TEALE FENNING

Xerxes I

It's a made up EMQ

a) Appendicectomy through pfannenstiel followed by a caesarean section
b) Appendicectomy through Mcburney's incision and await normal onset of labour for NVD
c) Appendicectomy through an incision over the maximum pain point and await normal onset of labour for NVD
d) Appendicectomy through an incision over the maximum pain point followed by induction of labour

26 yo, Primip, generally fit and well, uncomplicated pregnancy previously, well grown baby and normal CTG. T: 38.1, peritonism, WCC 28.9. Appendicitis is highly likely and a decision for appendicectomy has been made jointly by surgeons and obstetricians, both teams are available for operation.

1/ 39 weeks appendix looks normal
2/ 39 weeks and appendix is found to be ruptures with pus insude abdomen
3/ 39 weeks, appendix inflamed

cpeedahsa · Century Club Joined: 21 Apr 2007 Posts: 792

cpeedahsa · Century Club Joined: 21 Apr 2007 Posts: 792

Treatment of appendicitis is surgical. Perform surgery as soon as the diagnosis is seriously considered. Either laparotomy or laparoscopy can be performed.

Even if the appendix appears normal, there are 2 reasons to remove it: (1) early disease may be present despite its grossly normal appearance and (2) diagnostic confusion can be avoided if the condition recurs.

Most authorities suggest a right midtransverse incision directly over the point of maximal tenderness.

Some suggest a lower abdominal midline incision to accommodate unexpected surgical findings and the possibility of the need for cesarean delivery.

Tailor the surgical approach to the clinical situation.

Tilt the operating table 30° to the patient's left to help bring the uterus away from the surgical site and to improve maternal venous return and cardiac output.

cpeedahsa · Century Club Joined: 21 Apr 2007 Posts: 792

Xerxes I · Posted: Sun Apr 20, 2008 6:41 am Post subject:

She is 39 weeks, is it ok for her to push, say 2 days after her appendicectomy? Don't know the answer, just asking Confused

rpwalavalkar · Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 946

some other points --

negative laparotomy rate is 15 -35 %
at laparotomy diagnostic accuracy is about 50%

in first trimester laparoscopy is an option.

at laparotomy incision over point of max tenderness because -- as the uterine size increases the appendix is displaced above the McB's point with horizontal rotation of it's base. this migration continues till 8th month when 90% of appendix lie above the iliac crest and 80% rotate upwards and towards the rt sub-costal area.

preterm labour occurs in 1-5% of uncomplicated appendicitis.
ruptured appendix -- foetal loss is up to 30%

ref --

A De Cherney, L Nathan, M Pernoll. Surgical Diseases and Disorders in Pregnancy. Current obstetric and gynaecologic diagnosis and treatment. ISBN:0838514014
_________________
Dr Miss. Raj Walavalkar MBBS MRCOG
TealeFenning Administrator
SR O&G Wessex Region

cpeedahsa · Century Club Joined: 21 Apr 2007 Posts: 792

cpeedahsa · Century Club Joined: 21 Apr 2007 Posts: 792

A Smead-Jones closure with secondary wound closure 72 hours later may be advisable when the appendix is gangrenous or perforated or in the presence of peritonitis or abscess formation.

rpwalavalkar · Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 946

cpeedahsa · Century Club Joined: 21 Apr 2007 Posts: 792

Regarding tocolysis ( not for the case mentioned above)

Data are limited, so making definitive recommendations regarding the use of prophylactic tocolytics is difficult. Caution is indicated because of reports that tocolytics are associated with an increased risk of pulmonary edema in women with sepsis.

Wlliams Obstetrics says this-

cpeedahsa · Century Club Joined: 21 Apr 2007 Posts: 792

If appendicitis is undiagnosed before delivery, often when the large uterus rapidly empties, walled-off infection is disrupted causing an acute surgical abdomen.

