Appendicitis in Pregnancy
Comprehensive Nursing Notes & Care Guide
Introduction to Appendicitis in Pregnancy
Acute appendicitis is the most common nonobstetric surgical emergency during pregnancy, occurring in approximately 1 in 500 to 1 in 2000 pregnancies. The diagnosis and management of appendicitis in pregnant patients presents unique challenges due to anatomical and physiological changes that occur during pregnancy, along with concerns for fetal well-being.
Prompt diagnosis and appropriate management of appendicitis during pregnancy are crucial to minimize risks to both the mother and fetus. Delayed diagnosis can lead to appendiceal rupture, which significantly increases maternal morbidity and the risk of fetal loss.
Why This Matters for Nurses
Nursing professionals play a critical role in the early identification, perioperative care, and postoperative management of pregnant patients with appendicitis. Understanding the unique presentation, diagnostic challenges, and care considerations is essential for optimal maternal and fetal outcomes.
Epidemiology
- Incidence: 1 in 500 to 1 in 2000 pregnancies
- Most common nonobstetric surgical emergency in pregnancy
- Highest incidence during the second trimester
- Similar prevalence in pregnant women compared to nonpregnant women of the same age
- Accounts for approximately two-thirds of nontraumatic surgical emergencies during pregnancy
Memory Aid: Trimester Distribution
“A-2-Z”: Appendicitis peaks in the 2nd trimester but can occur in all trimesters, from Zero weeks through delivery.
Pathophysiology
The pathophysiology of appendicitis in pregnancy is similar to that in nonpregnant individuals, but with important anatomical considerations unique to pregnancy.
Core Pathophysiology
- Obstruction: Luminal obstruction of the appendix (typically by fecalith, lymphoid hyperplasia, or appendicolith)
- Distension: Continued mucous secretion leads to increased intraluminal pressure
- Bacterial Invasion: Bacterial overgrowth occurs in the obstructed appendix
- Inflammation: Wall inflammation and mucosal ulceration develop
- Ischemia: Vascular compromise and lymphatic stasis occur as pressure increases
- Gangrene/Perforation: Without treatment, necrosis and perforation may occur
Pregnancy-Specific Considerations
- Anatomic Displacement: The enlarging uterus displaces the appendix, typically moving it upward and laterally
- Position Changes: By third trimester, the appendix may be at the level of the right upper quadrant
- Omental Protection: Limited ability of the omentum to wall off infection due to uterine displacement
- Immunologic Changes: Altered immune responses during pregnancy may affect inflammatory presentation
Memory Aid: BLOAT Pathway
- B – Blockage of appendiceal lumen
- L – Luminal distension with continued secretion
- O – Overgrowth of bacteria
- A – Arterial and lymphatic compromise
- T – Tissue necrosis and potential perforation
Key Pathogens
Common bacteria involved in appendicitis during pregnancy include:
- Escherichia coli (most common)
- Bacteroides species
- Peptostreptococcus
- Pseudomonas species
Antibiotic coverage should target these organisms when treating suspected or confirmed appendicitis.
Clinical Presentation
The clinical presentation of appendicitis during pregnancy can be atypical and challenging to recognize. Physiological changes and the anatomical displacement of the appendix contribute to modified clinical features.
