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CASE PRESENTATION

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A 20-year-old female, G1P0 at 17 weeks’ gestation, presents to the emergency department (ED) complaining of right sided abdominal pain. The pain began 10 hours ago accompanied by nausea and two episodes of vomiting. The patient is afebrile and has a blood pressure of 130/72 mm Hg. Her heart rate is 86 beats per minute (bpm) and respiratory rate is 20 breaths per minute. She weighs 198 lb (90 kg) and is 5 ft 7 in (169 cm) in height, with a body mass index (BMI) of 31 kg·m−2. She admits to right sided tenderness to palpation, localized to the inguinal region. After ultrasonography by an obstetrician, the cause of pain is felt not to be related to pregnancy. The general surgery service is consulted, and it is their opinion that the patient has appendicitis and will require a laparoscopic appendectomy.

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The parturient has had an unremarkable pregnancy thus far and has no medical comorbidities or allergies. She is a nonsmoker and does not consume alcohol. She takes prenatal vitamins, but no prescription medications. She has had no prior anesthetics and has no family history of anesthesia-related problems. Physical examination of her heart and lungs is unremarkable. There are no physical abnormalities of her spine. Her airway examination reveals a Mallampati Class IV airway with limited mouth opening. She has a normal range of motion of her cervical spine, full dentition, and minimal mandibular protrusion. The thyromental distance is 5 cm and the hyomental distance is 3 cm.

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INTRODUCTION

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What Is the Incidence of Appendicitis in Pregnancy?

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Appendicitis has an incidence of approximately 1 in 500 to 1 in 635 pregnancies per year, with appendectomy being the most common non-obstetric surgical procedure during pregnancy.1 The relative incidence is estimated to be 30% in the first trimester, 45% in the second trimester, and 25% in the third trimester.2 Fetal loss in the first trimester usually occurs in 3% to 15% of women with complicated appendectomy during the first trimester.1 The risk of premature delivery occurs at a rate of 15% to 45%, and parturients are at increased risk of spontaneous abortion, premature labor, and perinatal morbidity and mortality.1 The risk of perforation increases with advanced gestation and delay in diagnosis.3,4 The estimated risk of fetal loss with appendiceal perforation is 36%.5 The risk of maternal mortality is minimal, which can be attributed to the use of advanced antibiotics, close perioperative monitoring, multidisciplinary case involvement, and improved perioperative management.1

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How Is Appendicitis Diagnosed During Pregnancy?

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Anatomic and physiologic changes accompanying pregnancy make the diagnosis of appendicitis challenging, therefore a careful history and physical examination, combined with a high index of suspicion, is required. The appendix is pushed superiorly and laterally with advancing gestation. It typically relocates from McBurney's point upward from ...

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