APPENDICITIS IN PREGNANCY
Primary appendicitis in pregnancy is very rare; recurrent
appendicitis is not so rare. When appendicitis goes on to suppuration
and perforative peritonitis the condition is worse in pregnant women
than in the non-pregnant. In pregnancy protective adhesions, walling
off, are less likely to occur; the inflammation is more intense owing
to increased vascularity; thrombosis and phlebitis are more frequent;
drainage may be obstructed and the burrowing of pus widespread;
tympany, too, causes dyspnoea earlier. About 75 per cent. of the
cases occur after the third month, and the earlier the appendicitis
appears, the better the prognosis. During labor the contracting
uterus sometimes tears open an adhesive appendix, or ruptures a pus
sac and starts a general peritonitis. This condition may be mistaken
for a general sepsis which is puerperal. Acute appendicitis is
likely to be confused with an inflammation of a Fallopian tube. When
the appendicitis is perforative abortion, infection of the uterine
contents and death of the child happen in most cases. Labor is very
painful when appendicitis is present, and the uterine contractions
are often weak. After delivery many forms of infection of the uterus
and its adnexa are possible.
Operation is much less difficult in the first half of gestation
than in the latter months. At the beginning of gestation the
operation does not, as a rule, cause abortion. Late in pregnancy
appendicitis rapidly goes on to suppuration and perforation, with
a high mortality. Hirst says that where there is reason to suspect
suppuration a median incision should be made and the pelvic cavity
examined for possible areas of infection. John Deaver says, "Always
cut down on the sore spot and do not handle the uterus." An infected
uterus after cesarean section complicated with appendicitis has to be
amputated.
The diagnosis between appendicitis, ectopic gestation, twisted
ovarian tumors, ureteritis, and ureteral stone is to be made. In a
discussion of a paper by Finley on Appendicitis in Pregnancy,[117]
Dr. John Murphy of Chicago, a great authority, advised operation
as soon as the diagnosis is made, and he was of the opinion that
this diagnosis is not difficult to make in pregnancy. Deaver said a
diagnosis of catarrhal appendicitis is not seldom very difficult to
make. This form is very rare in pregnancy. Deaver is not of the same
opinion as Murphy as to operating as soon as the diagnosis is made in
all cases. Where there is a general peritonitis, operation commonly
only makes matters worse by spreading infection. The mortality of
cases of appendicitis in pregnancy left without operation is as high
as 77 per cent.; where the cases are operated upon within forty-eight
hours after diagnosis the mortality is 6.7 per cent. and it would be
better if the operation were done within twenty-four hours. Finley
says that in the fifteen cases reviewed in his paper the operation
did not cause abortion. Deaver tells us the muscular rigidity in
the right groin characteristic of appendicitis is often missing in
pregnancy, and that sometimes the pain is on the left side of the
belly.
[117] _Jour. Amer. Med. Assoc._, December 24, 1912.