| Feature | Nonpregnant Presentation | Modifications in Pregnancy |
|---|---|---|
| Pain Location | Periumbilical pain migrating to right lower quadrant (RLQ) | May occur in RLQ, right flank, or right upper quadrant depending on trimester |
| Pain Intensity | Progressive, moderate to severe | May be less severe due to stretched abdominal wall |
| Physical Findings | RLQ tenderness, rebound tenderness, guarding | Modified by uterine size; may have less peritoneal signs |
| Associated Symptoms | Anorexia, nausea, vomiting | May be confused with normal pregnancy symptoms |
| Fever | Present in 40% of cases | Less reliable; baseline temperature may be elevated in pregnancy |
Key Assessment Findings
- Abdominal Pain: The cardinal symptom, but location may vary based on gestational age
- Nausea and Vomiting: Present in most cases but can be confused with hyperemesis gravidarum
- Anorexia: Common but may be difficult to distinguish from pregnancy-related appetite changes
- Fever: Usually low-grade if present; absent in early appendicitis
- Urinary Symptoms: May include frequency, urgency, or dysuria if the appendix is near the urinary tract
Warning Signs
The following may indicate appendiceal perforation:
- Diffuse abdominal pain instead of localized pain
- High fever (>38.5°C or 101.3°F)
- Tachycardia out of proportion to fever
- Absent bowel sounds
- Signs of preterm labor
Memory Aid: PREGNANCY PAIN MIGRATION
As pregnancy progresses, appendiceal pain migrates:
- 1st Trimester: Right Lower Quadrant (typical McBurney’s point)
- 2nd Trimester: Right Lateral/Flank region
- 3rd Trimester: Right Upper Quadrant or Right Flank
Diagnosis
Diagnosing appendicitis during pregnancy is challenging due to the physiological changes of pregnancy and concerns about radiation exposure to the fetus. A comprehensive approach incorporating clinical evaluation, laboratory studies, and safe imaging is essential.
Clinical Assessment
- History: Detailed pain assessment, chronology, and associated symptoms
- Physical Examination: Focused abdominal examination, considering the anatomical shift of the appendix
- Scoring Systems: RIPASA score has been identified as the most effective for pregnant patients
Laboratory Studies
| Test | Typical Findings | Limitations in Pregnancy |
|---|---|---|
| WBC Count | Leukocytosis (>10,000 cells/mm³) | Normal leukocytosis in pregnancy can reach 16,900 cells/mm³ |
| Neutrophil % | Left shift or bandemia | Mild neutrophil predominance is normal in pregnancy |
| C-reactive Protein (CRP) | Elevated in inflammation | May be elevated in normal pregnancy |
| Urinalysis | Usually normal; may show microscopic hematuria or pyuria | Urinary changes common in pregnancy |
| Neutrophil-to-Lymphocyte Ratio | Elevated in appendicitis | Emerging marker with improved accuracy in pregnancy |
Imaging Studies
| Modality | Benefits | Limitations | Recommendations |
|---|---|---|---|
| Ultrasound | No radiation, safe in pregnancy, can assess fetal well-being | Visualizes appendix in only ~60% of pregnant cases, operator-dependent | First-line imaging modality |
| MRI | No radiation, high sensitivity (91.8%) and specificity (97.9%) | Cost, availability, time to complete | Preferred when ultrasound is inconclusive |
| CT Scan | High accuracy (>95%) | Radiation exposure to fetus | Reserved for when MRI unavailable and diagnosis crucial |
Diagnostic Approach
- Clinical assessment including RIPASA score
- Laboratory studies (with pregnancy-adjusted interpretation)
- Ultrasound as first imaging approach
- If ultrasound inconclusive → MRI when available
- CT only if MRI unavailable and diagnosis critical
- Surgical consultation early in the process
Memory Aid: IMAGE Pregnancy Appendicitis
- I – Investigate clinical features thoroughly
- M – Measure labs (WBC, CRP, neutrophil ratio)
- A – Attempt ultrasound first
- G – Go to MRI if ultrasound inconclusive
- E – Employ CT only as last resort
Treatment and Management
The management of appendicitis during pregnancy primarily involves surgical intervention, with important modifications to standard approaches to ensure maternal and fetal safety.
Surgical Management
| Approach | Considerations | Pregnancy-Specific Modifications |
|---|---|---|
| Laparoscopic Appendectomy |
|
|
| Open Appendectomy |
|
|
Antibiotic Therapy
- Perioperative Prophylaxis: Single dose of broad-spectrum antibiotics
- Uncomplicated Appendicitis: 24-48 hours of antibiotics post-operatively
- Complicated/Perforated: Extended course (3-7 days) of IV antibiotics
- Pregnancy-Safe Options:
- Penicillins (ampicillin, piperacillin)
- Cephalosporins
- Carbapenems
- Aztreonam with metronidazole (if penicillin allergic)
Non-Operative Management
While antibiotics-only treatment has been studied in nonpregnant patients, current guidelines recommend against nonoperative management in pregnant patients due to:
- Higher failure rates
- Increased risk of complications
- Greater risk of maternal and fetal morbidity with delayed surgery
- Limited data on safety in pregnancy
Antibiotics alone may be considered as a bridge to surgery in remote locations where immediate surgical intervention is not available.
