Laparoscopic appendectomy secondary to afebrile acute perforated appendicitis mimicking threatened abortion in first trimester pregnancy in Tanzania: A case report

Abstract

Introduction

Appendicitis in pregnancy is the most common non-obstetric surgical condition which requires urgent evaluation and immediate intervention in a multidisciplinary approach. Pregnancy anatomical and physiological changes can mask the presentation of appendicitis and poses both diagnostic and management challenges.

Case presentation

A 32 year old female, G3P2L2 at gestation age of 11 weeks by USS, presented with recurrent episodes of acute abdominal pain for one day, afebrile but accompanied with poor appetite, nausea and vomiting along episodes of per vaginal spotting which started three days prior. She was initially diagnosed and treated as a threatened abortion case with no improvement of symptoms. Abdominal pain was refractory to analgesics. Abdominal pelvic USS was done twice and revealed no features of appendicitis while obstetric USS was unremarkable. Clinical examination revealed an Alvarado score of 7. A diagnostic laparoscopy confirmed acute perforated appendicitis and she underwent laparoscopic appendectomy with uneventful post-operative recovery.

Discussion

Acute appendicitis is challenging to diagnose and manage during pregnancy due to symptoms overlapping with maternal physiological and anatomical changes along with obstetric presentations like threatened abortion. Appendicitis scoring systems like the Alvarado score are still reliable diagnostic tools even during pregnancy while the use of preferred imaging like USS is more limited secondary to gravid uterus.

Conclusion

All pregnant women with acute abdomen pain and suspecting features of acute appendicitis should be screened thoroughly for the condition. Diagnostic laparoscopy is useful and friendly in diagnosis and management in pregnancy. Multidisciplinary approach in evaluating and managing such cases in pregnancy is of high clinical benefits for maternal-fetal outcomes.

Highlights

• •Appendicitis in pregnancy is the most common non-obstetric and emergency surgical condition.
• •Physiological and anatomical pregnancy changes and other pregnancy conditions can masks appendicitis presentation.
• •Absence of fever and negative inflammatory markers should not exclude acute appendicitis in pregnancy.
• •Appendicitis Clinical Score systems like Alvarado score are still useful in diagnosing the condition even during pregnancy.
• •Despite high rates of pregnancy loss post laparoscopic appendectomy, still it is a standard recommended intervention.

1. Introduction

Acute appendicitis is among the surgical emergencies which require immediate evaluation and proper management. During acute state, it commonly presents with acute periumbilical pain radiating to right iliac fossa or right iliac fossa, nausea or vomiting and fever episodes [1,2]. Rebound tenderness on abdominal palpation, rovsing's and psoas signs during abdominal physical examination may be present [2]. It can be uncomplicated (characterized by borderline dilated serosal vessels, intraluminal neutrophils and frank erosions), complicated appendicitis (characterized phlegmon and gangrenous non perforated appendicitis) or complicated perforated appendicitis with features of pus formation [1]. The use of clinical scoring systems which combines clinical symptoms, signs and serum inflammatory markers like white blood cell count (WBC) and serum C-reactive protein (CRP) to determine the likelihood of the condition have been developed. These include the Alvarado score which is scored out of 10 scores; (1–4: discharge, 5–6: admit and observe, 7–10: surgical intervention) with a 94.1% specificity and 90.4% specificity with positive predictive value of 78%–96% [[1], [2], [3]]. Appendicitis might be less likely when both WBC and CRP are normal while the likelihood of complicated appendicitis increases significantly when both are elevated [1]. Surprisingly, several cases of acute appendicitis with isolated abdominal pain with no history of fever and normal inflammatory markers have been reported [4].

Surgery is still the standard recommended management of acute appendicitis although evidences are accumulating on the conservative management with use of antibiotics alone in non-complicated cases [2,3]. When applicable, emergency surgical intervention is recommended within 24 to 36 h from the onset of symptoms or within 24 h after admission [5].

Appendicitis in pregnancy is the most common non-obstetric surgical condition which requires urgent evaluation and immediate intervention in a multidisciplinary approach incorporating general surgery team [5,6]. It can occur in any trimester and those between 20 and 30 years are the most affected compared to those between 5 and 45 years in the general population [1,5]. While it might present with typical clinical signs and symptoms of appendicitis like an acute abdomen, fever, nausea and vomiting, pregnancy anatomical and physiological changes might mask the clinical features and decrease the sensitivity of both physical examination findings and diagnostic approaches [1,5,7]. Distortion of the appendix position by a gravid uterus alters the appendix's location in terms of axis and distance from the anterior abdominal wall [5]. While most cases present with leukocytosis, some might have normal leukocyte count [5]. Neutrophil left shift of >70% in complete blood count has been found to be a useful parameter in diagnosing appendicitis in pregnancy in suspicious cases given its sensitivity and negative predictive value of 100% [5].

