The problem of acute inflammation of the appendix during pregnancy. Features of the diagnosis and treatment of appendicitis in a pregnant woman - is it possible to do surgery

Causes of appendicitis include:

These factors lead to blockage, that is, the appearance of a plug of the lumen. appendix, as a result of which pathogenic microbes actively multiply in this zone. Stretching, the appendix is ​​not sufficiently supplied with blood, develops inflammatory process. It causes significant pain, as it irritates nerve cells. Absence timely diagnosis disease entails the transition of appendicitis to the purulent stage.

Some diseases of an infectious nature can contribute to the development of appendicitis:

• typhoid fever;
• tuberculosis;
• yersiniosis.

The cause of this disease can be vasculitis - inflammation of the walls of blood vessels.

Symptoms

The manifestations of the disease in nursing mothers depend on its stage. To the signs acute appendicitis relate:

• pain sensations - as a rule, they are localized in the area above the navel or near it, but there are situations when it is difficult to isolate the place of pain. With the development of the disease, discomfort shifts to the right side of the abdomen. In this case, the pain can be described as dull, not stopping, but tolerable, which progresses with movement and even coughing. More serious stages of the disease can proceed without pain, which is associated with death nerve endings appendix. Such a situation is extremely dangerous, since it is estimated by a nursing mother as an improvement, although, in fact, significant complications may appear in the near future in the form of peritonitis and intestinal obstruction;
• violations normal functioning stomach, resulting in nausea, rare episodes of vomiting, a feeling of dryness of the mucous membranes of the mouth, decreased appetite, one-time stool disorders;
• increase in body temperature up to 38-39 degrees;
• sharp jumps in blood pressure;
• failures in the processes of breathing and heartbeat (rhythm instability).

The chronic stage of appendicitis does not have clear symptoms. A breastfeeding girl may regularly experience pain in the abdomen, which becomes more noticeable with intense physical activity and a change in position. As a rule, this form of the disease is not accompanied by other symptoms and does not reveal itself in any way.

Diagnosis of appendicitis in a nursing mother

Diagnosis of the disease is based on a preliminary collection of anamnesis, analysis of complaints and examination of the patient. The doctor also takes into account the family history and the history of life, that is, he will be interested in the following questions:

• what diseases were present in childhood;
• whether there were infections with infectious diseases;
• whether surgical interventions were carried out;
• whether close blood relatives suffer from problems with the gastrointestinal tract.

IN without fail examination of the patient, including:

• palpation of the abdomen;
• body temperature measurement;
• assessment of the condition of the mucous membranes and skin.

An experienced specialist can diagnose some of the special symptoms of appendicitis, such as:

• the flow of pain from the area around the navel to the right lower abdomen;
• the appearance of unpleasant sensations in the right iliac zone during percussion of the anterior abdominal wall;
• severe pain when raising a hand lying on the right iliac region;
• progression of pain when trying to roll over to the left side of the body.

In the list of mandatory laboratory tests when diagnosing appendicitis are:

Complications

The negative consequences of the disease include:

• peritonitis;
• intra-abdominal bleeding;
• suppuration of the incision site;
• the formation of adhesions between the abdominal organs, peritoneum and pelvic organs;
• breakthrough of the appendix and outpouring of its contents into the abdominal cavity;
• sepsis;
• purulent pylephlebitis;
• chronic appendicitis.

Treatment

What can you do

Treatment of appendicitis is carried out exclusively by surgery, so self-therapy can cause significant harm to the health of a nursing mother and cause serious complications. When alarming symptoms of the disease appear, you should immediately call a doctor.

What does a doctor do

Before the operation, the doctor conducts an examination and special training female patients. During surgery, the appendix can be removed from the body in two ways: through an incision (laparotomy) or a small opening (laparoscopy) in the abdominal wall. Last option is becoming more and more popular and has the least impact on health and appearance breastfeeding girl.

The postoperative period requires a reduction in physical activity for about 1-2 months, compliance bed rest in the first days, observation by the surgeon and therapist, as well as timely treatment of the wound.

IN further patient you should follow a certain diet that excludes muffins, fatty, sour, fried, spicy dishes, coffee, alcohol and semi-finished products. Meals should be fractional and frequent. Additional vitamins may be required.

