Complicated Appendicitis in Pregnant Women

Immediate operation for complicated appendicitis in pregnant women was associated with lower odds of maternal infectious complications, according to the latest research published in JAMA Network Open. Also, the odds of perinatal or other maternal complications were not higher compared with successful nonoperative management.

Acute appendicitis complication occurs in 1 in 700 to 1500 live birth pregnancies at some time during pregnancy, with most instances among women aged younger than 30 years. Also, more than 1 in 20 women of childbearing age who present with acute appendicitis are pregnant.

Unlike uncomplicated appendicitis, complicated appendicitis (e.g., perforation with peritonitis or abscess) among pregnant women does not have a clear optimal management strategy. For complicated appendicitis within the general population, immediate operation and nonoperative management, including antibiotics and percutaneous drainage for appendiceal abscesses, have been found to be associated with effective outcomes. However, when nonoperative management failed, the need for open surgery and bowel resection portending to increased morbidity was increased.

Given the scarcity of literature comparing management strategies for complicated appendicitis during pregnancy, this study conducted by Matthew Ashbrook et al. aimed to compare clinical outcomes between nonoperative and operative management of complicated appendicitis in pregnant women. This cohort study was conducted using National Inpatient Sample data between January 2003 and September 2015. This database approximates a 20% stratified sample of US inpatient hospital discharges. Included individuals were pregnant women discharged with the diagnosis of complicated appendicitis. Data were analyzed from February 2020 through February 2022.

Study patients were categorized into 3 groups:

• Those with successful nonoperative management
• Failed nonoperative management with the delayed operation
• Immediate operation for complicated appendicitis

Clinical outcomes, including maternal infectious complications and perinatal complications, hospital length of stay, and total hospital charges were measured.

The study results showed that:

• Among 8087 pregnant women with complicated appendicitis, nonoperative management of complicated appendicitis was successful among 954 patients (11.8%) and failed among 2646 patients (32.7%), who underwent delayed operation; 4487 patients (55.5%) underwent an immediate operation.
• In multivariate analysis, successful nonoperative management was associated with higher odds of amniotic infection and sepsis compared with the immediate operation, while there was no significant difference in preterm delivery, preterm labor, or abortion.
• However, failed nonoperative management that required delayed operation was associated with higher odds of preterm delivery, preterm labor, or abortion compared with immediate operation.
• An immediate operation was associated with decreased hospital charges compared with nonoperative management which was successful and that failed.
• In subgroup multivariate logistic regression analysis, each day in the delay to surgery was associated with an increase in odds of preterm delivery, preterm labor, or abortion by 23%.

"In this study, 74% of pregnant women who trialed nonoperative management of complicated appendicitis failed and subsequently underwent operative intervention during the same hospital stay," the authors wrote. "In this group of women, maternal and perinatal outcomes were uniformly worse compared with the immediate operation group. Furthermore, each day in delay to surgery was associated with higher odds of complication for every maternal and perinatal outcome assessed in this study. Additionally, as hospital cost containment and Length Of Stay play a greater role in decision-making, it is important to note that immediate operation was associated with shorter hospital stays and decreased hospital costs," they further added.

For the full article: JAMA Network Open