Fetal Monitoring
- Preoperative and postoperative fetal heart rate monitoring
- Continuous intraoperative fetal monitoring when feasible (>24 weeks gestation)
- Assessment for uterine irritability or contractions
Critical Timing Considerations
Delaying surgical intervention increases the risk of perforation by approximately 5% every 12 hours after the first 36 hours of symptoms. Perforation significantly increases maternal morbidity and fetal loss rates (up to 36% with free perforation).
Memory Aid: SAFE Surgery in Pregnancy
- S – Side positioning (left lateral after 20 weeks)
- A – Adjusted port placement (above fundus)
- F – Fetal monitoring (before, during if feasible, after)
- E – Early intervention (don’t delay surgery)
Nursing Care Considerations
Nursing care for pregnant patients with appendicitis requires specialized knowledge and skills to address both maternal and fetal needs throughout the care continuum.
Preoperative Nursing Care
- Assessment:
- Comprehensive pain assessment (location, migration, intensity)
- Vital sign monitoring with awareness of normal pregnancy changes
- Abdominal assessment considering anatomic changes of pregnancy
- Fetal heart rate assessment and monitoring
- Interventions:
- IV access and fluid management
- NPO status maintenance
- Pain management with pregnancy-safe analgesics
- Patient positioning (left lateral tilt after 20 weeks’ gestation)
- Emotional support and education about procedure
- Preparation:
- Surgical consent coordination
- Preoperative antibiotics administration
- Coordination with obstetric team
Postoperative Nursing Care
- Assessment:
- Routine vital signs with temperature monitoring
- Incision/wound assessment
- Pain assessment using appropriate scales
- Respiratory status monitoring
- Fetal heart rate monitoring
- Assessment for uterine contractions or preterm labor
- Interventions:
- Pain management with pregnancy-appropriate analgesics
- Early ambulation with assistance
- DVT prophylaxis (sequential compression devices, early mobilization)
- Gradual diet advancement as tolerated
- Wound care and infection prevention
- Administration of prescribed antibiotics
Nursing Diagnosis and Care Planning
| Nursing Diagnosis | Interventions | Expected Outcomes |
|---|---|---|
| Acute Pain related to inflammatory process and surgical intervention |
|
Patient reports pain at acceptable level (≤3/10) with effective management strategies |
| Risk for Infection related to surgical procedure and potential appendiceal rupture |
|
Patient remains afebrile with wound healing without signs of infection |
| Risk for Impaired Fetal Well-being related to maternal condition and surgical intervention |
|
Fetal heart rate remains within normal range with no signs of distress |
| Anxiety related to concerns for maternal and fetal well-being |
|
Patient verbalizes decreased anxiety and understanding of care plan |
| Risk for Venous Thromboembolism related to pregnancy and decreased mobility |
|
Patient demonstrates understanding of VTE prevention and remains free of VTE symptoms |
Patient Education
- Signs and symptoms of wound infection
- Activity restrictions and gradual return to activities
- Warning signs of preterm labor
- Medication management (timing, side effects, purpose)
- When to follow up with surgeon and obstetrician
- Nutrition recommendations for healing
Critical Nursing Documentation
- Pain assessments (location, intensity, quality, response to interventions)
- Vital signs with temperature trends
- Fetal heart rate patterns and maternal uterine activity
- Wound assessment findings
- Patient education provided and understanding demonstrated
- Response to medications and interventions
- Intake and output measurements
Complications
Appendicitis during pregnancy carries risks for both maternal and fetal complications, with the risk significantly increasing in cases of appendiceal perforation.