Appendicitis is an inflammation of the appendix of the caecum, which is called the appendix. For a long time the appendix was considered unnecessary. Now scientists have changed their minds: after all, this organ is a “reserve” for intestinal microflora thanks to which she recovers from illnesses.

But with inflammation of the appendix, an operation to remove it is mandatory, including during pregnancy, because without surgical intervention, the process will rupture and inflammation of the abdominal cavity, which will lead to the death of the fetus.

Figure 1 - The location of the appendix in a woman's body

Appendicitis during pregnancy: is it possible?

The risk of developing appendicitis during pregnancy is higher than in the normal state. So pregnancy is a factor for the appearance of an inflammatory process in the appendix.

This is presumably due to the fact that the enlarged uterus displaces the abdominal organs, putting pressure on them. Such squeezing disrupts blood circulation in the appendix, due to which it swells and becomes inflamed.

Another reason for the appearance of appendicitis in pregnant women is the fact that expectant mothers produce a large amount of the hormone progesterone, which relaxes the smooth muscles of the internal organs, including the muscles of the alimentary canal. As a result, food is delayed, and constipation occurs, as a result of which the feces harden. These fecal stones, due to their slow movement in the large intestine, can also penetrate the appendix, contributing to its blockage and inflammation.

Why is acute appendicitis dangerous during pregnancy?

During the period of bearing a child, a woman should listen to the slightest changes in her own state of health. The unwillingness of a pregnant woman to go to the doctor when possible signs of appendicitis appear will lead to terrible consequences.

For a child, this indifferent attitude is expressed in the form oxygen starvation(hypoxia) and placental abruption. The baby is threatened with death due to the irresponsibility of such a mother.

The woman herself exposes herself to the risk of developing intestinal obstruction, an infectious and inflammatory process in the peritoneum, massive blood loss, septic shock, and other things.

When the process is ruptured, a caesarean section is performed, regardless of the gestational age, the uterus and fallopian tubes are removed.

Stages of development of acute appendicitis

The first stage in medicine is called catarrhal. It is characterized by inflammation of the process, abdominal pain (usually in the navel), sometimes nausea and vomiting. Its duration is from 6 to 12 hours.

If at this time the operation is not performed, then further complications appear in the form of a second ( phlegmonous) the stage during which the destruction of the tissues of the appendage occurs, the appearance of ulcers and the accumulation of pus. Constant aching pain moves to the right side, body temperature can rise up to 38°C*. This stage of acute appendicitis lasts about 12-24 hours.

Next, there is necrosis of the walls of the appendix and its rupture - the third ( gangrenous) stage. Unpleasant sensations may subside for a while, but then when coughing, there will be severe pain in the abdomen. The duration of the third stage of appendicitis is 24-48 hours.

The last stage is a rupture of the appendix and inflammation of the peritoneum ( peritonitis) due to the ingestion of the contents of the process into the abdominal cavity. Further, without surgical intervention, the situation ends in death for both.

* Remember, during pregnancy, the normal body temperature is slightly higher than in a non-pregnant woman, and it reaches 37.4 ° C (in some, up to 37.6 ° C).

Let us give the statistics of fetal mortality in case of inflammation of the appendix in the mother.

The table shows that the progression of the disease increases the risk of death of the baby.

Therefore, it will not work to wait and lie down, and treatment folk remedies won't help in this situation either. At the slightest suspicion of appendicitis, you should immediately consult a doctor or call an ambulance. Ignoring the symptoms will bring disastrous consequences.

If there is a suspicion of appendicitis, then you can not:

• putting a heating pad on the stomach - this only accelerates the inflammatory processes, and such warmth will only bring harm to the child;
• take antispasmodics and painkillers - diagnosis is difficult, and when probed by a doctor, there will be no proper reaction;
• something to eat and drink - the operation is done on an empty stomach, otherwise the risk of complications during the operation increases.

Symptoms of appendicitis during pregnancy

During pregnancy, appendicitis occurs atypically. Vomiting and nausea may be absent.

The main symptom of appendicitis during pregnancy is pain in the right side. The location of the pain (see Figure 2) and its intensity varies depending on the period: the longer the gestation period, the more pronounced the pain.

In the early stages (first trimester), due to the absence of the abdomen, pain is felt near the navel, then it shifts to the right iliac region. With coughing and tension, it becomes more pronounced.

In the second trimester, the enlarged uterus moves the appendix back and up, so the pain is felt near the liver (in the right side, somewhere at the level of the navel).

