International Journal of Surgery Open 6 (2017) 5e11
Contents lists available at ScienceDirect
International Journal of Surgery Open
journal homepage: www.elsevier.com/locate/ijso
Appendicitis in pregnancy: Difficulties in diagnosis and management. Guidance
for the emergency general surgeon: A systematic review
Arkeliana Tase, MRCS *, Mohamad Fathul Aizat Kamarizan, MBBS, Keshav Swarnkar, FRCS
Department of General Surgery, Royal Gwent Hospital, Cardiff Rd, Newport, NP20 2UB, UK
a r t i c l e i n f o
Article history:
Received 5 January 2017
Accepted 11 February 2017
Available online 20 February 2017
1. Introduction
Abdominal pain in pregnancy presents many challenges to the
surgeon and obstetrician due to an altered clinical picture. This
paper aims to review recent literature on appendicitis in pregnancy
with emphasis on diagnostic difficulties and appropriate in-
vestigations and management.
The rationale for the review was the conflicting information
regarding the management of appendicitis in pregnancy and the
challenges associated with it.
The review looks in detail at different aspects of assessment and
management of these patients including the differences in pre-
sentation, differential diagnoses, investigations, surgery as well as
complications.
The paper presents the different investigation methods
including their shortcomings in confirming the diagnosis. The re-
view looks at the advantage of different imaging modalities with
the final aim of reducing the rate of negative appendicectomies.
An important aspect of this review was the surgical manage-
ment of these patients. In particular we looked at the evidence from
the literature with regards to laparoscopic surgery and its safety
and benefits. This included adjustments advised by different au-
thors in order to ensure safety and reduce the risk of foetal and
maternal complications.
* Corresponding author. Permanent address: 10 Oliver Court, Ley Farm Close,
Watford, WD25 9BL, UK.
E-mail addresses: arkeliana.tase@gmail.com (A. Tase), fathulaizat89@gmail.com
(M.F.A. Kamarizan), kswarnkar@hotmail.com (K. Swarnkar).
http://dx.doi.org/10.1016/j.ijso.2017.02.001
2405-8572/© 2017 The Authors. Published by Elsevier Ltd on behalf of Surgical Associates Ltd. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
2. Method
The terms “appendicitis” and “pregnancy” were searched in
PubMed, Medline, Embase, HMIC and Cochrane review. The search
included papers published from 2000 onwards. Article selection
was based on relevance to the aims of the study. The exclusion
criteria was papers not relevant to the study aim and not being
available in English language. Given that four different areas were
being reviewed in this study, papers were sub-divided into
different sections depending on the objective it was addressing. No
other review protocol exists. No assumptions or simplifications
were made in this review.
The comparison of imaging modalities was presented in terms
of their sensitivity and specificity as well as their NPV and PPV. The
remainder of the data on surgical management methods was pre-
sented unchanged from their presentation on the original paper.
The quality of studies was evaluated by the authors on the basis of
the aims of the study and the level of evidence presented.
Compliance with the PRISMA criteria was ensured throughout the
study.
3. Results & discussion
The initial literature search identified 7325 overall results. After
careful review, 42 papers were considered eligible for analysis
based on the requirement set at the start of the study.
3.1. Incidence
The incidence of appendicitis in pregnancy is between 1 in 500
to 1 in 635 pregnancies per year. There is variability in the reported
incidence [12,26,38]. The diagnosis is confirmed in 1 in 800 to 1 in
1500 pregnancies [10,16,24,26,27]. It accounts for 25% of non-
eobstetrical emergencies and is the most common cause of
abdominal pain requiring surgery during pregnancy [1,4].
The incidence is less compared to non-pregnant women and
greatest in the second trimester of pregnancy (30%, 45% and 25% in
1st, 2nd and 3rd trimester respectively) [19,24,26,37,40,41]. Re-
ported possible predictive factors are age over 35 (OR 1.92, 95% CI
1.65e2.23, p < 0.001) and BMI greater than 30 (OR 1.95, 95% CI
1.48e2.57, p < 0.001) [2].
6 A. Tase et al. / International Journal of Surgery Open 6 (2017) 5e11

