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15.7 Diagnosis
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tions with the clinical presentation of AA,
such as MD (Fig. 15.18). A low- dose
(<2.5mGy) protocol is sufficient to confirm or
rule out AA in 83% [193]. Standard-dose CT
or MRI can reveal the diagnosis of the remaining cases.
For diagnosing AA in pregnancy, a lowdose abdominal CT should be used for an
uncertain clinical diagnosis, equivocal laboratory or US ndings, or limited access to
MRI or MRI expertise.
The simplied diagnostic algorithm is pre-
sented in Fig.15.19.
Progrant patients
with suspected
appendicitis
391
Fig. 15.18 Contrast-enhanced abdominal CT shows an
intrauterine pregnancy of 29weeks with a uid-lled collection under the umbilicus containing an enterolith.
(Reproduced with permission from [130])
US positive for
appendicitis
Low clinical
Operation
Fig. 15.19 Algorithm for the evaluation of pregnant patients with suspected acute appendicitis. (Reproduced with
permission from [176])
suspicion for
appendicitis
observation
Nondiagnostic or
negative US
st
1
trimester
MRI
Moderate or high
clinical suspicion
nd
2
or 3rd trimester
MRI or CT
Clinical
indications for
operation
OR
392
80
Percent %
Drug LA OA
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15 Acute Appendicitis
15.8 Treatment
In these cases, the usually conservative surgeons
of Germany take, as a rule, the same radical stand
which is taken by their American and French
colleagues.
(Howard Atwood Kelly, 1909)
In case of a relapse in a pregnancy, the operation
is to be recommended even while the clinical symptoms are of a mild nature, especially in the earlier
months of the pregnancy.
(Fränkel)
If appendicitis comes on during labor, it is best to
terminate labor rst and then make sure of the
diagnosis and operate on the appendicitis.
(Alfred Labhardt, 1904)
15.8.1 Conservative Treatment
Conservative management in pregnancy is
increasing (Fig. 15.20). It ranges from 5.8–9%
[34, 195], over 19% [196] to even 67% in
population- based studies [194]. In Korea,
approximately 25% of pregnancies affected by
uncomplicated AA are treated conservatively
[197], compared to 63% in China [198].
Three conservative management strategies
exist. One is denitive antibiotic treatment [199].
There were attempts to use the transabdominal US
to distinguish between uncomplicated and complicated AA as an indicator for denitive antibiotic
treatment [199]. Still, there is no consensus on
antibiotic therapy route, type, and duration, with
reported durations of 3–10days [42, 200, 201].
An abdominal MRI is mandatory for the
decision on nonoperative treatment [74,
200–204].
Another strategy is to localize the process with
interval appendectomy later in the pregnancy or
postpartum [74]. During the active disease, US or
CT-guided drainage can be performed [205].
Even with image-guided drainage, a lengthy,
symptomatic course should be expected [205].
The last option, during active labor, is when
delivery is imminent, the operation may be delayed
for a short time until the placenta is delivered.
Otherwise, immediate appendectomy is advised if
prolonged labor is anticipated [40, 69, 206].
Potential advantages mainly related to the
fetus include the following:
Fig. 15.20 Changes in
the constituent ratios of
the three treatment
methods for acute
appendicitis in
pregnancy. Drug
pharmaceutical
treatment, LA
laparoscopic
appendectomy, OA open
appendectomy.
(Reproduced with
permission from [194]
under the CC Attribution
License)
70
60
50
40
30
20
10
0
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
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393
• Elimination of intra- and postoperative
complications,
• Minimization of fetal loss from surgery and
anesthesia,
• Elimination of fetal loss from a negative
appendectomy,
• Elimination of adverse effects of anesthesia.
Shortcomings of nonoperative therapy include
the following:
• 25% failure rate even with uncomplicated AA
in rst and second trimester [199],
• Increased incidence of recurrent AA during
the same pregnancy (see Sect. 15.4.3),
• Unknown impact of antibiotic therapy followed
by surgery due to treatment failure on fetal loss,
• Increased incidence of septic shock (6.3×),
peritonitis (1.6×), and venous thromboembolism (2×) [34],
• Higher rate of obstetric complications [205].