Maternal Complications
- Wound infection: More common with perforated appendicitis
- Intra-abdominal abscess: Requires drainage and prolonged antibiotics
- Peritonitis: Can lead to sepsis and shock
- Surgical site complications: Bleeding, hematoma, wound dehiscence
- Venous thromboembolism: Risk increased due to pregnancy and surgery
- Adhesion formation: May affect future pregnancies or cause bowel obstruction
Fetal Complications
- Preterm labor: Incidence 4% in uncomplicated appendicitis, 11% in complicated cases
- Fetal loss: Risk varies by clinical scenario:
- 2% with uncomplicated appendectomy
- 6% with peritonitis or abscess
- Up to 36% with free appendiceal perforation
- Preterm birth: Higher risk with complicated appendicitis
- Intrauterine growth restriction: Secondary to maternal systemic inflammation
Complications of Diagnostic Delay
Delayed diagnosis significantly increases complication rates:
- 2% risk of perforation at 36 hours after symptom onset
- 5% increased risk of perforation for every additional 12 hours
- Increased maternal morbidity and mortality
- Higher rates of preterm labor and fetal loss
Warning: Negative Appendectomy
While avoiding diagnostic delay is critical, negative appendectomy (removal of normal appendix) also carries risks in pregnancy:
- 10% risk of preterm labor
- 4% risk of fetal loss
- Unnecessary surgical complications
This emphasizes the importance of accurate diagnosis through appropriate imaging and clinical assessment.
Best Practices & Recent Updates
Current Best Practices
Best Practice #1: Enhanced Diagnostic Protocol
Use a step-wise diagnostic approach combining the RIPASA clinical scoring system with laboratory markers and targeted imaging. Ultrasound is the first-line imaging modality, with MRI as the preferred second-line imaging when ultrasound is inconclusive. This approach reduces negative appendectomy rates by nearly 50% without increasing perforation rates.
Best Practice #2: Modified Laparoscopic Technique
Current guidelines from the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) recommend laparoscopic appendectomy as the standard of care in all trimesters with specific modifications:
- Left lateral decubitus positioning after 20 weeks gestation
- Open Hasson technique for first port placement
- Port placement above the palpable fundus
- Limited insufflation pressure (10-12 mmHg)
- Minimal uterine manipulation
Best Practice #3: Multidisciplinary Team Approach
Implement a collaborative care model with general surgery, obstetrics, anesthesiology, and nursing working together throughout the care continuum. This approach includes:
- Early obstetrical consultation
- Preoperative, intraoperative (when feasible), and postoperative fetal monitoring
- Joint decision-making about timing of surgery
- Coordinated postoperative care including VTE prophylaxis, pain management, and monitoring for preterm labor
- Integrated follow-up with both surgical and obstetric teams
Recent Updates and Emerging Trends
- Biomarker Research: Emerging evidence supports the use of the neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio as more accurate diagnostic markers for appendicitis during pregnancy than traditional WBC count or CRP.
- Surgical Timing: Recent studies emphasize that immediate operation for complicated appendicitis in pregnant women is associated with lower odds of maternal infectious complications compared to delayed intervention.
- Non-Operative Management: While antibiotic-only treatment has shown promise in nonpregnant patients with uncomplicated appendicitis, current evidence still supports surgical management as the standard for pregnant patients. Antibiotics alone may serve as a bridge to surgery in remote locations where immediate surgical intervention is not available.
- Enhanced Recovery After Surgery (ERAS): Modified ERAS protocols are being adapted for pregnant patients, focusing on early mobilization, multimodal pain management with reduced opioid use, and early diet advancement when appropriate.
- VTE Prophylaxis Updates: Current recommendations emphasize mechanical prophylaxis with pneumatic compression devices and early ambulation. Chemical prophylaxis with unfractionated or low-molecular-weight heparin requires individualized assessment but can be safely used with appropriate monitoring.