3.2. Presentation trimester accordingly. All patients presented with abdominal pain
(60.9% in RIF, 13% in RUQ) [16]. Another study also reported highest
Patients commonly present with right lower quadrant pain on incidence in second trimester with 51.7% (n ¼ 15) of cases pre-
all stages of pregnancy. The increase in uterine volume in the third senting with RIF pain. In this study, all patients in third trimester
trimester can result in migration of the appendix a few cm caudally. and 50% of patients in second trimester showed cephalic distribu-
This may lead to pain shifting to right flank or upper quadrant tion of pain in right flank [23].
[1,10,19,26]. The appendix displacement stops contact with omen-
tum which results in higher rates of peritonitis especially in the
3.3. Differential diagnosis
third trimester [1,26]. This is due to foetal membranes not able to
block the inflammatory process. Reluctance to operate may also
In all pregnant women with lower abdominal pain, ectopic
affect rates of peritonitis [26].
pregnancy should be ruled out. Nausea and vomiting of pregnancy
Recent studies (Table 1) describe pain in right lower quadrant as
is not associated with abdominal pain. Round ligament pain is not
the most common presenting symptom (86%e100%, 80%e85% and
progressive or associated with other symptoms [26]. Other
60%e85% on 1st, 2nd and 3rd trimester accordingly) [24,31,41]. A
gynaecological differentials are ovarian torsion and fibroid degen-
typical picture is however only present in 50e60% of cases and
eration [8,16,41].
right lower quadrant pain is also the most common symptom in
Pyelonephritis is more common during pregnancy [23]. Renal
non-appendicitis pain [4,24].
stones and hydronephrosis may be present in patients with a
In addition, pregnancy is associated with physiological leuco-
previous history [8]. Pre-eclampsia and HELLP syndrome in the 2nd
cytosis (16 900 cells/mL in 3rd trimester). Thus, biochemical find-
trimester are associated with nausea, vomiting, RUQ, epigastric
ings are unreliable [10,19,26]. Nausea, vomiting and anorexia are
pain and hypertension but rarely fever [26,41].
common and indistinguishable from pregnancy related symptoms
Premature detachment of placenta and uterine rupture present
[10,16].
with lower abdominal pain, vaginal bleeding, changes in foetal
Terzi A et al. (2010) reported that 17.3% (n ¼ 8), 56.5% (n ¼ 26)
heart rate and uterine stiffness differing them from appendicitis
and 26% (n ¼ 12) presented with appendicitis in 1st, 2nd and 3rd
[26,41].

Table 1
Baseline characteristics of study group.

Reference Year No of patients Pain location Trimester No of women Perforation

rate
1st 2nd 3rd Open Laparoscopic

Abbasi N et al. [1] 2014 7114 OD 2.0 OD 0.5 20.3%

48.1% 46.1% OR 1.3
Brown JJS et al. [4] 2008 450 RLQ PPV 61.7
PPV% 58.1, NPV% 36.6 NPV 49.6
RUQ
PPV% 61.8, NPV% 43.2
Flexer S M et al. [10] 2014 38 articles
Jung SJ et al. [16] 2012 25 RLQ -68% 40% 56% 4% 84% (n ¼ 21) 16% (n ¼ 4)
Periumbilical e 28%
RUQ e 4%
Mourad J et al. [24] 2000 67 RLQ 25% 40% 34% 12%
n1 ¼ 12. n2 ¼ 15, n3 ¼ 11
Sharma A K et al. [31] 2012 15 RLQ 20% 40% 40% 13% (n ¼ 2)
n1 ¼ 2 (100%) (n ¼ 2) (n ¼ 6) (n ¼ 6)
n2 ¼ 4 (80%)
n3 ¼ 3 (60%)
Neto A H F et al. [25] 2014 68 articles RLQ ¼ 75% 14-43%
RUQ ¼ 20%
Wei P L et al. [37] 2012 908 n ¼ 780 n ¼ 85 n ¼ 43
Wilasrusmee C et al. 2012 3415 n ¼ 2816 n ¼ 599
[38] (11 studies)
Zingone F et al. [42] 2015 362,219 n ¼ 60 n ¼ 80 n ¼ 42
(156 during
pregnancy.
88 post partum)
Miloudi N et al. [23] 2012 29 RLQ en ¼ 24 32% 42% 26% n ¼ 11 n ¼ 18 (n ¼ 2 n¼5
n1 ¼ 7, n2 ¼ 15, n3 ¼ 7 n1 ¼ 2, n2 ¼ 4, n3 ¼ 5 converted)
n1 ¼ 4, n2 ¼ 11, n3 ¼ 1
Ito K et al. [15] 2012 87 n ¼ 29 n ¼ 47 n ¼ 11
Terzi A et al. [33] 2010 46 RLQ (n ¼ 28) 17.3% 56.5% 26%
RUQ (n ¼ 6)
Generalized (n ¼ 5)
Kazim S F et al. [18] 2009 38 RLQ (n ¼ 33) 86.8% 30% 37% 34% 97% (n ¼ 37) 16% (n ¼ 6)
RUQ (n ¼ 2) 5.3%
Generalized (n ¼ 3) 7.9%
Machado N O et al. [20] 2009 26 RLQ (n ¼ 14) n¼6 n ¼ 20
Rt flank (n ¼ 2)
Central (n ¼ 4)
Peled Y et al. [28] 2014 85 69% (n ¼ 59) 31% (n ¼ 26) n ¼ 11
Peled Y et al. [28] 2014 85 69% (n ¼ 59) 31% (n ¼ 26) n ¼ 11

*. n1 ¼ number on first trimester, n2 ¼ number on second trimester, n3 ¼ number on third trimester.

