancer risk, although not as great as with ulcerative colitis, is increased substantially.
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Inflammatory Bowel Disease and Fertility
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Subfertility is commonly linked to chronic medical disease, but Mahadevan (2006a) cited a normal fertility rate for inflammatory bowel disease unless severe disease warranted surgery. Similarly, Alstead (2003) reported that decreased female fertility from active Crohn disease returned to normal with remission. For women requiring surgical resection, laparoscopic anastomosis has a higher subsequent fertility rate (Beyer-Berjot, 2013). With colectomy, however, even though fertility is improved, up to half of women will be persistently infertile (Bartels, 2012). Sexual function and fertility are only modestly affected by ileal pouch-anal anastomosis (Hor, 2016). Subfertility may also be partially due to sulfasalazine, which causes reversible sperm abnormalities (Feagins, 2009).
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Inflammatory Bowel Disease and Pregnancy
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Because ulcerative colitis and Crohn disease are relatively common in young women, they are encountered with some frequency in pregnancy. In this regard, a few generalizations can be made. First, consensus supports that pregnancy does not increase the likelihood of an inflammatory bowel disease flare (Mahadevan, 2015). Indeed, in a 10-year surveillance of women in the European Collaborative on Inflammatory Bowel Disease, the likelihood of a flare during pregnancy was decreased compared with the preconceptional rate (Riis, 2006). Although most women with quiescent disease in early pregnancy do not have relapses, when a flare develops, it may be severe. Also, active disease in early pregnancy increases the likelihood of poor pregnancy outcome, which is discussed subsequently. In general, most usual treatment regimens may be continued during pregnancy. Diagnostic evaluations should be undertaken if needed to direct management, and surgery should be performed if indicated. For women who successfully complete pregnancy, about half experience improvement in their health-related quality of life (Ananthakrishnan, 2012).
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At first glance, it appears that adverse pregnancy outcomes are increased with inflammatory bowel disease (Boyd, 2015; Cornish, 2012; Getahun, 2014). Initially, this was attributed to the fact that most studies included women with either form of disease. Specifically, Crohn disease was noted to be linked to excessive morbidity (Dominitz, 2002; Stephansson, 2010). But, according to Reddy (2008) and others, these adverse outcomes were in women with severe disease and multiple recurrences. Indeed, in the prospective European case-control ECCO-EpiCom study of 332 pregnant women with inflammatory bowel disease, Bortoli and coworkers (2011) found similar outcomes in women with ulcerative colitis or Crohn disease compared with normally pregnant women. Importantly, perinatal mortality rates are not appreciably increased.
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Ulcerative Colitis and Pregnancy
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Ulcerative colitis does not significantly alter the course of pregnancy in affected women. In one review of 755 pregnancies, colitis that was quiescent at conception worsened in approximately a third of pregnancies (Fonager, 1998). In women with active disease at the time of conception, approximately 45 percent worsened, 25 percent remained unchanged, and only 25 percent improved. These observations are similar to those previously described in an extensive review by Miller (1986) and a later report from Oron and colleagues (2012).
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Osteoporosis is a significant complication in up to a third of these women, and thus vitamin D—800 IU daily—and calcium—1200 mg daily—are given. Folic acid, 4 mg orally daily, is recommended preconceptionally and during the first trimester for neural-tube defect prevention. This high dose counteracts the antifolate actions of sulfasalazine. Flares may be caused by psychogenic stress, and reassurance is important.
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Management for colitis for the most part mirrors that outside of pregnancy. Treatment of active colitis and maintenance therapy incorporate drugs that deliver 5-aminosalicyclic acid (5-ASA) or mesalamine. Sulfasalazine (Azulfidine) is the prototype, and its 5-ASA moiety inhibits prostaglandin synthase in colonic mucosa. Others include olsalazine (Dipentum), balsalazide (Colazal), and delayed-release 5-ASA derivatives (Apriso, Asacol, Pentasa, Lialda). Glucocorticoids are given orally, parenterally, or by enema for moderate or severe disease that does not respond to 5-ASA. However, these latter drugs are not given for maintenance therapy. Recalcitrant disease is managed with immunomodulating drugs, including azathioprine, 6-mercaptopurine, or cyclosporine, which appear relatively safe in pregnancy (Briggs, 2015; Mozaffari, 2015). Importantly, methotrexate is contraindicated in pregnancy.