15.8.2 Open Appendectomy
Until recently, OA in pregnancy predominated, from 60 to 76% [195, 207]. Despite the
surgical access, the treatment algorithm is presented in Fig.15.21.
Several incisions could be used.
• The operation should be completed with
(1) minimal or no uterine manipulation,
(2) good hemostasis, and (3) and prevention of cooling and drying of the
uterine surfaces, which increases the
risk of postoperative uterine contractions [208, 209]. Temporary exteriorization of the gravid uterus to facilitate
operation should be avoided,
• The most experienced abdominal surgeon available should perform the procedure to shorten the operative,
anesthesia [210, 211], and immobilization time and reduce potential intra- and
postoperative complications.
Treat the disease early, regardless of pregnancy.
(Paul Fortunatus Mundé)
APPENDICITIS IN PREGNANCY
Frank peritonitis
Operation
IV Abx
<9 wks
No monitoring
Simple
No Abx 24h Abx
Pre-/Postop FHM
9–24 wks
Gangrenous Perforated
Worsening/No
improvement
>24 wks
Continuous
Abx until
afebrile/WBC <10
Periappendicular mass
IV Abx, supportive care,
Abscess drainage
Fetal monitoring (>24 wks)
PO Abx
(1–2 wks)
Consider
observe 1 wk
Interval appendectomy
after delivery
Fig. 15.21 Treatment algorithm for acute appendicitis during pregnancy. IV intravenous, PO peroral, Abx antibiotics,
wks weeks, FHM fetal heart monitoring, WBC white blood cells
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15 Acute Appendicitis
15.8.2.1 Muscle Splitting Incision
(McBurney’s Incision,
Gridiron Incision)
This is the incision of choice for the open
approach in general and pregnant patients. The
advantages are as follows:
• Procedure steps are the same regardless
of the gestational age,
• Direct access to the suppurative process
without spreading it in clean areas,
• Minimization or elimination of uterine
manipulation,
• Extremely low risk of wound disruption
or postoperative hernia.
In advanced pregnancy, the incision could be
positioned above McBurney’s incision and
slightly lateral because of possible displacement
of the appendix in the RUQ [10]. However, no
indication of the change in the location of the
incision exists. The appendix is easily located in
94% of the incisions through McBurney’s point
and in 80% of the incisions above McBurney’s
point [80, 212].
To prevent compression of the inferior vena
cava after 24weeks of pregnancy, a small rigid
pillow under the patient’s right buttocks tilts the
uterus to the left. It can be used in early pregnancy, as in the general population, to bring
closer the ileocecal segment to the anterior
abdominal wall.
15.8.2.2 Lower Midline Vertical
Incision
The incision is preferred with diffuse peritoneal
irritation for three main reasons [44] as follows:
• Dealing with unexpected surgical
ndings,
• Completion of “difcult” appendectomy started through other incisions or
laparoscopy,
• Indicated CS performed through the
same incision.
When CS is not indicated, there are several
disadvantages of midline and paramedian incisions as follows:
• Difculty of access,
• Much pressure and handling of the uterus to
reach the appendix,
• Increased rate of abdominal wall dehiscence
in near-term pregnancy due to increased intra-
abdominal pressure,
• Increased rate of a postoperative hernia in
operations performed in near-term pregnancy
due to increased intra-abdominal pressure.
The USA population-based study showed that
the laparotomy rate was doubled compared to the
nonpregnant population [34].
15.8.2.3 Right Transrectal/Pararectal/
Paramedian Incision
In 1902 right transrectal incision was favored
by Donoghue [213]. He stated that it is easy to
reach the appendix. The incision is easy to
enlarge without cutting muscle bers. In healing, the rectus bers constantly tend to close
opening. If the incision is closed correctly, a
rupture before, during, or after delivery is
minimal.