In the last stages of pregnancy, it hurts right under the ribs, it feels like somewhere behind the uterus. The pain may also radiate to the lower back. right side.

Figure 2 - The location of the appendix in pregnant women, depending on the duration of pregnancy

How to self-diagnose appendicitis? Symptoms of appendicitis during pregnancy are blurred due to natural changes in the body of the expectant mother. But there are two scientific method or a sign of appendicitis in a pregnant woman:

1. Increased pain when turning from the left side to the right (Taranenko's symptom).
2. Increased pain in the position on the right side due to the uterus exerting pressure on the appendix (Mikhelson's symptom).
3. Nausea, vomiting, together with indigestion (diarrhea) and dull constant pain on the right side.

If the appendage is located near the bladder, then symptoms of cystitis appear: frequent urination, pain in the perineum, radiating to the legs.

Signs of peritonitis (inflammation of the abdominal cavity): high body temperature, rapid pulse, shortness of breath, bloating.

Diagnosis and treatment of appendicitis during pregnancy

Diagnosis of appendicitis during pregnancy is somewhat difficult. Usually, fecal stones stuck at the junction of the process with the caecum are detected using x-rays. But during pregnancy, X-ray exposure is harmful, especially in the early stages, because this kind of rays disrupt the division of embryonic cells, which can lead to the development of diseases. nervous system fetus or the birth of a seriously ill child.

As for ultrasound (ultrasound), it is used only to exclude diseases of the internal genital organs of a woman, because pain in inflammation of the uterus and appendages is often confused with pain in appendicitis. Well, in order to diagnose appendicitis, ultrasound is not very informative, since during pregnancy the uterus pushes the appendage of the caecum deep into, and the appendix cannot be visualized.

Please note that symptoms of gynecological diseases are not nausea, vomiting and diarrhea. This is typical for appendicitis and other diseases of the gastrointestinal tract.

Necessarily, if appendicitis is suspected, doctors take blood and urine tests: any inflammatory process increases the content of lymphocytes in these substances to high values.

Well, the main method for diagnosing appendicitis is an examination of a pregnant woman by a surgeon who will palpate (feel) the stomach and interrogate the patient:

• how severe the pain is (insignificant, unbearable);
• whether it is felt when walking, coughing, or raising the right leg while lying down;
• what was the body temperature;
• Was there nausea, vomiting, etc.

Due to mild symptoms, women in position are more likely to go to the hospital for late stages illness. There are five times more pregnant women with gangrenous appendicitis than non-pregnant women.

The only treatment for appendicitis is an appendectomy (surgery to remove the appendix). Cut out the appendix in one of two ways:

• laparotomically - a ten-centimeter incision is made above the process;
• laparoscopically - three punctures are made in the abdomen.

During pregnancy, the second variant of the operation is more often used.
Laparoscopy is performed using a tube with an optical camera and two manipulator devices. This technique leaves no seams behind, which is important for the aesthetics of the female body.

The patient is operated on under general anesthesia so that the expectant mother does not worry. In the later stages, an emergency caesarean section can be performed.

After the operation, the pregnant woman is regularly examined by a gynecologist. Prescribe bed rest. You can only get up for 4-5 days.

After the operation, you must follow the diet prescribed by the doctor. The first two days you can grated cereals, mashed potatoes, chicken broth, dairy products. Then, soups chopped with a blender, scrambled eggs without oil, steam cutlets are gradually introduced into the diet, but fresh fruits included only on the fourth day. After three months, sweets, fried foods, drinks with gases are allowed.

On the seventh day, the sutures are painlessly removed (with laparotomy). Pregnant women do not put ice, heating pads and other loads on their stomachs.

Medical personnel carry out the prevention of complications and disorders of the peristalsis of the digestive tract, prescribing:

• tocolytics - drugs that relax the muscles of the uterus and prevent premature birth;
• vitamins that strengthen immunity and are necessary to protect the fetus (tocopherol, ascorbic acid);
• antibiotic therapy (duration 5–7 days);
• physiotherapy.

After discharge, the woman is included in the risk group for miscarriage and premature birth. Prevention of fetoplacental insufficiency.

If childbirth occurs shortly after the removal of the appendix, then doctors perform full anesthesia and apply a bandage on the seams, doing everything very carefully and carefully.