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In the past, biological therapy was reserved for recalcitrant moderate to severe disease. Because of their considerable efficacy, these medications are now frequently given initially for severe disease to prevent future complications. These agents are antibodies against tumor necrosis factor-alpha (TNF-alpha). Those approved for treatment of ulcerative colitis include infliximab (Remicade), adalimumab (Humira), and golinumab (Simponi). These drugs are administered intravenously or subcutaneously. Several studies indicate that they are safe for use in pregnancy, although there are concerns that their discontinuance may prompt a relapse (Torres, 2015). Another worry is that they may cause immunosuppression in the neonate (Bröms, 2016; Diav-Citrin, 2014; Gisbert, 2013).
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Colorectal endoscopy is performed as indicated (Katz, 2002). During pregnancy, colectomy and ostomy creation for fulminant colitis may be needed as a lifesaving measure, and it has been described during each trimester. Dozois (2006) reviewed 42 such cases and found that, in general, outcomes have been good in recent reports. Most women underwent partial or complete colectomy, but Ooi and colleagues (2003) described decompression colostomy with ileostomy in a 10- and a 16-week pregnancy. Parenteral nutrition discussed in Upper Gastrointestinal Tract Disorders is occasionally necessary for women with prolonged exacerbations.
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For women with an ileal pouch and an anal anastomosis performed before pregnancy, sexual function and fertility are improved (Cornish, 2007). Disadvantages that temporarily worsen in pregnancy include frequent bowel movements, fecal incontinence, and pouchitis. The last is an inflammatory condition of the ileoanal pouch probably due to bacterial proliferation and stasis. Pouchitis usually responds to cephalosporins or metronidazole. In one rare case, adhesions to the growing uterus led to ileal pouch perforation (Aouthmany, 2004).
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Women who have had a prior proctocolectomy and ileal pouch–anal anastomosis can be safely delivered vaginally (Ravid, 2002). Hahnloser (2004) reviewed routes of delivery in women with 235 pregnancies before and 232 pregnancies after ileoanal pouch surgery. Functional outcomes were similar, and it was concluded that cesarean delivery should be reserved for obstetrical indications. Postcesarean delivery ileoanal pouch obstruction has been described (Malecki, 2010).
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To reiterate, ulcerative colitis likely has minimal adverse effects on pregnancy outcome. Modigliani (2000) reviewed perinatal outcomes in 2398 pregnancies and reported them to be not substantively different from those in the general obstetrical population. Specifically, the incidences of spontaneous abortion, preterm delivery, and stillbirth were remarkably low. In a population-based cohort study of 107 women from Washington state, perinatal outcomes, with two exceptions, were similar to those of 1308 normal pregnancies (Dominitz, 2002). One exception was an inexplicably increased incidence of congenital malformations. These authors and others also describe a cesarean delivery rate that was substantially increased compared with that for normal controls (Mahadevan, 2015). The previously described ECCO-EpiCom study reported similar outcomes in 187 gravidas with ulcerative colitis compared with normal pregnant controls (Bortoli, 2011).
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Crohn Disease and Pregnancy
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In general, Crohn disease activity during pregnancy is related to its status around the time of conception. In a cohort study of 279 pregnancies in 186 women whose disease was inactive at conception, a fourth relapsed during pregnancy (Fonager, 1998). In 93 with active disease at conception, however, two thirds either remained active or worsened. Miller (1986) had described similar findings from his earlier review, as did Oron and associates (2012).
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Calcium, vitamin D, and folic acid supplementation mirror that for ulcerative colitis. For maintenance during asymptomatic periods, no regimen is universally effective. Sulfasalazine is effective for some, but the newer 5-ASA formulations are better tolerated. Prednisone therapy may control moderate to severe flares but is less effective for small-bowel involvement. Immunomodulators such as azathioprine, 6-mercaptopurine, and cyclosporine are used for active disease and for maintenance. These appear relatively safe during pregnancy (Briggs, 2015; Chande, 2015). As discussed in Chapter 12 (Antimicrobial Drugs and Immunosuppressant Medications), methotrexate, mycophenolate mofetil, and mycophenolic acid are contraindicated in pregnancy (Briggs, 2015; Food and Drug Administration, 2008).