 A. Tase et al. / International Journal of Surgery Open 6 (2017) 5e11 7

Lastly, uterine vein thrombophlebitis post partum presents with
right lower abdominal pain if the right vein is affected [26].
3.4. Investigations
The investigation is both biochemical and radiological.
3.4.1. Biochemical
White cell count and C-reactive protein levels are physiologi-
cally raised with increasing gestational age thus findings are non-
diagnostic [19,22,33,40]. Some authors propose that these param-
eters in conjunction with lymphocyte count, neutrophil to
lymphocyte ratio and platelet to lymphocyte ratio are useful in
diagnosis with a high sensitivity and specificity [37,40].
New markers such as IL-1 and IL10, bilirubin, procalcitonin and
calprotectin are being studied for their diagnostic accuracy [21].
3.4.2. Radiological
In pregnancy, USS and MRI are most commonly used. Use of CT
scanning is also reported with limited usage due to associated ra-
diation. Imaging is critical in reducing the rate of negative appen-
dicectomy [16]. Table 2 shows a breakdown of the imaging
modalities as discussed in different studies.
USS is easily accessible but has variable accuracy. The highest
levels of positive and negative predictive values reported are 88.2%
and 100% respectively. This varies between studies and affected by
gestational age [8,21]. The rate of indeterminate findings is 88e97%
in women above 16 weeks gestation [10]. Other studies have re-
ported non diagnostic findings in 63% and confirmed appendicitis
in 34% of cases. It has a sensitivity of 20% and specificity of 100%
[14].
The American College of Radiology criteria, recommends graded
compression USS as the initial imaging in first and second trimester
of pregnancy. In indeterminate cases, MRI is the next imaging
modality. MRI has the advantage of identifying other diagnoses in
the absence of ionising radiation [7,8,10,26,39]. Oral contrast using
gadolinium is not advised as it crosses the placenta with unknown
consequences to the foetus [8]. MRI scan has a NPV of 97%e100%
and a PPV of 98.7%e100%. Late stages of pregnancy present chal-
lenges to interpretation of MRI scans [8,14]. It has a sensitivity of
90e100% and a specificity of 94e98% in identifying appendicitis
[8,10]. It is associated with a 0e7% rate of negative laparotomy and
8% perforation rate [8,9].
CT is indicated if MRI is contraindicated due to pacemaker or
other non-compatible devices and USS scan in non-diagnostic
[8,39]. Whilst very reliable in diagnosing appendicitis, the effects
of radiation exposure to the foetus are linked with double the risks
of development of childhood cancers [10]. If considering its use, it

Table 2
Advised Investigations on individual studies and their effectiveness.

