Currently, laparoscopy is almost always used to treat suspected appendicitis during the irst 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, laparo scopic 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 gestation should be performed only by the most experienced endoscopic surgeons (Parangi, 2007).
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, p. 917).
Because of European studies, some have advocated that many cases of appendicitis can be treated successfully with intravenous antimicrobials alone (Flum, 2015; J00, 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).
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).
Long-term complications are not common. The possible link between sepsis and neonatal neurological injury has not been veriied (Mays, 1995). Finally, appendicitis during pregnancy does not appear to be associated with subsequent infertility (Viktrup, 1998).