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As with ulcerative colitis, treatment with antitumor necrosis factor monoclonal antibodies is often used initially for active Crohn disease and maintenance (Casanova, 2013; Cominelli, 2013; Friedman, 2015). These biological compounds include infliximab, adalimumab, certolizumab (Cimzia), natalizumab (Tysabri), and vedolizumab (Entyvio). As discussed in Inflammatory Bowel Disease and Fertility, this class of immunomodulators is considered safe in pregnancy (Briggs, 2015; Clowse, 2015). Their discontinuance may be followed by a relapse (Torres, 2015).
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Endoscopy or conservative surgery is indicated for complications. Patients with small-bowel involvement are more likely to require surgery for complications that include fistulas, strictures, abscesses, and intractable disease. An abdominal surgical procedure was required during 5 percent of pregnancies described by Woolfson (1990). Parenteral hyperalimentation has been used successfully during severe recurrences (Russo-Stieglitz, 1999). Those with an ileal loop colostomy may have significant problems. Women with a perianal fistula—unless these are rectovaginal—usually can undergo vaginal delivery without complications (Forsnes, 1999; Takahashi, 2007).
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As discussed, the likelihood is greater that Crohn disease is associated with adverse pregnancy outcomes compared with ulcerative colitis (Stephansson, 2010). Outcomes are probably related to disease activities. In a case-control Danish study, Norgård (2007) reported a twofold risk of preterm births. Dominitz (2002) reported a two- to threefold increased risk for preterm delivery, low birthweight, fetal growth restriction, and cesarean delivery in 149 women with Crohn disease. Recall, however, that the prospective ECCO-EpiCom study found outcomes to be similar to those for normal pregnancies.
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A colostomy or an ileostomy can be problematic during pregnancy because of its location (Hux, 2010). In a report of 82 pregnancies in 66 women with an ostomy, stomal dysfunction was common, but it responded to conservative management in most cases (Gopal, 1985). Surgical intervention was necessary, however, in three of six women who developed bowel obstruction and in another four with ileostomy prolapse—almost 10 percent overall. In this older study, only a third of 82 women underwent cesarean delivery, but Takahashi (2007) described six of seven cesarean deliveries in women with Crohn disease and a stoma. Although adhesions usually are involved with an obstructed ileostomy, the enlarging uterus may act to obstruct (Porter, 2014). Finally, Farouk and coworkers (2000) reported that pregnancy did not worsen long-term ostomy function.
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Intestinal Obstruction
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The incidence of bowel obstruction is not increased during pregnancy, although it generally is more difficult to diagnose. Meyerson (1995) reported a 20-year incidence of 1 in 17,000 deliveries at two Detroit hospitals. In one study, adhesive disease leading to small-bowel obstruction was the second most common cause of an acute abdomen in pregnancy following appendicitis—15 versus 30 percent, respectively (Unal, 2011). Approximately half of cases are due to adhesions from previous pelvic surgery that includes cesarean delivery (Al-Sunaidi, 2006; Andolf, 2010; Lyell, 2011). Another 25 percent of bowel obstruction cases are caused by volvulus—sigmoid, cecal, or small bowel. These have been reported in late pregnancy or early puerperium (Bade, 2014; Biswas, 2006; Al Maksoud, 2015). Small-bowel obstruction has been reported in pregnancy following the currently popular Roux-en-Y gastric bypass for weight loss (Bokslag, 2014; Wax, 2013). Intussusception is occasionally encountered (Bosman, 2014; Harma, 2011). Bowel obstruction subsequent to colorectal surgery for cancer was increased threefold in women who had open versus laparoscopic surgery (Haggar, 2013). Finally, Serra and colleagues (2014) described a massive ventral hernia with intestinal obstruction.