Reference Year No of patients Primary USS MRI CT Comments

investigation

Neto A H F et al [26] 2014 68 articles USS Sensitivity 67 Sensitivity 91% Sensitivity 85.7% CT indicated when
e100% (95% CI 54e99%) (95% CI 63.7e96%) MRI is inconclusive
Specificity 86e96% Specificity 98% (95% Specificity 97.4% or unavailable
CI 87e99%) (95% CI 86.2-99.9%)
Yan J et al [39] 2012 1 USS Graduated Useful in
compression differentiating
technique between
appendicitis and
other differentials
Israel G M et al [14] 2008 33 USS followed 1/5 confirmed 4/5 confirmed MRI able to suggest
n¼5 by MRI 2/5 indeterminate 1/5 indeterminate alternative
confirmed 1/0 negative USS diagnoses
appendicitis
Dewhurst C et al [8] 2013 56 papers NPV of non Sensitivity 90 MRI preferred in
visualised appendix e100% 2nd and 3rd
90% Specificity 94e98% trimesters
2% of appendix A normal appendix
visualised on MRI excludes
appendicitis
Burke L M B et al [5] 2015 709 MRI 49.5% of pts had Sensitivity 96.8%
USS Specificity 99.2%
90.6% non NPV 99.5%, PPV
diagnostic 92.4%
Flexer S M et al [10] 2014 38 papers USS followed 7e96% Sensitivity 50e95% 8% negative
by MRI indeterminate Specificity 93 appendicectomy
findings e100% rate
Radiation linked to
doubled risk of
childhood cancer
Negoi I e al [25] 2015 8 USS 75% identified Advised in
appendicitis (n ¼ 6) indeterminate
cases but not used
Ito K et al [15] 2012 87 USS then CT 24% identified Not used Used in 20%
appendicitis Correct diagnosis in
(n ¼ 21) 66.7%
Terzi A et al [33] 2010 46 Uss Sensitivity 37.5%
Specificity 66.66%
PPV 88.23%, NPV
13.79%
Kazim S F et al [18] 2009 38 Uss Identified
appendicitis in
n¼15 (39.5%)
8 A. Tase et al. / International Journal of Surgery Open 6 (2017) 5e11
needs to be thoroughly discussed with the patient.
Early exploration prior to imaging has been challenged due to a
higher negative appendicectomy rate in pregnant patients (36% vs
14%, p < 0.001). In up to 87% of cases no cause for the pain is found
[15].
3.5. Management
There is little evidence on safety of medical management of
appendicitis. It is not advisable in pregnancy due to poor outcomes
and complications. One study showed greater rates of septic shock,
venous thromboembolism and peritonitis after conservative man-
agement [1,10,13,20]. The risk of foetal loss is increased to 36% in
perforated vs 1.5% in non-perforated cases [13].
Surgical options include open and laparoscopic approach.
Complication rates are related to the underlying diagnosis and
maternal factors rather than surgical approach [30]. Table 3 gives a
breakdown of the reviewed evidence.
3.5.1. Laparoscopy
The outcomes of laparoscopy during pregnancy vary signifi-
cantly between different studies. Most recent studies show no
difference between it and the open approach. Some authors report
a higher incidence of preterm delivery (<37 weeks gestation) and a
higher rate of foetal loss (6% vs 3% with open surgery) with lapa-
roscopy [1].
Main concerns with laparoscopy in pregnancy are foetal acidosis
and issues with maternal ventilation. Maximum CO2 pressures of
12 mmHg are recommended. In addition, trocar location should be
based on location of the gravid uterus. TED stockings and flowtrons
should be used both pre and post operatively. A left lateral tilt of
15e30 is suggested to reduce pressure on the inferior vena cava
and aorta. These modifications can minimise the reduction of blood
flow to the uterus thus reduce foetal hypoxia and risk of premature
labour [9,10]. Some authors advice diagnostic laparoscopy if diag-
nosis is unclear with conversion to open in the third trimester [10].
Other modifications suggested are avoidance of cervix instru-
mentation, use of open techniques or use of a Hasson technique for
the first port [20,26]. One study reported insertion of a 10 mm first
port just below the xiphoid with other ports inserted under direct
vision. The authors concluded that laparoscopy is safe in the third
trimester if adjustments are made to the technique [9].
Machado NO et al. (2009) suggested placing the initial port in
the midline approximately 2 cm above the superior level of the
uterus followed by two other ports in left lower and right upper
quadrant. This could be used in all trimesters of pregnancy with
lower rates of intraoperative complications. The rate of foetal loss
was almost 6% which is higher than after open appendicectomy
