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

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?