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Most cases of intestinal obstruction during pregnancy result from pressure of the growing uterus on intestinal adhesions. According to Davis and Bohon (1983), this more likely occurs around midpregnancy when the uterus becomes an abdominal organ; in the third trimester when the fetal head descends; or immediately postpartum when uterine size acutely shrinks. Perdue (1992) reported that 98 percent of affected pregnant women had either continuous or colicky abdominal pain, and 80 percent had nausea and vomiting. Abdominal tenderness was found in 70 percent, and abnormal bowel sounds noted in only 55 percent. Plain abdominal radiographs following soluble contrast showed evidence of obstruction in 90 percent of women (Fig. 54-3). Plain radiographs, however, are less accurate for diagnosing small-bowel obstruction, and we and others have found that CT and MR imaging can be diagnostic (Biswas, 2006; Essilfie, 2007; McKenna, 2007). Colonoscopy can be both diagnostic and therapeutic for colonic volvulus (Dray, 2012; Khan, 2012).
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During pregnancy, mortality rates with obstruction can be excessive because of difficult and thus delayed diagnosis, reluctance to operate during pregnancy, and the need for emergency surgery (Firstenberg, 1998; Shui, 2011). In an older report of 66 pregnancies, Perdue and associates (1992) described a 6-percent maternal mortality rate and 26-percent fetal mortality rate. Two of the four women who died were in late pregnancy, and they had bowel perforation from sigmoid or cecal volvulus caused by adhesions.
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Colonic Pseudo-obstruction
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Also known as Ogilvie syndrome, pseudo-obstruction is caused by adynamic colonic ileus. It is characterized by massive abdominal distention with cecal and right-hemicolon dilatation. Approximately 10 percent of all cases are associated with pregnancy, and its frequency has been reported as high as 1 in 1500 deliveries (Reeves, 2015). The syndrome usually develops postpartum—most commonly after cesarean delivery—but it has been reported antepartum (Tung, 2008). Rarely, the large bowel may rupture (Singh, 2005). Treatment with an intravenous infusion of neostigmine, 2 mg, usually results in prompt decompression (Song, 2015). In some cases, colonoscopic decompression is performed, and laparotomy is needed for perforation (De Giorgio, 2009; Rawlings, 2010).
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The lifetime incidence for appendicitis ranges from 7 to 10 percent (Flum, 2015). Thus, it is not surprising that an evaluation for possible appendicitis is relatively common during pregnancy. Theilen and colleagues (2015) studied 171 such women during a 5-year period, but only 12 women ultimately were found to have pathologically confirmed appendicitis. After clinical and imaging evaluation, the frequency of suspected appendicitis is much lower and that of confirmed appendicitis in more than 8 million women ranged from 1 in 1000 to 1 in 5500 births (Abbasi, 2014; Hée, 1999; Mazze, 1991).
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It is repeatedly—and appropriately—emphasized that pregnancy makes the diagnosis of appendicitis more difficult. Nausea and vomiting accompany normal pregnancy, but also, as the uterus enlarges, the appendix commonly moves upward and outward from the right lower quadrant (Baer, 1932; Erkek, 2015; Pates, 2009). Another often-stated reason for late diagnosis is that some degree of leukocytosis accompanies normal pregnancy. For these and other reasons, pregnant women—especially those late in gestation—frequently do not have clinical findings “typical” for appendicitis. Thus, it commonly is confused with cholecystitis, labor, pyelonephritis, renal colic, placental abruption, or uterine leiomyoma degeneration.
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Most reports indicate increasing morbidity and mortality rates with advancing gestational age. And as the appendix is progressively deflected upward by the growing uterus, omental containment of infection becomes increasingly unlikely. It is indisputable that appendiceal perforation is more common during later pregnancy (Abbasi, 2014). In the studies by Andersson (2001) and Ueberrueck (2004), the incidence of perforation was approximately 8, 12, and 20 percent in successive trimesters.
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Persistent abdominal pain and tenderness are the most reproducible findings. Right-lower quadrant pain is the most frequent, although pain migrates upward with appendiceal displacement (Mourad, 2000). For initial evaluation, sonographic abdominal imaging is reasonable in suspected appendicitis, even if to exclude an obstetrical cause of pain (Butala, 2010). That said, graded compression sonography is difficult because of cecal displacement and uterine imposition (Pedrosa, 2009). Appendiceal computed tomography is more sensitive and accurate than sonography to confirm suspected appendicitis (Katz, 2012; Raman, 2008). Specific views can be designed to diminish fetal radiation exposure (Chap. 46, Computed Tomography). It is generally accepted that when available, MR imaging is the preferred modality for evaluation of suspected appendicitis in pregnancy (Fig. 54-4). MR imaging has high diagnostic yield and accuracy, and it also provides alternative diagnoses (Fonseca, 2014; Theilen, 2015). One metaanalysis cited positive- and negative-predictive values for MR imaging of 90 and 99.5 percent, respectively (Blumenfeld, 2011). Burke and associates (2015) reported similar findings. Using a decision-analysis model, CT and MR imaging were found to be cost effective (Kastenberg, 2013). This was verified in the clinical study of more than 7000 cases reported by Fonseca and coworkers (2014).
