Outcomes of Antibiotic Therapy for Uncomplicated Appendicitis in Pregnancy

doi:10.1016/j.amjmed.2017.04.046

The American Journal of Medicine

Volume 130, Issue 12, December 2017, Pages 1467-1469

https://doi.org/10.1016/j.amjmed.2017.04.046 Get rights and content

Abstract

Objective

The aim of the present study is to determine the feasibility and safety of antibiotics for uncomplicated simple appendicitis in pregnancy.

Method

We conducted a 6-year prospective observational study on 20 pregnant women in whom uncomplicated simple appendicitis (appendiceal diameter ≤11 mm and with no signs of appendicoliths, perforation, or abscess) was radiologically verified and managed with a 4-day course of antibiotics. Treatment failure rate, defined as the need for an appendectomy during hospitalization and recurrence in the follow-up period (median 25 months), and maternal or fetal complications during the pregnancy were evaluated.

Results

Mean age of patients was 33.4 years, and gestational age was 17.8 weeks. Three patients failed to respond to antibiotic therapy during hospitalization and underwent subsequent appendectomy (2 suppurative and 1 perforated appendicitis). There was 1 wound infection postoperatively. During follow-up, 2 patients during their ongoing pregnancy experienced recurrence at 3 and 6 months post-treatment, and a new course of antibiotics was determined. Patients also experienced recurrence at 8 and 10 months post-treatment and underwent appendectomy. Treatment failure occurred in 5 patients (25%) with no fetal complications during the pregnancy.

Conclusions

Antibiotic therapy for uncomplicated appendicitis in pregnancy may be a feasible treatment option without severe maternal and fetal complications.

Section snippets

Study Design

This was conducted as a prospective observational study in a single medical training center, and all participants provided informed consent. Pregnant women admitted with suspected acute appendicitis and diagnosed as having uncomplicated simple appendicitis, based on radiologic examinations, were included in this study.

Ultrasound and magnetic resonance imaging criteria for uncomplicated simple appendicitis included an appendiceal diameter between 6.1 and 11.0 mm without appendicoliths or signs

Clinical Characteristics

This study included 20 pregnant women (26-43 years; mean, 33.4 ± 4.5 years), primarily presenting with right abdominal pain and tenderness. We found 5 patients had vomiting, indigestion, fever, labor pain, or whole abdominal pain as a chief symptom, and 7 women (35%) had fever (body temperature ≥38.3°C).

Two patients had previous abdominal surgery (caesarean section and tubo-ovarian abscess), and 2 patients had comorbidities (hyperthyroidism and diabetes). Median gestational age was 17.8 weeks

Discussion

It is generally accepted that acute appendicitis during pregnancy warrants an immediate surgery to avoid delayed diagnosis, complicated disease, or adverse pregnancy outcomes. However, the risk of negative appendectomy and surgery-related maternal or fetal complications still remained.

We analyzed pregnant patients who underwent surgery (57 patients) and found a tolerable rate of postoperative complications (8/57; 14%). However, the negative appendectomy rate was higher (6/57; 11%) than in other

Conclusions

The clinical result of this study does not essentially change the treatment strategy for appendicitis in pregnancy; however, it may contribute meaningfully as a treatment option for selected uncomplicated appendicitis. Accordingly, some patients with uncomplicated appendicitis in pregnancy could be treated with antibiotic therapy without serious maternal and fetal complications to obviate the need for unnecessary surgery.

Acknowledgments

The authors thank all of the staff who were involved in the care of pregnant patients at the Department of Surgery and Obstetrics.

References (7)

P.L. Wei et al.
Acute appendicitis and adverse pregnancy outcomes: a nationwide population-based study
J Gastrointest Surg
(2012)
M.L. McGory et al.
Negative appendectomy in pregnant women is associated with a substantial risk of fetal loss
J Am Coll Surg
(2007)
C. Vons et al.
Amoxicillin plus clavulanic acid versus appendicectomy for treatment of acute uncomplicated appendicitis: an open-label, non-inferiority, randomised controlled trial
Lancet
(2011)

There are more references available in the full text version of this article.