Currently, these incisions are rarely used. If
the diagnosis is certain, then McBurney’s incision is made. With diffuse peritoneal irritation, a
midline vertical incision is a better option.
Before the era of US, when the diagnosis
between acute cholecystitis and AA was not
clear, the right transrectal incision was also diagnostic. The incision was extended cranially when
the appendix appeared normal, and cholecystectomy was performed if indicated. Colin
C. McCorriston, in 1963, suggested using the
right paramedian incision when the diagnosis
was uncertain [214].
15.8.3 Laparoscopic Appendectomy
Some recommend routine use of a nasogastric
tube due to increased intra-abdominal pressure
and pregnancy-related gastric stasis [215].
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395
15.8.3.1 Trimester
LA is safe during all trimesters of pregnancy
[151, 216–218]. A higher percentage of OA is
used during the third trimester [151]. In
Columbia, LA is performed in 4.5% of pregnant
patients [219].
When LA was introduced in pregnancy, operation times were approximately 50% longer but
with decreased length of hospital stay [220, 221].
With the increased use of LA, the duration of OAs
and LAs became the same [151]. Currently, the
mean operative times are 45min [222, 223], with
longer operating times with advanced gestational
age [223]. This is shorter than the median operating time for LA in a nonpregnant population
(median 60min) partly because LA in pregnancy
is usually performed by experienced surgeons
[223, 224]. No signicant difference in the intraoperative complication rates exists between trimesters [223, 225] or OA and LA [224]. Potential
disadvantages of LA compared to OA are the
necessity of general anesthesia and the inability to
perform CS (compared to median laparotomy).
LA has many advantages. Laparoscopy expands
the ability to explore the abdomen with less uterine
manipulation [226]. Further, it increases the ability
to locate and treat dislocated appendix and results
in relatively small incisions compared with the OA
or helps detect other unexpected causes of acute
abdomen [151, 227–229]. Even with the gynecologic disease, neither insertion of additional trocars
nor extension of the incision is required [224].
Reduced cecal manipulation during LA with less
cecal trauma causes earlier restoration of large
bowel function and earlier passage of the rst atus
and rst postoperative stool. With an open (Hasson)
technique for the rst trocar placement, the injury
to intra-abdominal organs is eliminated. Direct
uterine injury during trocar placement has been
reported but without a fetal loss [230]. In addition
to the general advantage of smaller incisions, less
postoperative pain, and earlier return to normal
activity, lower rates of abdominal wall dehiscence
or herniation during labor are other benets. Rapid
return to full activity could reduce the frequency of
maternal thromboembolic events, which are
increased in pregnancy [228, 231, 232]. Some
found signicantly shorter hospital stay in the LA
group [151], while others did not [224, 233]. This
can be explained by the LA group being hospitalized for fetal, not maternal surveillance [233]. A
Swedish study (1973–1993) evaluated 2233 LA
and 2491 OA cases from two million deliveries
[234]. Outcomes were evaluated with no statistically signicant differences between the LA and
OA, and outcomes evaluated birth weight, gestational duration, intrauterine growth retardation,
congenital malformations, stillbirths, and neonatal
deaths. There was an increased risk for infants in
both LA and OA groups to weigh <2500 g, be
delivered before 37 weeks and have an increased
incidence of growth restriction compared with the
total population [234].
Laparoscopic appendectomy may be performed
safely in pregnant patients with suspicion of
appendicitis. Laparoscopic appendectomy can be
performed safely in any trimester and is considered by many to be the standard of care for gravid
patients with suspected appendicitis. (SAGES
clinical practice guideline (2009 and 2011))
15.8.3.2 Pneumoperitoneum
See Chap. 3.
15.8.3.3 Laparoscopic Technique
In the rst and early second trimesters, trocar
position and technique are similar to nonpregnant
patients. The third trimester poses difculty
because of (1) the diminished working space
from the enlarging uterus (Fig. 15.22), (2) the
risk of injuring the uterus, and (3) the risk of
excessive manipulation of the gravid uterus leading to preterm labor. In advanced pregnancy, the
port positions are slightly different (see further
text). The patient is placed supine on the operating room table. Restraining straps are placed
across the chest and thighs, and sequential pneumatic compression devices are placed on both
lower extremities. Some recommend a Foley
catheter [236] and a nasogastric tube placement
with removal at the end of the operation. Maternal
end-tidal CO2 is monitored and kept within the
physiological range (30–40mmHg).