[20]. A systematic review of 25 studies compared open to lapa-
roscopy however in the absence of strong evidence, no preferred
surgical approach could be recommended [36].
Other studies reported a higher post-operative complication
rate following open surgery (25% vs 3.8%, p < 0.009). No statistical
significance was found in perioperative obstetric or neonatal out-
comes. The hospital stay for the laparoscopic group was higher
mainly for foetal surveillance [32].
The American society of gastrointestinal and endoscopic sur-
geons (SAGES) reviewed many aspects of care from multiple large
trials [32]. Level 1 evidence from their review demonstrated that
laparoscopic appendicectomy offers a shorter hospital stay. The
difference between open and laparoscopic approaches was higher
wound infections in the open approach but higher deep pelvic
abscess rates after laparoscopy. Later studies however showed no
difference between the approaches. The conversion to open surgery
varied between 0 and 27% depending on the surgeon's decision,
experience and operative findings. They concluded that laparos-
copy is safe even in the third trimester of pregnancy [32].
3.5.2. Laparotomy/open appendicectomy
Laparotomy is a well established approach. Studies have shown
that it is twice more common in pregnancy compared to non-
pregnant women (p < 0.001) [1]. The advice is a transverse inci-
sion through McBurney's point or through the point of maximum
tenderness. In unclear cases, a lower midline incision is recom-
mended through which a caesarean section can also be carried out.
The surgical approach used depends on the patient's physical status
especially their BMI, gestational age and the choice of the on call
surgeon as guided by their experience [23].
3.6. Complications
3.6.1. Foetal complications
Appendicitis in pregnancy is related to babies with lower birth
weight and small for gestational age. This is more common in 1st
and 2nd trimesters whilst preterm labour is more common in the
1st and 3rd trimesters. Congenital anomalies can occur in the 1st
trimester and surgery in 3rd trimester is associated with early
delivery [10,16,37].
Risk of foetal loss is between 3 and 15% in women with
complicated appendicitis in their 1st trimester. This can be as high
as 20e37% and associated with a delivery rate of 15e45%
[34,35,38].
Cases of delayed diagnosis are associated with foetal mortality
of up to 35e55% in patients with perforated appendix compared to
1.5% in noneperforated cases [8,17]. Long term data on this is
however limited [26].
McGory ML et al. (2007) found a higher rate of negative ap-
pendicectomy in pregnant women (23% vs 18%, p < 0.05). (Table 4
shows the rates of negative appendicectomy reported in the liter-
ature). The study showed that laparoscopy had a higher rate of
foetal loss compared to open appendicectomy (odds ratio 2.31)
[22]. Pre-term labour is highest in the first week following surgery
which suggests that both appendicitis and surgical complications
lead to preterm contractions [25,41].
3.6.2. Maternal complications
Incidence of perforation of appendix is 20.3%e43% (16,1%e19%
in the general population) in pregnancy. It is highest in the third
trimester and gives rise to pelvic collections, wound infection and
sepsis [15,20,38,41]. This risk increases with gestational age and
rates of perforation are 8.7%, 12.5% and 26.1% for each trimester
respectively [1,10,27] Multivariate analyses showed that abscess
development is related to diagnosis rather than surgical approach
[29]. A delay in surgery by more than 24 h s is related to 66%
incidence of perforation [20]. Other complications are ileus and
respiratory infections [16,42].
4. Conclusion
Pregnant women with suspected appendicitis should be inves-
tigated and managed without delay. A multidisciplinary approach
is to the best interest of the patient. Important differential di-
agnoses should be ruled out. Imaging investigations are essential
and include USS followed by MRI whilst biochemical tests are non-
diagnostic.
Surgical management is planned based on the surgeon's skills
and experience. Patient factors such as BMI, gestational age,
trimester of pregnancy and previous abdominal surgery should be
considered. Both open and laparoscopic approaches can be suc-
cessful in the right hands. Modifications to the laparoscopic
 A. Tase et al. / International Journal of Surgery Open 6 (2017) 5e11 9