Cited by (26)

Is non-operative treatment of acute appendicitis possible: A narrative review
2024, African Journal of Emergency Medicine
Acute appendicitis (AA) represents the most frequent surgical emergency. Perforation was long considered the ultimate outcome of AA, prompting appendectomy; which remains the standard treatment. New data have clarified the role of the appendix, justifying conservative treatment. This narrative review aims to summarize the evidence regarding the non-operative treatment (NOT) of AA in adults.
The literature search was performed via the PubMed Medline database. Our criteria-based selection resulted in a total of 48 articles for review.
Recent trials and meta-analyses have assessed NOT, which support primary antibiotic treatment of uncomplicated AA. Although it has a significant recurrence and failure rate, NOT does not appear to increase the risk of appendicular perforation. Moreover, NOT compared with appendectomy, seems to be associated with less morbidity, lower cost of care and preserved quality of life.
First-line NOT seems to be a reasonable approach for the treatment of uncomplicated CT-confirmed AA. Careful patient screening would definitely enhance the success rate.
Surgical emergencies in the pregnant patient
2023, Current Problems in Surgery
Antibiotics alone as an alternative to appendectomy for uncomplicated acute appendicitis in adults: Changes in treatment modalities related to the COVID-19 health crisis
2020, Journal of Visceral Surgery
Citation Excerpt :
This is another reason why a non-surgical alternative is so important in patients with confirmed or suspected COVID-19 infection. Several case series have described successful non-operative treatment in the pregnant woman [13,14], however, in one study on 400 pregnant women treated medically for non-complicated appendicitis, the risk of severe sepsis, septic shock and thromboembolic disease was higher compared to pregnant women who had undergone appendectomy [15]. Thus, medical management of appendicitis in pregnant women carries a higher risk compared to surgery and should be avoided whenever possible.
The massive inflow of patients with COVID-19 requiring urgent care has overloaded hospitals in France and impacts the management of other patients. Deferring hospitalization and non-urgent surgeries has become a priority for surgeons today in order to relieve the health care system. It is obviously not simple to reduce emergency surgery without altering the quality of care or leading to a loss of chance for the patient. Acute appendicitis is a very specific situation and the prevalence of this disease leads us to reconsider this particular disease in the context of the COVID-19 crisis. Indeed, while the currently recommended treatment for uncomplicated acute appendicitis is surgical appendectomy, the non-surgical alternative of medical management by antibiotic therapy alone has been widely evaluated by high-quality studies in the literature. Insofar as the main limitation of exclusively medical treatment of uncomplicated acute appendicitis is the risk of recurrent appendicitis, this treatment option represents an alternative of choice to reduce the intra-hospital overload in this context of health crisis. The aim of this work is therefore to provide physicians and surgeons with a practical guide based on a review of the literature on the medical treatment of uncomplicated acute appendicitis in adults, to offer this alternative treatment to the right patients and under good conditions, especially when access to the operating room is limited or impossible.
The Reply
2020, American Journal of Medicine
MRI is Mandatory for the Assignment into Antibiotic Treatment or Appendectomy Group of Patients During Pregnancy
2020, American Journal of Medicine
Non-obstetric surgery in pregnancy (including bowel surgery and gallbladder surgery)
2020, Best Practice and Research: Clinical Gastroenterology
Citation Excerpt :
On the other hand, a recent prospective observational study showed that antibiotics may be a meaningful treatment option for selected pregnant patients with uncomplicated appendicitis [57]. In this study maternal and fetal complications appeared to be limited and the need for surgery could be obviated in 75% of the patients [58]. However, more and larger studies are needed to change therapy recommendations.
Non-obstetric surgery during pregnancy is required in 0.75–2% of pregnancies. Physiologic changes during pregnancy, both hormonal and anatomic, can have interactions with surgery and anesthesia. Indication, timing as well as risks of anesthesia and surgery should be considered in surgical decision making. The health status of the mother should always be put first. A preoperative multidisciplinary approach, also including an obstetrician and neonatologist, is mandatory. Delay in diagnosis and treatment carry risks of complications in all septic visceral indications. Considerations should be individualized.

View all citing articles on Scopus

: Funding: None.

: Conflict of Interest: None.

: Authorship: All authors had access to the data and played a role in writing this manuscript.

View full text

Brief observationOutcomes of Antibiotic Therapy for Uncomplicated Appendicitis in Pregnancy

Abstract

Objective

Method

Results

Conclusions

Section snippets

Study Design

Clinical Characteristics

Discussion

Conclusions

Acknowledgments

J Gastrointest Surg

J Am Coll Surg

Lancet

Brief observation
Outcomes of Antibiotic Therapy for Uncomplicated Appendicitis in Pregnancy