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Fig. 15.22 Laparoscopic appendectomy at 32weeks of
gestation. The appendix (AP) was extracted between the
uterus (UT) and the ascending colon (AC). (Reproduced
with permission from [235])
15 Acute Appendicitis
Patients are tilted to the left to displace the
uterus from the inferior vena cava with the
removal of the small bowel from the operating
eld and a slight Trendelenburg position, if necessary. The procedure is performed using three
ports, and their placement is modied by gestational age. In advanced pregnancy, the rst port
for a laparoscope (5 or 10mm) is placed 2–4cm
cephalad to the gravid uterus in the upper midline between the umbilicus and xiphoid process.
The bigger the uterus, the more cranial the rst
trocar is placed for easier intraperitoneal
manipulation.
Modications of trocar sites and size depend
on the laparoscopic technique and equipment.
Some recommend placing the second port (5 or
12mm) laterally in the RLQ and the third port (5
or 10mm) in the RUQ in a more cranial location.
When the linear cutting stapler is used for the
transection of the appendix at its base 12mm port
is necessary [237]. Other combinations of trocar
placement are presented in Fig.15.23, depending
on the degree of uterine enlargement [236].
The evacuation of infected liquid in the rectouterine pouch could be inadequate in the second
half of pregnancy. It is difcult to reach the pouch
without uterine manipulation. It is essential to
eliminate infective uid to avoid pelvic abscess
formation and eliminate the possibility of uterine
irritability with its consequences (see Chap. 4).
Single-port laparoscopy is used in small
series. The method is feasible but without conversion to OA, but (1) 33% rate of conversion to
Fig. 15.23 Different trocar positions for a laparoscopic
appendectomy in different stages of pregnancy
reduced-port laparoscopic appendectomy and (2)
an increased rate of wound complications (8%)
[238] and additional port [238].
15.8.4 Perioperative Considerations
See Chap. 2.
15.8.4.1 Pathohistological
Examination
Extracted specimens should be sent for pathohistological examination because, especially in the
pregnant patient group, other pathologies were
common [151] before the era of MRI.
Pregnancy complicated with appendiceal
endometriosis (AE) ranges from 3–8/10,000
deliveries [239], with less than 30 cases of AE
mimicking AA in pregnancy being published.
Hematoxylin-eosin shows AA, and the appendiceal wall has foci of endometrial implants with
acute inammation. A panel of immunohistochemical stains, including cytokeratins CK7 and
CK20, estrogen receptor, and CD10, PAX8, can
differentiate intramural glands and appendiceal
mucosa, as the former react as endometrial
mucosa. In contrast, the latter responds as a
colonic-type mucosa [240]. Cytoplasm positivity
of valentine, the nuclear presence of progesterone receptors, and the lack of pan-cytokeratin,
15.9 Specic Considerations
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397
HMB-45, and calretinin are characteristic of
deciduosis. A decidual polyp, which occludes
most of the appendiceal lumen, is an extremely
rare cause of AA during pregnancy.
15.8.4.2 Postoperative Course
LA’s potential advantages in pregnant patients
include decreased fetal depression due to lessened postoperative narcotic requirements, lower
risks of wound complications, and diminished
postoperative maternal hypoventilation (see
Chap. 21). A nasogastric tube is extracted after
the operation, and early ambulation starts after
several hours. Without postoperative nausea and
vomiting, oral uids could be commenced within
12h after the operation.
15.9 Specic Considerations
15.9.1 Normal Appendix
15.9.1.1 Incidence
NARs during pregnancy and through decades
(1951–1954 up to 65%; up to 1973 up to 42%)
vary considerably (4–65%) [10, 13, 14, 19–26,
28, 29, 37, 68, 88, 153, 168, 175, 176, 216, 236,
241–245]. Before the CT era, NAR in the gen-
eral population ranged from 10 to 15% and as
high as 26% among reproductive age females.