The use of USS in diagnosis is limited given its low sensitivity (20%–77%). MRI without contrast is the recommended imaging of choice especially when there is negative abdominal pelvic USS findings due to its safety in pregnancy and high sensitivity (91.8%) and specificity (97.7%) [5]. Definitive management is surgery while the medical approach is less preferred due to the possible maternal and fetal fatal complications [5]. Laparoscopic surgery has been found to be the best and safest surgical approach for both the mother and the fetus. Although the rate of pregnancy loss post laparoscopic appendectomy is higher probably due to excessive intraoperative pelvic manipulations, still it is the recommended standard management approach [5,6].

Threatened abortion should be considered when vaginal bleeding or spotting is accompanied with uterine cramping in a viable pregnancy before 20 weeks with closed cervix [8]. It commonly occurs in the first trimester and presents with acute abdominal pain. The etiology of threatened abortion remains unclear with placental progesterone insufficiency and sub-chorionic hemorrhage or hematoma being among the most studied possible etiologies [8]. Diagnosis is made depending on the clinical history, physical examination findings, imaging and laboratory investigations including blood group and rhesus status. Pelvic USS, specifically trans-vaginal USS imaging is the imaging of choice with sub-chorionic hemorrhage being the most diagnostic finding [8]. While progesterone supplementation is encouraged up to 16 weeks of gestation age as the management and potential determinant of fetal viability, still there is the controversy on its beneficial effect [8,9].

This case report highlights the diagnostic challenges of acute appendicitis in pregnancy given its atypical presentation and limitations of routinely done laboratory tests and imaging modalities along the recommended management approach. It has been written under SCARE criteria [10].

2. Case presentation

A 32 year old female, G3P2L2 and amenorrhoeic for almost two months, presented with episodes of acute onset of abdominal pain which were progressive with time for one day, more marked below the umbilicus and right lower quadrant regions. This was accompanied with generalized body malaise, episodes of nausea and loss of appetite. Moreover, she reported a prior history of per vaginal spotting episodes for 3 days before presenting with the abdominal pain. She was attended at first at our facility whereby an obstetric USS was done which showed impression of single live intrauterine pregnancy of approximately 11 weeks gestational age. She was treated as a threated abortion case whereby she received antipain medications (Hyoscine butlybromide 20 mg IV STAT then 10 mg PO TDS 7/7), Domperidone 10 mg PO TDS 3/7, kept empirically on dydrogesterone tablets 10 mg PO OD 1/12 and was advised on complete bed rest. This relieved her symptoms. Few hours later, she presented again at our facility with acute severe abdominal pain not responding to hyoscine tabs given along generalized body malaise, nausea and one episode of vomiting while still reporting to experience per vaginal spotting episodes. She denied history of fever on the course of illness. Upon admission, she received fluids and 3 doses of analgesics including hyoscine 20 mg IV STAT and pethidine 100 mg IM STAT at intervals but with refractory abdominal pain.

On physical examination, she was in agony, not pale, afebrile with BP: 107/51 mmHg, PR-98 bpm and saturating 96% in room air. Per abdominal examination revealed right lower quadrant and severe suprapubic tenderness on superficial palpation with positive rovsing's sign. The following laboratory investigations were done with their respective findings; Blood group: B Positive, FBP: WBC within normal range with elevated neutrophils percent of 76.9% (45–75), Hb-12.7 g/dl, low hematocrit of 35.1% (40–54) with platelets within normal range, Malaria rapid diagnostic test-Negative, Serum BUN, Creatinine and potassium were within normal ranges but with mild hyponatremia of 133 mmol/l (136–145), Urinalysis revealed normal findings and serum CRP was slightly elevated by 0.04 mg/dl (0.00–1.00). Abdominal-pelvic USS was done twice which revealed same findings as the obstetric USS done prior with no impression of appendicitis. Alvarado score was done and she scored 7 (high risk of acute appendicitis).

General surgery team was consulted with the above history and findings. Patient was then after scheduled for diagnostic laparoscopy and for possible laparoscopic appendectomy whereby intra-op findings revealed inflamed and perforated appendix with localized peritoneal pus collection (Fig. 1). Laparoscopic appendectomy was done along with peritoneal lavage and abdominal drainage tube was left in situ. Postoperative orders included anti-pain injections, intravenously antibiotics and dehydrogesterone tabs. Four days post-surgery, the patient had significant clinical improvement and was discharged home with removed abdominal drainage tube and was kept on oral antibiotics for 5 days and continued to use dehydrogesterone supplementation.

