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Grand Rounds

Risk of Preterm Birth Following Appendectomy in Pregnancy

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BACKGROUND AND PURPOSE:

  • For pregnant women, appendectomy is the most common indication for emergency surgery (non-Ob)
  • Ibiebele et al. (Australian and New Zealand journal of Obstetrics & Gynecology, 2018) sought to determine the risk associated with appendectomy during pregnancy

METHODS:

  • Population cohort study
    • All women with a singleton pregnancy ≥20 weeks delivering between July 2002 and December 2014
    • Birth data linked to hospital data using national databases
  • Exposure: Appendectomy (with diagnosis of appendicitis)
    • Subclassified to open or laparoscopic
  • Comparison group: Pregnancies without appendicitis or any abdominal surgeries
  • Primary outome: Preterm birth (<37 weeks)
    • Spontaneous vs planned
  • Secondary outcomes included
    • Time from surgery to delivery | Antepartum hemorrhage | PPH | Mode of birth | Length of hospital stay | Maternal readmission within 42 days postpartum | Maternal morbidity

RESULTS:

  • 124,551 pregnancies included
    • 1,024 in appendectomy group
      • Laparoscopic: 55.3% | Open: 44.7%
    • Median gestational age at appendectomy: 15.4 weeks
    • Median time between appendectomy to birth: 164 days
  • Appendecectomy at later gestational ages was associated with increasing rates of preterm birth
  • There were higher rates of preterm birth following appendecectomy (10.6%) vs comparison group (5.9%)
  • Preterm birth rates were higher with advancing gestational age
    • <24 weeks: 7.6%
    • 24–28 weeks: 12.9%
    • 29–36 weeks: 35.2%
  • In 181 pregnancies with appendecectomy ≥24 weeks
    • 17.7% delivered during the hospital admission
    • 8.3% delivered <34 weeks
  • After adjustment potential confounders, appendectomy was associated with
    • Increased risk of preterm birth
      • Overall: Adjusted hazard ratio (aHR) 1.73 (95% CI, 1.42–2.09)
      • Planned delivery: aHR 2.08 (95% CI, 1.60–2.72)
    • Increased risk of maternal morbidity:  
      • adjusted relative risk (aRR) 2.68 (99% CI, 1.88–3.83)
    • Increased risk for neonatal morbidity
      • aRR 1.42 (99% CI, 1.03–1.94)
    • Decreased risk for postpartum hemorrhage
      • aRR 0.72 (95% CI, 0.53-0.99)
  • No difference in perinatal mortality rates were identified

CONCLUSION:

  • Appendecectomy during pregnancy is linked to increased risk of spontaneous and planned preterm birth, maternal and neonatal morbidity
  • Risk of preterm birth (10.6%) comparable to previous studies
  • Higher risk of preterm birth may be due to appendectomy and cesarean being scheduled for the same admission and planned earlier delivery to preempt perinatal morbidity or fetal loss
  • No differences between open or laparoscopic surgical approach was seen 
  • The authors suggest

Given the increased risk of preterm birth, availability of neonatal care or the need to transfer to a tertiary facility should be considered; as should the use of maternal corticosteroids and magnesium sulphate for neuroprotection (for those women with expected births <30 weeks gestation)

Learn More – Primary Sources:

Appendicectomy during pregnancy and the risk of preterm birth: A population data linkage study

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Related ObG Topics:

Antenatal Corticosteroids – When to Administer?
Antibiotic Treatment Instead of Appendectomy for Uncomplicated Appendicitis – Long-Term Outcomes at 5 Years
Surgery or Nonoperative Management for Uncomplicated Appendicitis?

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