Table 3
Management and complications as per individual studies.

Reference Year No of Management Risk of Maternal complications Foetal complications Hospital stay
patients perforation/
Surgery Conservative
peritonitis/
(Open/
pelvic
laparoscopic)
abscess

Negoi I e al [25] 2015 8 100% performed Not advised Nil nil

open
Flexer S M et al. [10] 2014 38 Treatment- surgical Not advised
papers Open or
Laparoscopic
Equally advised
Neto A H F et al. [26] 2014 68 If diagnosis certain Not advised 14-43% Risk of foetal loss 1.5%
articles e laparotomy (36% in perforated cases)
If diagnosis Premature delivery 4%
uncertain e (11% perforated cases)
laparoscopy with
modifications
Abbasi N et al. [1] 2014 7114 Open e 48.1%, OD 5.8% 20.3% Ileus 5.3% Post op stay >3 days
2.0 (95% CI 1.9e2.1) (n ¼ 413) Conservative Pneumonia 1.1% (2.6% with 45.5%
Laparoscopic e 28.8% peritonitis) 82.4% in peritonitis
46.1%, OD 0.5 (95% Open - 19.8% Haemorrhage/haematoma
CI 0.5e0.5) 0.2% (0.2% with peritonitis)
Venous thromboembolism
0.4% (0.6% with peritonitis)
Jung SJ et al. [16] 2012 25 Open 84% (n ¼ 21) Not advised Wound infection ¼ 2 (open) Spontaneous abortion Open (mean 6.7 days)
Laparoscopic 16% n ¼ 0 (Lap) n¼1 Lap (mean 3.8days)
(n ¼ 4)
Wei P L et al. [37] 2012 908 5.8% (n ¼ 53) Low birth weight 12%
Preterm birth 11.6%
Small for gestational age
22.4%
Miloudi N et al. [23] 2012 29 Open 38% (n ¼ 11) Not 17% (n ¼ 5)
Laparoscopic 55.2% practiced
(n ¼ 16)
Converted to open
6.8% (n ¼ 2)
Sadot E et al. [30] 2009 65 Open 26% (n ¼ 17) Not advised Nil No difference between Open 4.2 days
Laparoscopic 74% open and lap on foetal Lap 3.4 days
(n ¼ 48) outcome (p ¼ 0.001)
1st trimester e
100% laparoscopic
(p < 0.001)
2nd trimester e
73% lap, 27% open
3rd trimester e 71%
lap, 29% open
Abbasi N et al. [2] 2014 1203 Open 60.3% 9.1% 27% Antepartum haemorrhage Pre-term delivery
Laparoscopically n ¼ 10 (0.83%) n ¼ 213 (17.71%)
30.7% Abruption placentae n ¼ 26 Intrauterine death
(2.16%) n ¼ 12 (1%)
Zainuddin Z R B et al. 2014 31 Perforated appendix risk e Foetal loss risk 1.5e9%
[41] papers up to 43% Consequences of
pneumoperitoneum
Wilasrumee C et al. 2012 3415 Open (n ¼ 2816) None Wound infection e RR 0.91 Preterm labour RR 1.4
[38] 11 Laparoscopic (0.12e7.18) (0.68e3.06)
studies (n ¼ 599) Foetal loss RR 1.91 (1.31
e2.77)
Pastore P A et al. 2006 2 N ¼ 1 foetal loss 7 days
[27] post laparotomy
MCGory M L et al. 2007 3133 Negative appendicectomy Non complicated
[22] rate 23% appendicitis
Foetal loss 2% p < 0.05
Early delivery 4%
p < 0.05
Complicated appendicitis
Foetal loss 6% p < 0.05
Early delivery % p < 0.05
Ito K et al. [15] 2012 87 Wound infection n ¼ 2 Foetal loss n ¼ 3 Non perforated 3 days
Abscess n ¼ 1 [1e11]
Bowel obstruction n ¼ 1 Perforated 4 days [2
DVT/PE n ¼ 1 e12]
Terzi A et al. [33] 2010 46 Wound infection n ¼ 50 Pre-term delivery n ¼ 1
Kazim S F et al. [18] 2009 38 Open (n ¼ 37) 97% Wound infection (n ¼ 3) 8% Pre-term delivery n ¼ 3
Intraabdominal abscess (8%)
(n ¼ 1) 3% Foetal loss n ¼ /1
PE (n ¼ 2)

OR ¼ odds ratio, RR ¼ relative risk.

10 A. Tase et al. / International Journal of Surgery Open 6 (2017) 5e11

Table 4
Negative appendicectomy rate.

Reference Year of publication Rate of negative appendicectomy

Machado N O et al. [20] 2009 19.2% (n ¼ 5)

Ito K et al. [15] 2012 36%
Zingone F et al. [42] 2015 n1 ¼ 17.4%, n2 ¼ 26.2%, n3 ¼ 7.1%
Wilasrusmee C et al. [38] 2012 12-24%
Neto A H F et al. [26] 2015 20-35%
Sharma A K et al. [31] 2012 20% (n ¼ 3)
Mourad J et al. [24] 2000 33%, (n1 ¼ 3, n2 ¼ 5, n3 ¼ 7)

n1 ¼ Number on 1st trimester, n2 ¼ Number on 2nd trimester, n3 ¼ Number on 3rd trimester.

