Surgical Emergencies in Pregnancy

Acute Appendicitis This is the commonest emergency encountered, with an incidence of approximately I :2,000 pregnancies. The classical symptoms of acute appendicitis are as follows: abdominal pain, which is at first central and colicky, later moving 1 0 the right iliac fossa and becoming conslant; a sudden disappearance of the pain sometimes indicates perforation. Associatebd with the pain there is a slight rise in tcmperature and pulse rate. There is local tenderness and often rigidity over the site of the appendix. In pregnancy, these sane features occur, but the pain is perhaps more apt to start on the right side than it is in non-pregnant individuals; and the tenderness, in the later months of pregnancy, is naturally higher and more lateral -after the sixth month the maximum tenderness is at the level of the umbilicus or even higher. There is one particularly difficult type of appendix which occurs during pregnancy, and that is the “retro-uterine” appendix. Normally, as the uterus enlarges the caecum and appendix are displaced progressively upwards and laterally. Sometimes, however, the uterus enlarges anterior to the caecum and the caecum and appendix may lie at a relatively normal level behind the uterus. Such cases of appendicitis are particularly awkward, from the point of view of both diagnosis and treatment. Local tenderness may be absent, or when present it may easily be confused with uterine tenderness. Operation is difficuIt because the appendix lies behind the uterus. In such cases it may be necessary to perform Caesarean section in order to get access. The most important feature in the diagnosis of acute appendicitis is localised tenderness. I think any pregnant woman who has a reasonably acceptable history and shows localised deep tenderness at the appropriate site should be regarded as suffering from acute appendicitis until proved otherwise by operation. ’If in doubt, it is safer from the point of view of both the mother and the foetus to operate early rather than to wait and see. When assessing local tenderness, it is important to remember the possibility of a spontaneous rupture of the rectus abdominis muscle which may occur during pregnancy. I f the patient is made to tense her abdominal muscles, in the case of appendicitis the tenderness is reduced, whereas, in the case of a ruptured rectus abdominis, the tenderness is increased. Appendicectomy may need to be combined with a Caesarean section under the following circumstances: (i>