A 20-year-old female, G1P0 at 17 weeks’ gestation, presents to the emergency department 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 mmHg. 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.
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.
What Is the Incidence of Appendicitis in Pregnancy?
The incidence of acute appendicitis in pregnancy has been reported between 1:1000 and 1:1500,1–5 which is similar to the incidence in nonpregnant women of childbearing age.6 Appendicitis is the most common nonobstetrical cause of acute abdomen in the parturient, and appendectomy is the most common nonobstetrical surgical procedure performed during pregnancy.7 Relative incidence varies throughout pregnancy, ranging from 19% to 36% during the first trimester, 27% to 60% during the second trimester, and 15% to 33% during the third trimester of pregnancy.8 While pregnancy does not appear to increase the risk of appendicitis, the anatomic and physiologic changes that accompany pregnancy may obscure the diagnosis.9 Perforation and complicated acute appendicitis may be more prevalent in pregnant patients than in the nonpregnant population,9,10 though some recent studies dispute this notion.11,12 The risk of appendiceal perforation ranges from 11% to 43%,5,10–13 and increases with advanced gestation and delay in diagnosis.13,14
Parturients with appendicitis are at increased risk of perinatal morbidity and mortality. Historically, premature delivery occurred at a rate of 15% to 45%, although a recent, large population study demonstrated an incidence of 4% to 11%.12 The rate of fetal loss for simple and complex appendectomies is 2% and 6%, respectively,12 which is much lower ...