The difculty in making a clinical and radiological diagnosis particularly close to term, combined with the high incidences of fetal mortality
and maternal morbidity from appendiceal perforation, has led to a low threshold for surgical
intervention.
The combination of physical examination,
US, and CT has the lowest NAR [168]. NAR with
clinical evaluation only is 54%, 36% in the clinical assessment and US group, and 8% in the US
and CT scan group [168]. Recent studies without
abdominal CT use have a lower incidence of
NAR (11% and 16%, respectively) [80, 232].
With the increased use of abdominal CT, the
NAR declines without the cost of a higher perforation rate but with the additional risk of radiation consequences.
The highest NAR is during the second trimester [47]. However, some claim similar NAR in
the second and third trimesters (18% in the rst,
40% in the second and 3rd [26, 246]), partly
because obstetric complications from abdominal
operations are the rarest in the second trimester.
There is a decreased risk of NAR in the puerperium. Puerperal women are less prone to seek
care for abdominal pain [47] and more liberal
abdominal CT use in the puerperium.
NA does not mean negative exploration.
Approximately 15–20% of patients with a normal appendix have another pathology (e.g., ovarian cyst, ovarian torsion, mesenteric adenitis,
broids, and salpingitis) [176]. No signicant
difference in NAR between LA and OA exists
[236].
The fetal loss rate of 2–3% for both NA and
non-perforated AA is reported [208, 247]. Its
relation to the type of procedure, undetected
underlying pathology, or fetal loss rate in general
pregnant patients is unclear.
15.9.1.2 Appendectomy
Removing the “normal” appendix to rule out AA
histologically and eliminating AA’s differential
diagnosis with recurrent symptoms is recommended. The gross changes are not visible if
intramural or mucosal changes in the appendix
exist responsible for the symptoms.
Approximately 9% have recurrent RLQ pain
after negative laparoscopy without appendectomy [248], and 20–22% who underwent appendectomy responded very well to appendectomy
despite a normal microscopic examination of the
appendix. The explanation is functional appendiceal conditions such as appendix colic, appendicopathy, or appendiceal fecalith without acute
inammation [249, 250]. Up to 30% of intraoperative diagnoses of normal appendix conrmed
inammation histologically [251]. These conclusions are similar to SAGES guidelines for LA in
the general population (04/2009): If no other
pathology is identied, the decision to remove the
appendix should be considered but based on the
individual clinical scenario. Macroscopically
normal appendices may have abnormal histopathology. Several studies have shown a 19–40%
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15 Acute Appendicitis
rate of pathologically abnormal appendix in the
setting of no visual abnormalities. Therefore, the
risk of leaving a potentially abnormal appendix
must be weighed against the risk of appendectomy in each scenario.
Furthermore, appendiceal inammation/
obstruction can be due to appendiceal neoplasms.
If pseudomyxoma peritonei is found, the appendix should be removed and sent for a histological
examination.
As a surgeon, you should not be deterred
from removing an appendix once the diag-
nosis is suspected because pregnancy is not
affected by removing a normal appendix
[252].
15.9.2 Incidental Meckel’s
Diverticulum
Given the high incidence of perforation
(57%) resulting in signicant maternal and
fetal mortality, removal of incidentally
found MD is justied [124], especially
when: (1) future pregnancies are desired
and (2) specic diagnostic difculties dur-
ing pregnancy are expected.
When one, two, three, or all four criteria are
met, the proportion of symptomatic MD is 17%,
25%, 42%, and 70%, respectively [253].
Laparoscopic treatment is rare partly due to
simultaneous CS in advanced pregnancy [122]. If
the asymptomatic MD or symptomatic MD is
found, diverticulectomy or wedge small bowel
resection with subsequent bowel continuity is
performed during OA and LA. During LA, an
endoscopic linear cutting stapler is introduced
through a 12mm trocar and applied to the base of
the MD, perpendicular to the base of the MD, but
transverse to the longitudinal axis of the bowel.