approach should be considered as described above. Whilst one
approach may not fit all, careful risk analysis should direct the
surgeon towards the best possible management and outcome.
The main limitation of the study is the variability in outcome of
different studies and opinions regarding investigative tools and
surgical method used. This we believe is related to local practice
and individual surgeon's preference. Performing a study of all
pregnant patients presenting in UK hospitals over a time period
with acute appendicitis will certainly aid with creation of a set
protocol for investigating and managing this group of patients.
Ethical approval
None.
Sources of funding
None.
Author contribution
Arkeliana Tase e Data collection, analysis, writing.
Mohamad Kamarizan e Data collection.
Keshav Swarnkar e Review of manuscript and input on the
submission aspects.
Conflicts of interest
None.
Guarantor
Arkeliana Tase.
Appendix A. Supplementary data
Supplementary data related to this article can be found at http://
dx.doi.org/10.1016/j.ijso.2017.02.001.
References
[1] Abbasi N, Patenaude V, Abenhaim HA. Management and outcomes of acute
appendicitis in pregnancy e population based study of over 7000 cases. BJOG
2014;121:1509e14.
[2] Abbasi N, Patenaude V, Abenhaim HA. Evaluation of obstetrical and fetal
outcomes in pregnancies complicated by acute appendicitis. Arch Gynecol
Obstet 2014;290:661e7.
[3] Anderson REB, Lambe M. Incidence of appendicitis during pregnancy. Int J
Epidemiol 2001;30:1281e5.
[4] Brown JJS, Wilson C, Coleman S, Joypaul BV. Appendicitis in pregnancy: an
ongoing diagnostic dilemma. Colorectal Dis 2009;11(2):116e22.
[5] Burke LMB, Bashir MR, Miller FH, Siegelman ES, Brown M, Alobaidy M, et al.
Magnetic Resonance imaging in acue appendicitis in pregnancy: a 5 year
multi-institutional study. Am J Obstet Gynaecol 2015;693:e1e5.
[6] Christos C, Kostantinous S, Nikolaos K, Elias M, Giorgos I, Fred L. Appendicitis
in pregnancy: a case report and a review of the current literature. Clin Exp
Obstet Gynecol 2007;34(2):115e6.
[7] Debnath J, Sharma V, Ravikumar R, Kumar J, Chatterjee S, Sampath S, et al.
Clinical mimics of acute appendicitis: is there any role of imaging? Med J
Armed Forces India 2016 Jul;72(3):285e92. http://dx.doi.org/10.1016/
j.mjafi.2015.01.017.
[8] Dewhurst C, Beddy P, Pedrosa I. MRI Evaluation of acute appendicitis. J Magn
Reson Imaging 2013;37:566e75.
[9] Donkervoort SC, Boema D. Suspicion of acute appendicitis in the third
trimester of pregnancy: pros and cons or a laparoscopic procedure. JSLS
2011;15(3):379e83.
[10] Flexer SM, Tabib N, Peter MB. Suspected appendicitis in pregnancy. Surg
2014;12:82e6.
[11] Giorgakis E, Karydakis V, Farghaly A. Perforated endometrial appendicitis in
pregnancy. Hippokratia 2012;16(2):181e3.
[12] Hiersch L, Yogev Y, Ashwal E, From A, Ben-Haroush A, Peled Y. The impact of
pregnancy on the accuracy and delay in diagnosis of acute appendicitis.
J Matern Fetal Neonatal Med 2014;27(13):1357e60.
[13] Holzer T, Pellegrinelli G, Morel P, Toso C. Appendectomy during the third
trimester of pregnancy in 27-year old patient: case report of a “near miss”
complication. Patient Saf Surg 2011;5:11.
[14] Israel GM, Malguria N, McCarthy S, Copel J, Weinreb J. MRI vs Ultrasound for
suspected appendicitis during pregnancy. J Magn Reson Imaging 2008;28:
428e33.
[15] Ito K, Ito H, Whang EE, Tavakkolizadeh A. Appendicectomy in pregnancy:
evaluation of the risk of a negative appendicectomy. Am J Surg 2012;203(2):
145e50.
[16] Jung SJ, Lee DK, Kim JH, Kong PS, Kim KH, Bae SW. Appendicitis during
pregnancy: the clinical experience of secondary hospital. J Korean Soc Colo-
proctol 2012;28(3):152e9.
[17] Jusoh AC, Ghazi AFNM, Ghani MSA. Appendectomy for presumed acute
appendicitis in pregnancy: an obsolete concept? J Minim Invasive Surg Sci
2015;4(1):e25543.
[18] Kazim SF, Pal KMI. Appendicitis in pregnancy: experience of thirty-eight pa-
tients diagnosed and managed at a tertiary care hospital in Karachi. Int J Surg
2009;7(4):365e7.
[19] Kumamoto K, Imaizumi H, Hokama N, Ishiguro T, Ishibashi K, Baba K, et al.