Memory Aids for Nursing Students
APPENDIX in Pregnancy
A – Abdominal pain location varies by trimester
P – Physical exam findings may be subtle
P – Perforation risk increases with delay
E – Early imaging (ultrasound first, then MRI)
N – Nausea/vomiting may be confused with normal pregnancy
D – Delayed diagnosis increases maternal-fetal risk
I – Immediate surgical consultation is crucial
X – EXpect WBC elevation (normal in pregnancy)
PREGNANT with Appendicitis Care
P – Position patient with left lateral tilt
R – Risk for perforation increases with time
E – Evaluate fetal status regularly
G – Gravid uterus displaces appendix location
N – Nursing care focuses on both mother and fetus
A – Assess for preterm labor signs
N – Note temperature trends carefully
T – Thromboprophylaxis is essential
TRIMESTER Pain Locations
1st Trimester: Right Lower Quadrant (typical McBurney’s point)
2nd Trimester: Right Lateral/Flank
3rd Trimester: Right Upper Quadrant or Right Flank
SAFE Surgery in Pregnancy
S – Side positioning (left lateral after 20 weeks)
A – Adjusted port placement (above fundus)
F – Fetal monitoring (before, during if feasible, after)
E – Early intervention (don’t delay surgery)
Fetal Risk Calculator
Remember the fetal risk percentages by procedure and complication:
2-6-36 Rule
- 2% – Fetal loss with uncomplicated appendectomy
- 6% – Fetal loss with peritonitis/abscess
- 36% – Fetal loss with free appendiceal perforation
4-11 Rule for Preterm Labor
- 4% – Preterm labor with uncomplicated appendicitis
- 11% – Preterm labor with complicated appendicitis
References
- StatPearls Publishing. (2023). Appendicitis in Pregnancy. National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/books/NBK551642/
- StatPearls Publishing. (2023). Appendicitis (Nursing). National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/books/NBK568712/
- Mallon, M., & Pfeifer, C. (2023). Appendicitis During Pregnancy: Best Surgical Practices and Clinical Management. Open Access Surgery, 16, 57-63. https://www.dovepress.com/appendicitis-during-pregnancy-best-surgical-practices-and-clinical-man-peer-reviewed-fulltext-article-OAS
- Lipping, E., Saar, S., Rull, K., Tark, A., Tiiman, M., Jaanimäe, L., Lepner, U., & Talving, P. (2023). Open versus laparoscopic appendectomy for acute appendicitis in pregnancy: a population-based study. Surgical Endoscopy, 37(8), 6025-6031.
- Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). (2017). Guidelines for diagnosis, treatment, and use of laparoscopy for surgical problems during pregnancy. https://www.sages.org/publications/guidelines/guidelines-for-diagnosis-treatment-and-use-of-laparoscopy-for-surgical-problems-during-pregnancy/
- Choi, Y.S., Seo, J.H., Yi, J.W., Choe, Y.M., Heo, Y.S., & Choi, S.K. (2023). Clinical Characteristics of Acute Appendicitis in Pregnancy: 10-Year Experience at a Single Institution in South Korea. Journal of Clinical Medicine, 12(9), 3059.
- Lee, S. H., Lee, J. H., Choi, Y. Y., Park, K. H., Yun, J. W., Baek, J. Y., Lee, J. N., Ryu, B. Y., & Kim, Y. W. (2019). Laparoscopic appendectomy versus open appendectomy for suspected appendicitis during pregnancy: a systematic review and updated meta-analysis. BMC Surgery, 19(1), 41.
- Segev, L., Segev, Y., Rayman, S., Nissan, A., & Sadot, E. (2017). Appendicitis During Pregnancy: A Diagnostic Challenge. Israel Medical Association Journal, 19(10), 639-644.
- Chakraborty, J., Kong, J. C., Su, W. L., Gourlas, P., Gillespie, C., & Slack, T. (2019). Safety of laparoscopic appendicectomy during pregnancy: A systematic review and meta-analysis. ANZ Journal of Surgery, 89(11), 1373-1378.
- Simplenursing.com. (2023). Appendicitis Nursing Care Plan, Diagnosis & Interventions. https://simplenursing.com/appendicitis-nursing-care-plan/