The stapler is red, and the MD resected off the
ileum. Small bleeding points at the edge of the
staple line are sutured intracorporeally with 3–0
resorbable sutures. The specimens are delivered
through a 12mm port (which can be extended if
needed) using a bag if needed. A wedge resection
is rarely necessary for incidental MD because the
base is not inamed. If suture techniques are used
after excision, bowel continuity is achieved by
placing intracorporeal sutures with 2–0 or 3–0
resorbable sutures. Specimens should always be
sent for pathohistological examination. The hospital stay is 7.9days for open surgery and 4.6days
for laparoscopic surgery [122].
Since 1990 symptomatic and removed MD
does not increase maternal mortality, which is
0%. An increased rate of premature labor is
observed, with fetal mortality of 7.4% [122].
The benets of removing an incidental MD in
the general population are far superior to the risk
of developing complications. If any of the following criteria are fullled, the incidental MD
should be removed [253]:
• Patient age<50years,
• Male sex,
• MD length>2cm,
• Ectopic or abnormal features within a
diverticulum.
Delayed surgical treatment of symptomatic
MD increases fetal mortality [122].
15.9.3 Ectopic/Heterotopic
Pregnancy
15.9.3.1 Incidence
andPathophysiology
Ectopic pregnancies (EP) occur in approximately
16/1000 patients [254], with the rarest form of
heterotopic pregnancy (HP). Around 30 cases of
EP/HP have been reported in conjunction with
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399
AA since 1960 [254–269]. EP may trigger AA
through a contiguous initial inammation, creating a portal for infection in the appendix by normal colonic bacterial ora, so-called
periappendicitis [255]. Lymphoid hyperplasia
causes luminal obstruction. A subsequent
increase in intraluminal pressure results in ischemia of the appendiceal wall. This could be a reason for the development of AA up to 1week after
(the treatment) of EP [254, 261]. In the opposite
direction, an antecedent AA with spontaneous
resolution could also conceivably result in peritubular inammatory adhesions favoring the development of the EP.It is of particular interest that
75% of tubal pregnancies involve the right tube
[23]. Also, concurrent EP and AA show rightsided tubal EP predilection (75%) versus left
tubal EP (16%) [255]. HP with AA is challenging
due to potentially three causes of abdominal pain
as follows: appendix, intrauterine, and extrauterine pregnancy [262–264].
15.9.3.2 Clinical Presentation
Hickam’s dictum, after the late Dr. Hickam from
Duke University, is the following quotation
“Patients can have as many diseases as they
damn well please.” Thus, with mixed clinical presentation, both pathologies could be present (see
Chap. 9). Even a concurrent appendiceal EP, carcinoid tumor, and AA case were published [270].
[29, 46, 255, 262]. Another option is to use
abdominal MRI with excellent sensitivity and
specicity for AA (see Sect. 15.7.5) and EP (see
Chap. 9).
15.9.3.4 Treatment
An uncertain diagnosis indicates emergent
exploration by (mini)laparoscopy or laparotomy
[255, 259, 260] when the hemorrhagic shock is
encountered. Appendectomy is recommended if
Fallopian tube sparing surgery is performed due
to the following: (1) no additional postoperative
morbidity and risk of postoperative complications, (2) further pregnancies or recurrent EPs
have a shorter list of differential diagnoses in
patients with lower abdominal pain, (3) elimination of future AA in this high-risk group
(younger age and right-sided recurrent EP)
[254], and (4) future AA can cause periadnexal
adhesions increasing the risk of recurrent rightsided EP.
If the appendix appears normal, Meckel
diverticulitis should be ruled out. With AA
with amenorrhea in early pregnancy or a
small amount of blood in the pelvis, ectopic pregnancy should be ruled out.