Remember, with timely seeking medical help, life-threatening consequences for the mother and child can be avoided.

Health to you and your puszozhiteley!

INTRODUCTION

The relevance of the topic of the thesis is due to the fact that at present acute appendicitis is the most common cause of emergency surgical operations in pregnant women. So among all pregnant women there are from 2 to 5% of women who still develop such a condition as appendicitis. The main predisposing factor may be a sharp increase in the volume of the uterus, which, of course, can cause some displacement of the entire appendix and, as a result, a violation of its normal blood supply. And this, in turn, can lead to various inflammatory processes. Needless to say, there are a number of other real reasons for the development of appendicitis during pregnancy. And this: a tendency to constipation, and displacement of the caecum, and various failures in the entire immune system of a woman, which can lead to changes in the general properties of the blood. Normal plays an important role in this. balanced diet and, of course, the abnormal location of the process directly in the abdominal cavity.

The difficulty of recognizing acute appendicitis is well known, especially in pregnant women. The clinic, which develops, for example, with premature termination of pregnancy or its threat, is capable, under certain conditions, of stimulating a picture of acute appendicitis. The same condition can occur with incomplete uninfected miscarriages, perforation of the uterus during criminal abortion, and others. pathological conditions organ (Dekhtyar E.G. Acute appendicitis in women. M., 1965, 194 pp.; Kalitievskiy P.F. Diseases of the appendix. M., 1970, 202 pp.; Kasymov Sh.Kh. Some clinical and laboratory parameters in the diagnosis of various forms of acute appendicitis. Abstract of the candidate of diss. Tashkent, 1973).

The purpose of this work is the role of obstetrics in the management of pregnancy and childbirth in acute appendicitis.

The object of the study is pregnant women with acute appendicitis.

The subject of the study is the role of obstetrics in the management of pregnancy with acute appendicitis.

Research objectives:

1.To study the etiology, pathogenesis of acute appendicitis during pregnancy

2.Consider the features of the course of pregnancy and childbirth.

3.To determine the features of the management of pregnancy and childbirth in acute appendicitis and the role of obstetrics in the analysis of the incidence of acute appendicitis during pregnancy and childbirth.

4.List the complex of therapeutic and preventive measures for acute appendicitis and its complications during pregnancy.

Thus, an integrated approach to the diagnosis of acute appendicitis, the development of an examination algorithm, rational surgical and obstetric management of pregnant women with suspected acute appendicitis will reduce the incidence of obstetric and surgical complications, as well as perinatal losses.

CHAPTER 1. APPENDICITIS IN PREGNANCY: SIGNS, SYMPTOMS AND DIAGNOSIS

1Acute appendicitis in pregnancy

Acute appendicitis is the most common ectopic surgical emergency pathology in pregnant women. According to various authors, the incidence of acute appendicitis ranges from 0.38 to 1.41 per 1000 pregnant women. However, in general, the incidence of acute appendicitis in pregnant women does not increase. The diagnosis of acute appendicitis in pregnant women is quite difficult to make, especially in the third trimester of pregnancy. The main difficulty is that anorexia, nausea, vomiting and vague abdominal pain are common during pregnancy. Palpation of the abdomen is also much more difficult due to the enlargement of the uterus. Protective tension of the muscles of the anterior abdominal wall and symptoms of irritation of the peritoneum are less common, since the muscles of the abdomen in to a large extent weakened. In addition, the diagnosis of acute appendicitis in pregnant women is complicated by the fact that the caecum and appendix are displaced by an enlarged uterus.

In 1932 Bayer (Baer) examined 78 pregnant women. He performed irrigoscopy, as a result of which he noted the degree of displacement of the appendix depending on the duration of pregnancy. After the third month of pregnancy, the appendix is ​​displaced above the point of McBurney (McBurney). By the eighth month, in 93% of women, the appendix was found above the ridge ilium, and in 80% the base of the process was deployed in a horizontal plane.