New-onset appendicitis during the immediate puerperium is very uncommon simply because of chance. It is important to remember that puerperal pelvic infections typically do not cause peritonitis.

Ref:Williams

rpwalavalkar · Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 946

about tocolysis --

we had a case of acute appendicitis in preg at 33 weeks some time back. my consultants preferred not to give tocolysis, cover with antibiotics and steroids and deliver by LSCS 24 hrs later, did appendisectomy at the same sitting.

the logic was that deli better than conservative Mx and the gravid ut may contain spread of infection even if appendix bursts + pt already under Abx cover.

the problem usually faced is to decide when to deliver. with the above case it made sense not to wait.

have also read about the risk of pulm oedema if sepsis present and if tocolysis given
_________________
Dr Miss. Raj Walavalkar MBBS MRCOG
TealeFenning Administrator
SR O&G Wessex Region

Xerxes I · Posted: Sun Apr 20, 2008 8:30 am Post subject:

So in this case (ruptures Appendix) where pressumably there will be acute abdomen and pus everywhere, would you close and await normal onset of labour or would you section?

rpwalavalkar · Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 946

LSCS under strong antibiotic cover. the foetal mortality can be as high as 30% so better to section
_________________
Dr Miss. Raj Walavalkar MBBS MRCOG
TealeFenning Administrator
SR O&G Wessex Region

cpeedahsa · Century Club Joined: 21 Apr 2007 Posts: 792

Xerxes I · Posted: Sun Apr 20, 2008 12:27 pm Post subject:

Exactly, However, Raj's argument is also valid. That's why I wrote the questions seperately depening on the findings of laparotomy.

If you do proper washing, and when you've got good antibiotic cover and have removed the source of infection, infectious environment should be less of an issue but I agree that it is still a bit dodgy, if that's the right medical term.

I also agree that high risk of fetal loss is probably due to the delay in surgery and subsequent poor maternal condition and severe infection in the abdomen,, etc. When you have treated the cause, there should be no reason for the baby to die more that it would after a laparotomy.

But these are all assumptions and not backed by RCTs Twisted Evil

I think it is perfectly reasonable to use your common sense. in this situation.

For exam purposes, I liked your paragraph about balancing ..., always the right thing to say.

Xerxes I · Posted: Sun Apr 20, 2008 12:37 pm Post subject:

About the balancing paragraph (and I think there should be one in EVERY essay) I would say something like:

A caesarean section in this situation is best avoided if at all possible. The risk of opening the uterus in an infectious environment and creating a uterine scar should be balanced against the potential benefits of avoiding probable higher risk of perinatal mortality if undelivered.

If a caesarean section was necessary (for example for fetal distress), meticulous pelvic washing should be performed prior to opening the uterus and broad spectrum antibiotics etc. drain should be considered.

cpeedahsa · Century Club Joined: 21 Apr 2007 Posts: 792

cpeedahsa · Century Club Joined: 21 Apr 2007 Posts: 792

all in all, Beautiful scenario Xerxes I .

Was it a real scenario? It would make a very good case report.
"Dilemma in Management of Appendicitis in Pregnancy-Case Report and Review of literature".. Xerxes et al.... Very Happy

We can quote your publication next time we try to answer a question on Appendicitis in Pregnancy

Xerxes I · Posted: Sun Apr 20, 2008 2:16 pm Post subject:

I am going to say a very unscientific thing:

If it was my wife, I would convince her to have a caesarean at laparotomy. Evidence or no evidence, I don't want my baby anywhere near severe inflammation and intraabdominal pus. It just feels better. If she woke up after the laparotomy and says: but is it not dangerous for the baby to be in there? I can see how she'd look at me if I go: but darling, there is no evidence....

What you are saying is perfectly sensible but it doesn't feel right to me. On the other hand, no evidence of harm is not the same as evidence of no harm. There will be no RCTs comparing conservative management at term after ruptured appendicectomy and pus in the tummy with caesarean.

Have I told you about Prof. Smith's Parachute analogy?