Fig. 1.

Intra-operative images showing perforated complicated appendicitis (yellow arrow) with pus formation (red arrow) during laparoscopic appendectomy along extracted appendix post appendectomy with inflamed and gangrenous features (yellow arrow). (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

Post-surgical intervention, the patient was counselled and educated on the possible complication of the surgery made and follow up visits were planned to monitor pregnancy progress. One week, two weeks and one month post-surgery follow up visits revealed no new complain with good progress and she was initiated on ANC care with close follow ups.

3. Discussion

Acute appendicitis typically presents with acute abdomen pain more marked or radiating to the right iliac fossa, fever episodes of sudden onset and nauseas or vomiting both in pregnancy and non-pregnancy population [1,5]. The patient above presented with these features too. The age of the patient is also epidemiologically almost within the reported ranges in pregnancy population (20–30 years) and within that of a general population (5 to 45 years) [1,5].

Despite the fact that inflammatory markers findings were slightly elevated than expected given the intra-op findings, still neutrophil left shift was a useful indicator towards appendicitis diagnosis [5]. Although it is rare, interestingly, the patient was afebrile on the course of illness, which is contrary to the common presentation of acute appendicitis which often presents with episodes of fever [4,5]. Nevertheless, Alvarado score was definitely useful in making the clinical diagnosis of the case above which was later confirmed and managed surgically through laparoscopic approach [2].

The use of abdominal pelvis USS in diagnosis of acute appendicitis in pregnancy was limited also in this case despite being repeated twice with different operators. This might be due to the effect of anatomical changes of appendix position secondary to displacement following the pushing effect of the gravid uterus [5].

While per vaginal bleeding or spotting posed a dilemma of whether it was a threatened abortion alone or threatened abortion super-imposed on another surgical condition in pregnancy like appendicitis [1,8], the use of abdominal pelvic USS was not able to differentiate the two conditions given the negative diagnostic features of threatened abortion in obstetric USS which was done twice [8]. Collaborative clinical discussion between obstetric and general surgery teams was done and collective clinical decisions enabled proper identification and management of the case as per recommended approaches [5,6].

Close follow up was made to monitor possible post-laparoscopic appendectomy complications in pregnancy like pregnancy loss [5]. Despite the controversy in clinical benefits of progesterone supplementation in the management of threatened abortion, the patient was still kept on progesterone in case of progesterone insufficiency as the cause of threatened abortion features [8,9].

4. Conclusion

Presentation and diagnosis of acute appendicitis might be challenging given the ambiguity of clinical presentation and diagnostic limitations of commonly used approaches. Absence of fever with normal or slightly significant changes in inflammatory markers should not be relied diagnostically towards exclusion of acute appendicitis. The use of appendicitis scoring systems like Alvarado score is still reliable in establishing appendicitis diagnosis even in pregnancy. Timely diagnosis and management is essential to prevent and control possible maternal and fetal complications secondary to the condition. Close follow up after surgical intervention is necessary so as to screen and monitor possible complications like miscarriage.

5. Recommendation

Emergency multidisciplinary approach like inclusion of general surgery and facility imaging teams should be emphasized in assessing, investigating and managing any suspected appendicitis case in pregnancy. Moreover, whenever acute appendicitis is highly suspected based on the appendicitis scoring system, the use of diagnostic laparoscopy should be considered.

Since it has not been established clinically whether or not, appendicitis can also present with per vaginal bleeding or spotting during pregnancy, all pregnant women presented with acute abdominal pain or threatened abortion features should be screened for appendicitis too using appendicitis scoring systems and available proper imaging modalities. Clinicians should not under-estimate the possibility of this fatal condition in pregnancy given the suspicious presentation.

Furthermore, while laparoscopic surgical intervention services might not be available to some health facilities in low resource countries like Tanzania, these patients should be referred to facilities where this potential expertise is available when it is convenient.

Author contribution

HLM conceptualized and administered the project. All authors did data curation. KBN, AGN and AMM performed the laparoscopic surgery. HLM, KBN and AGN wrote the first draft. AMM critically reviewed and edited the first draft. AMM supervised the project. Both authors approved the manuscript for publication.

Consent

Patient's informed written consent was obtained to publish this case report. It can be obtained from the corresponding author upon a reasonable request.

Ethical approval

This study did not require ethical approval as it is a case report. However, informed consent from the ethical committee of Kamanga Medics Hospital was obtained and can be provided upon request.

Guarantor

Harold L. Mashauri.

Research registration number

Not applicable.

Funding

Not applicable.

Conflict of interest statement

Authors declare no any conflict of interest.