With an increase in the uterus, the appendix rotates counterclockwise with a displacement of its apex in the head direction. As a result, the localization of the maximum pain detected by palpation of the abdomen also varies depending on the duration of pregnancy. In addition, during pregnancy, the greater omentum cannot move to the right iliac region, delimiting the inflammatory process, which leads to a higher incidence of diffuse peritonitis. During an objective examination of a pregnant woman with abdominal pain, it is recommended to perform next move. The patient is asked to turn to the left side. If the pains migrate at the same time, then most likely the cause of their occurrence is in the uterus. If the pain persists in the right iliac region, then most likely it is acute appendicitis. Laboratory data do not play a big role in the differential diagnosis, since moderate leukocytosis, which is characteristic of acute appendicitis, as a rule, also occurs during a normal pregnancy. However, the shift leukocyte formula to the left for a normal pregnancy is not typical.

Often the surgeon does not want to operate on a pregnant woman for fear of induction of labor and loss of the fetus. This position is a gross mistake, leading to a very high incidence of perforated appendicitis (according to the literature, up to 25%). The best rule if acute appendicitis is suspected, the patient should be treated as if they were not pregnant. When the appendix is ​​perforated, labor can begin, leading to miscarriage or the birth of a premature baby. Peritonitis leads to an increase in the frequency of fetal loss, which, according to different authors, ranges from 35 to 70%. Between 24 and 36 weeks' gestation, nearly 25% of women go into preterm labor about a week after an appendectomy. In addition, there is an increased risk of having premature babies in those women who underwent an appendectomy during pregnancy.

Babler's statement at the very beginning of the century remains relevant today: "The cause of mortality from appendicitis in pregnant women is late diagnosis and untimely treatment of patients."

In order to identify the main signs of appendicitis, you should find out the mechanism of the onset of the disease. As you know, the uterus during pregnancy increases in size and the caecum with the appendix rises above its usual position.

This physiological change often leads to constipation, which, in turn, leads to a violation of the microflora in the intestine, as well as to the fact that the contents of the intestine stagnate. Through the lumen of the appendix, pathogens (staphylococci and Escherichia coli) are introduced into it, it is because of this factor that appendicitis occurs during pregnancy.

In addition, the cause of the disease can also be the physiological characteristics of the body, for example, the location of the appendix.

Types of appendicitis during pregnancy

There are several forms of appendicitis, the main differences of which are in the course of the disease.

1.Simple or catarrhal appendicitis. With this form, the process is tense, enlarged, often swollen. Usually, during catarrhal appendicitis, pus does not enter the abdominal cavity, since the appendix remains intact.

2.Destructive appendicitis (acute). This form, in turn, is divided into three separate types:

·gangrenous,

Phlegmous

perforative.

Phlegmous appendicitis is the second stage in complexity and danger after a simple form. At the same time, the appendix is ​​maximally enlarged and filled with pus. The next gangrenous form can develop literally within an hour.

With this form, the appendix breaks in one or more places, and part of the pus enters the abdominal cavity. If timely treatment is not started, then the entire contents of the appendix will fall into the peritoneal region - this form of appendicitis is called perforated. The combination of two conditions of the body: pregnancy and acute appendicitis - can be extremely dangerous and pose a threat to the life of the mother and child.

2 Symptoms of appendicitis during pregnancy and its diagnosis

The leading symptom of acute appendicitis is pain in the lower part right half belly.

As a rule, such pains arose suddenly, were constant, aching in nature; much less often they acquired a sharp cutting character and became cramping. IN rare cases acute attack pain was preceded by constant aching pain in the right side of the abdomen. Pain, usually moderate, did not cause disability; the patients themselves explained them developing pregnancy.

There are simple (i.e. catarrhal) and destructive (phlegmonous, gangrenous and perforated) forms of appendicitis. All of them are stages in the development of a single process, and for their occurrence in the progressive course of the disease, it is necessary certain time: for catarrhal appendicitis (when only the mucous membrane of the appendix is ​​involved in the process of inflammation) - 6-12 hours, for phlegmonous (changes can be traced on the mucous, submucosal and partially on the muscular layer) - 12-24 hours, for gangrenous (when all layers of the appendix wall die off) - 24-48 hours: perforation of the appendix may also occur later, in which the contents of the intestine enters the abdominal cavity.

Manifestations of appendicitis largely depend on pathological changes in the process, as well as on its location in the abdominal cavity. As long as the inflammatory process is limited to the process itself, without passing to the peritoneum - a layer connective tissue covering the walls and organs of the abdominal cavity - the manifestations of the disease do not depend on the location in the abdominal cavity relative to other organs and are expressed by pain in upper third abdomen, which gradually shift down to the right half of the abdomen. This may cause nausea, vomiting. Pain in the abdomen can be minor and occur not only in the right iliac region, but also in other parts of the abdomen. Often, pain during examination is not detected immediately and is determined much higher than the uterus, often the greatest pain is determined in the right lumbar region. Characterized by increased pain in the supine position on the right side, due to the pressure of the pregnant uterus on the inflamed focus.