Recent trend of acute appendicitis during pregnancy. Surg Today 2015;45:
1521e6.
[20] Machado NO, Grant CS. Laparoscopic Appendicectomy in all trimesters of
pregnancy. JSLS 2009;13(3):384e90.
[21] Marshall MJ, Smart NJ, Hyde C, Winyard PG, Shaw AM, Daniels IR. Biomarkers
for diagnosis of acute appendicitis in adults. Cochrane Database Syst Rev 2015.
http://dx.doi.org/10.1002/14651858.CD011592.
[22] McGory ML, Zingmond DS, Tillou A, Hiatt JR, Ko CY, Cryer HM. Negative ap-
pendectomy in pregnant women is associated with a substantial risk of fetal
loss. J Am Coll Surg 2007;205(4):534e40.
[23] Miloudi N, Brahem M, Abid SB, Mzoughi Z, Arfa N, Khalfallah MT. Acute
appendicitis in pregnancy: specific features of diagnosis and treatment. J Visc
Surg 2012;149(4):e275e279.
[24] Mourad J, Elliot JP, Erickson L, Lisboa L. Appendicitis in pregnancy: new in-
formation that contradicts long-held clinical beliefs. Am J Obstet Gynecol
2000;182(5):1027e9.
[25] Negoi I, Paun S, Hostiuc S, Moldoveanu A, Beuran M. Acute appendicitis during
pregnancy: no place for maybe. JSS, 2(4): 159e162.
[26] Neto AHF, Amorim MMR, Nobrega BMSV. Acute Appendicitis in pregnancy:
literature review. Rev Assoc Med Bras 2015;61(2):170e7.
[27] Pastore PA, Loomis DM, Sauret J. Appendicitis in pregnancy. J Am Board Fam
Med 2006;19:621e6.
[28] Peled Y, Hiersch L, Khalpari O, Wiznitzer A, Yogev Y, Pardo J. Appendectomy
during pregnancy e is pregnancy outcome depending by operation tech-
nique? J Matern Fetal Neonatal Med 2013;27:365e7.
[29] Ruffolo C, Fiorot A, Pagura G, Antoniutti M, Massani M, Caratozzolo E, et al.
Acute appendicitis: what is the gold standard of treatment? World J Gastro-
enterol 2013;19(47):8799e807.
[30] Sadot E, Telem DA, Arora M, Butala P, Nguyen SQ, Divino CM. Laparoscopy: a
safe approach to appendicitis during pregnancy. Surg Endosc 2009;24(2):
383e9.
[31] Sharma AK, Sharma RK, Sharma SK. Appendicitis in pregnancy: a novel
approach for diagnostic dilemma. SLJOG 2012;34:6e10.
 A. Tase et al. / International Journal of Surgery Open 6 (2017) 5e11
[32] Society of American Gastroinestinal and Endoscopic Surgeons. Guidelines for
Diagnosis, treatment and use of laparoscopy for surgical problems during
pregnancy. 2007. http://www.sages.org/publications/guidelines/guidelines-
for-diagnosis-treatment-and-use-of-laparoscopy-for-surgical-problems-
during-pregnancy/.
[33] Terzi A, Yildiz F, Vural M, Coban S, Cece H, Kaya M. A case series of 46 ap-
pendectomies during pregnancy. Cent Eur J Med 2010;122:686e90.
[34] Thompson MM, Kudla AU, Chisholm CB. Appendicitis during pregnancy with a
normal MRI. West J Emerg Med 2014;15(6):652e4.
[35] Vasireddy A, Atkinson S, Sherman A, Bewley S. Surgical Management of
appendicitis remains best option during pregnancy. BMJ 2012;344:e3575.
[36] Walker HG, Samaraee AA, Mills SJ, Kalbassi MR. Laparoscopic appendicectomy
in pregnancy: a systematic review of the published evidence. Int J Surg
2014;12:1235e41.
[37] Wei PL, Keller JJ, Liang HH, Lin HC. Acute appendicitis and adverse pregnancy
outcomes: a nationwide population based study. J Gastrointest Surg 2012;16:
11
1204e11.
[38] Wilasrusmee C, Sukrat B, McEvoy M, Attia J, Thakkinstian A. Systematic re-
view and meta-analysis of safety of laparoscopic versus open appendicectomy
for suspected appendicitis in pregnancy. Br J Surg 2012;99:1470e9.
[39] Yan J, Sabbagh R, Adu A, Gilet A. MRI of early appendicitis during pregnancy.
BMJ Case Rep 2012. http://dx.doi.org/10.1136/bcr-2012-006878.
[40] Yazar FM, Bakacak M, Emre A, Urfalıoglu A, Serin S, Cengiz E, et al. Predictive
role of neutrophil-to-lymphocyte and platelet-to-lymphocyte ratios for
diagnosis of acute appendicitis during pregnancy. Kaohsiung J Med Sci
2015;31:591e6.
[41] Zainuddin ZRB, Sulaiha SA, Azmi MN. Acute appendicitis in pregnancy: a
diagnostic and management challenge. IMJM 2014;13(1):77e80.
[42] Zingone F, Sultan AA, James D, West J. Risk of acute appendicitis in and around
pregnancy, a population ebased cohort study from England. Ann Surg
2015;261(2):332e7.