Appendicitis and

Cholecystitis in
Pregnancy
Meghan Donlevy TUSM3
March 2006

Introduction

Nonobstetrical abdominal surgery is

required in approximately 1 in 500
pregnancies
Altered anatomy, physiology, and potential
risks to mother and fetus make diagnosis
and management of surgical disorders
more difficult in these women
Acute appendicitis and cholecystitis are
the two most common nonobstetrical
emergencies requiring surgery during
pregnancy

Maternal Physiology

30-50% increase in
plasma volume
Diastolic BP drop in 2nd
trimester
Lung tidal volumes
increase->mild
respiratory alkalosis
Increases in GFR,
decreased creatinine
Decreased GI motility
Mild leukocytosis

Diagnostic
Considerations

Pain- most common symptom reported in

acute abdominal conditions in pregnancy
Careful history and physical
Lab values
Imaging
Early, accurate diagnosis is difficult, yet
imperative to maternal and fetal health
Delay in diagnosis and surgery is the
factor primarily responsible for increase
maternal and fetal morbidity and mortality

Anesthesia During
Pregnancy

Adverse affects correlated with underlying

condition, not general anesthesia
independently
Teratogenicy- with exception of cocaine
hydrochloride- no toxicity associated with
LA
Short term postop use of narcotics in
combo with Tylenol or NSAIDs- no adverse
affects
Maternal-Fetal monitoring is a necessity

Appendicitis

Suspected appendicitis
accounts for 2/3 of all
nonobstetric abdominal
surgeries
Occurs in 0.1 to 1.4% of all
pregnancies
Babler (1908) stated The
mortality of appendicitis is
the mortality of delay.
Difficult Diagnosis
Appendiceal rupture and
generalized peritonitis are
more common in later
pregnancy

Ultrasound vs CT

CT for appendicitis

Management of
Appendicitis

If appendicitis is suspected, treatment is prompt

surgical intervention
Diagnosis is verified in only 36-50% of pregnant
women
Prophylactic antibiotic therapy is controversial
Open vs. Laparoscopic
Incidence of fetal loss is 1.5% in uncomplicated
appendicitis and 35% in the presence of a ruptured
appendix.

Cholecystitis

Cholecystitis is the second most common surgical

disorder during pregnancy, yet it is the most common
laparoscopic procedure.
1 in 1600 to 1 in 10,000 pregnancies
Increase in lithogenicity of the bile and a decrease in
GB contractility seen during pregnancy
Signs and symptoms similar to nonpregnant women
Diagnostic accuracy in U/S detecting gallstones in
pregnancy is 95%

Management of
Cholecystitis

Initial management: NON operative

Recurrence rates for symptomatic
biliary disease during pregnancy- up to
60%
Open vs. laparoscopic
Similar to appendicitis, uncomplicated
cholecystectomy is associated with a
4% fetal loss rate, but fetal mortality in
gallstone pancreatitis is up to 60%

Conclusions

Although the incidence of acute

appendicitis and cholecystitis are not
increased in pregnancy, the consequences
are more profound
Avoid delay in diagnosis
Consider gestational physiological and
anatomical alterations in management
Laparoscopy performed by an experienced
surgeon is becoming the standard of care

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