At further development inflammatory process, pain appears in the right iliac region - in the lower abdomen or higher, up to the hypochondrium, depending on the degree of displacement of the process by the uterus, that is, on the gestational age. Symptoms of peritoneal irritation (soreness with a sharp removal of the hand pressing on the anterior abdominal wall) are absent in pregnant women or are mild due to stretching of the abdominal wall. In pregnant women, all symptoms may be unexpressed and appear late.

Among other features of appendicitis, an atypical location of the process can be distinguished. So, with a "high" location of the process (under the liver), gastritis symptoms may appear with pain in the upper abdomen, nausea, and vomiting. With a "low" location (in the pelvis), especially if the process borders on bladder, there may be a picture of cystitis - inflammation of the bladder, with pain radiating to the leg, perineum, with frequent urination in small portions.

The development of appendicitis in pregnant women also affects the fetus, especially if appendicitis develops in the second trimester of pregnancy. The most common complication of pregnancy is the threat of termination. Among other complications, postoperative infectious processes are distinguished, intestinal obstruction. In rare cases, premature detachment of a normally located placenta occurs when the placenta exfoliates from the uterine wall over a more or less extended area. In this situation, the prognosis depends on the degree of detachment - with a small detachment and timely treatment, pregnancy can be saved. Chorioamnionitis (inflammation of the membranes) and intrauterine infection of the fetus require antibiotic therapy.

The likelihood of complications is especially high during the first week after surgery. In this regard, all patients after appendectomy are prescribed drugs that relax the muscles of the uterus. For prevention infectious complications after appendectomy in pregnant women, all patients are prescribed antibiotics.

Diagnosis of appendicitis in pregnant women is combined, that is, it is carried out in several stages.

1.Examination by a doctor and questioning of the patient. At this stage, the doctor primary signs makes a presumptive diagnosis. Often, patients have a fever, and pain increases when walking or changing position. The patient finds a forced position in which pain is felt the least. Determination of appendicitis in pregnant women is extremely difficult, because due to the location of the appendix and stretching of the anterior wall of the peritoneum, some signs typical of the disease are sometimes absent. However, at earlier stages of pregnancy, the patient may experience rebound pain when probing.

2.Taking a blood test. This method diagnostics is necessary to confirm the presumptive diagnosis, which the doctor made after examination and conversation with the patient. In the blood, with inflammation of the appendix, the number of leukocytes (white blood cells) increases. At the initial stage of the disease, the composition of the blood may be normal, but more often you can notice at least a slight increase in leukocytes. However, a blood test alone cannot be the reason for the diagnosis of appendicitis, since in almost any inflammatory process the number of white blood cells increases.

.Examination of urine under a microscope. This analysis may indicate inflammation of the appendix, since appendicitis in the patient's urine may contain white and red blood cells, as well as bacteria. But it is impossible to draw conclusions on the basis of these studies alone, since these same signs may indicate diseases of the kidneys or the genitourinary system.

.Ultrasonography. The definition of appendicitis using an ultrasound machine is not always effective, since the appendix can be seen in only 50% of patients.

.laparoscopy method. This procedure - the only way accurately diagnose appendicitis. During laparoscopy, the doctor inserts a small tube with a camera into the abdominal cavity. An image with the state of the abdominal cavity is displayed on the monitor. If an appendicitis is found, it can be excised immediately. This procedure is performed under general or epidural anesthesia.

With appendicitis, only surgical treatment is possible - appendectomy. Antibiotics are started before surgery, as soon as the diagnosis is made, in order to prevent postoperative suppurative complications.

In an appendectomy performed through an incision, an incision 8-10 cm long is made through the skin and layers of the abdominal wall above the area where the appendix is ​​located. The surgeon examines the appendix. After examining the area around the appendix to make sure there are no other diseases in this area, the appendix is ​​removed. If there is an abscess, it can be drained with drains (rubber tubes) that come from the abscess and exit through the incision. The incision is then sutured.