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When appendicitis is suspected, treatment is prompt surgical exploration. Although diagnostic errors may lead to removal of a normal appendix, surgical evaluation is preferable to postponed intervention and generalized peritonitis (Abbasi, 2014). In earlier reports, the diagnosis was verified in only 60 to 70 percent of pregnant women. As indicated above, however, with CT and MR imaging, these figures have improved (Blumenfeld, 2011; Theilen, 2015). Still and importantly, the accuracy of diagnosis is inversely proportional to gestational age.
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Currently, laparoscopy is almost always used to treat suspected appendicitis during the first two trimesters. In a report from a Swedish database of nearly 2000 laparoscopic appendectomies, perinatal outcomes were similar to those of more than 1500 open laparotomies done before 20 weeks’ gestation (Reedy, 1997). Conversely, in their review, Wilasrusmee and coworkers (2012) reported a higher rate of fetal loss with laparoscopy. Authors of a more recent systematic review indicate that the level of evidence is not strong enough to demonstrate a preferred approach to appendectomy. They concede that laparoscopy may be associated with a higher risk of miscarriage (Walker, 2014). It has evolved that in many centers, laparoscopic appendectomy is also performed in most cases during the third trimester (Donkervoort, 2011). This is encouraged by the Society of American Gastrointestinal and Endoscopic Surgeons (Pearl, 2017; Soper, 2011). That said, most are of the opinion that laparoscopic surgery in pregnancy after 26 weeks’ gestation should be performed only by the most experienced endoscopic surgeons (Parangi, 2007).
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Before exploration, intravenous antimicrobial therapy is begun, usually with a second-generation cephalosporin or third-generation penicillin. Unless there is gangrene, perforation, or a periappendiceal phlegmon, antimicrobial therapy can usually be discontinued after surgery. Without generalized peritonitis, the prognosis is excellent. Seldom is cesarean delivery indicated at the time of appendectomy. Uterine contractions are common, and although some clinicians recommend tocolytic agents, we do not. De Veciana (1994) reported that tocolytic use substantially increased the risk for pulmonary-permeability edema caused by sepsis syndrome (Chap. 47, Acute Pulmonary Edema).
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Antimicrobial versus Surgical Treatment
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Because of European studies, some have advocated that many cases of appendicitis can be treated successfully with intravenous antimicrobials alone (Flum, 2015; Joo, 2017). At this time, we discourage this practice until appropriate studies have been done with pregnant women. In one study, 6 percent of pregnant women with appendicitis were treated medically, and these gravidas had “considerably” elevated risks for septic shock, peritonitis, and venous thromboembolism compared with surgically managed cases (Abbasi, 2014).
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Appendicitis increases the likelihood of abortion or preterm labor, especially if peritonitis has developed. In two studies, spontaneous labor after 23 weeks ensued with greater frequency following surgery for appendicitis compared with surgery for other indications (Cohen-Kerem, 2005; Mazze, 1991). In one study, the fetal loss rate was 22 percent if surgery was performed after 23 weeks’ gestation. Two large population-based studies attest to the adverse outcomes from appendicitis in pregnancy. From the California Inpatient File of 3133 pregnant women undergoing surgery for suspected appendicitis, the fetal loss rate was 23 percent, and it was doubled—6 versus 11 percent—with simple versus complicated disease (McGory, 2007). A nationwide study from Taiwan found that risks for low birthweight and preterm delivery rose 1.5- to 2-fold when outcomes in 908 women with acute appendicitis were compared with those of controls (Wei, 2012).
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Long-term complications are not common. The possible link between sepsis and neonatal neurological injury has not been verified (Mays, 1995). Finally, appendicitis during pregnancy does not appear to be associated with subsequent infertility (Viktrup, 1998).