15.9.3.3 Diagnosis
Although advances in transabdominal and transvaginal US and highly sensitive βHCG tests have
facilitated the earlier diagnosis of EP even before
the onset of clinical symptoms, differences in
operator technique and obscuring bowel and gas
may render a diagnosis of AA or EP inconclusive
[266]. The discriminatory zone is the level of
βHCG at which ndings of a normal IUP are
expected to be visualized on US.It is often considered 1500 and 6000 mIU/mL for transvaginal
and transabdominal US, respectively [271],
although βHCG levels cannot reliably discriminate between early intrauterine pregnancy and EP
[271]. With high clinical suspicion, the inconclusive US should not preclude a AA and EP/HP
15.9.4 Assisted Reproductive
Techniques
15.9.4.1 Incidence
EP/HP occurs in 1–3% [272, 273] of IVF-ET
pregnancies, while HP has been estimated at
1/30,000 non-IVF pregnancies [272]. The transfer of four or more embryos poses an additional
risk for HP [273]. Five AA cases in IVF-ET pregnancy pose signicant incidence compared to
non-IVF pregnancies (24 cases—see Sect.
15.9.3.1). Of these, two cases had HP (9weeks
[260] and 6weeks [264]). The remaining two are
iatrogenic appendiceal punctuations with the
needle for oocyte retrieval and subsequent development of perforated AA [274, 275].
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15.9.4.2 Dierential Diagnosis
With IVF-ET pregnancies, AA and EP should be
included in the differential diagnosis [264].
15.9.4.3 Diagnosis
Indicative of iatrogenic appendiceal injury is the
development of AA up to 9days following the
IVF procedure [274, 275].
15.9.4.4 Treatment
Both patients underwent right salpingectomy and
appendectomy and delivered by CS. The third
case described a woman with a perforated appendix and an EP [259]. During a (diagnostic) laparoscopy, the appendix and adnexa should always
be examined in IVF patients despite normal intrauterine pregnancy, especially if AA is proven
intraoperatively with fresh blood in the pelvis or
around the adnexa or appendix. This rule conrms that βHCG in HP is elevated due to normal
intrauterine pregnancy and is not diagnostic for
HP.
Appendectomy is mandatory (Fig. 15.24),
while management of simultaneous ruptured EP/
HP includes the following:
Ruptured HP
1. Intrauterine pregnancy preserved,
2. Salpingectomy or salpingotomy.
15 Acute Appendicitis
Ruptured EP
1. Salpingectomy or salpingotomy.
The benets of salpingectomy over salpingotomy are uncertain. Salpingectomy is easier and
safer, especially with a live intrauterine pregnancy. It reduces the risk of complications such
as persistent bleeding or retention of trophoblastic tissue after salpingotomy [272]. Salpingectomy
is recommended if fallopian tubes are signicantly damaged and not functional for further
spontaneous pregnancies. Salpingectomy could
be considered with a healthy contralateral fallopian tube, as this treatment does not preclude
future fertility. For unruptured EP/HP, therapeutic recommendations are as follows:
Unruptured HP
1. Intrauterine pregnancy preserved,
2. Salpingectomy or salpingotomy.
Unruptured EP
1. Methotrexate.
Fig. 15.24 Laparoscopic view of unruptured ectopic
pregnancy of the right fallopian tube. The knot is placed
on the base of the antecedent appendectomy (arrow).
(Reproduced with permission from [267])
Even simultaneous ovarian hyperstimulation
syndrome (OHSS) with AA is described [276].
Epigastric pain is not an uncommon symptom in
patients with severe OHSS with massive ascites.
Pyrexia is common with severe OHSS without
infection [277]. A WBC count is elevated with
severe OHSS [278] and AA. The possibility is
raised that OHSS might affect the course of concurrent AA.An increased rate of infectious diseases was reported with OHSS, possibly due to
immunodeciency from hypoglobulinemia, frequent with severe OHSS [277]. Severe stress
associated with symptoms of OHSS, a hospital
stay, multiple monitoring, and therapies might
also impair immunoprotective status. It may be
that AA with OHSS could be more aggressive and
is more likely to rupture than without OHSS.Once
bacteria are seeded into the peritoneal cavity asso-
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