3 Frequency of acute appendicitis in pregnant women

Information about the incidence of acute appendicitis in pregnant women in the available literature is descriptive in nature and is reduced to bringing cases from practice.

However, acute appendicitis in terms of frequency of occurrence occupies the first place in the modern pathology of the abdominal organs, including in pregnant women. According to numerous studies, acute appendicitis is more common in women. The prevalence of morbidity in females over males is explained by the proximity of the ileocecal angle to the pelvic organs, which are often subject to inflammatory diseases of the pelvic organs in women, and by neurohumoral features. female body.

The prevalence of acute appendicitis varies widely: according to N.A. Vinogradov (1941) - 2.5%, I.I. Grekov (1952) - 10%, V.I. Efimov (1959) - 1.92%, A.A. Rusanov (1979) - 0.7%, V.S. Saveliev et al. (1986) - 1.4%, I.L. Rotkov (1988) - 3.3%.

G.I. Ivanov (1968) indicates that acute appendicitis during pregnancy is 1.2% of the total number of pregnant women.

According to the results of a study by I.P. Korkan (1991), acute appendicitis occurs in 59.2% of all acute surgical diseases in pregnant women.

Even more conflicting data on the frequency of appendicitis in pregnant women are presented in the works of obstetrician-gynecologists. So, according to G.T. Genter (1937), M. Reed and M. Irman-Wering (Reed M. et Irrmang-Wearing M., 1936), the percentage of patients with appendicitis among the pregnant women observed by them ranged from 0.007%) to 0.4%.

According to N.V. Vinogradov (1941), V.R. Braitsev (1946), Ts.ANass (Nass S.A., 1956), B.I. Efimov (1959), G.I. Ivanov (1968), I.P. Korkan (1991), most often acute appendicitis occurs between the ages of 20 and 30 years.

During childbirth, acute appendicitis is extremely rare, and each case is described as casuistic (Feiertag G.M., 1926; Vinogradov N.A., 1941; Vvedensky K.K., 1944; Guaran R. and Martin-Laval I., 1953).

According to foreign researchers (Balthazar E.J., Birnbaum B.A., Yee J., 1992; Bard J.L., O "Leary J.A., 1995), the frequency of this pathology is from 1:700 to 1:3000 and does not tend to decrease. In general, the first half of pregnancy accounts for % of all observations. The largest number observations of acute appendicitis occur in the 1st (19-32%) and 11th (44-66%) trimesters of pregnancy, less often in the III (15-16%) trimester and postpartum period (6-8%).

Thus, according to the literature, appendicitis in pregnant women is a relatively common disease with a tendency to increase. Most often it is observed in nulliparous aged 20 to 30 years in the I, II trimesters of pregnancy. In the works cited above, reliable reasons for these features of the distribution of the incidence of appendicitis in pregnant women are not indicated.

CHAPTER 2

1 Etiology, pathogenesis and clinical and anatomical forms of appendicitis in pregnant women

The issues of the influence of pregnancy on the onset, development, symptoms and clinical course of acute appendicitis have not yet been fully resolved.

M.A. Terebinskaya-Popova (1924), H. Mühler (1932), C. Optits (1913) see the reason for the exacerbation of chronic appendicitis in pregnant women as congestion of the pelvic organs. In contrast to them, S.S. Pevsner (1926), K.K. Scrobansky (1946), V.R. Braitsev (1952) believe that congestion, caused by pregnancy, on the contrary, prevent the development of appendicitis.

V.F. Weber (1900), A.A. Zykov (1942) believe that hyperemia of the pelvic organs and the ileocecal angle can have favorable influence only in chronic forms of appendicitis. In acute cases purulent inflammation appendix, it, on the contrary, contributes to the spread of infection, that is, the development of peritonitis. N.A. Vinogradov (1941) believes that the leading role in stimulating the microflora in the appendix belongs to the stagnation of the contents in the atonic intestine of pregnant women. T. Kramer (1892) and E. Kehrer (1925) explain the increase in the virulence of the bacterial flora of the intestine in pregnant women by a decrease in the acidity of gastric juice, that is, a decrease in its barrier role.

N.L. Clado (1892), A.V. Aleksandrov (1938), I.P. Yakuntsev (1940), N.A. Vinogradov (1941) points to the possibility of the transition of the inflammatory process in pregnant women to the process along the lymphatic pathways of the right uterine appendages and vice versa.

However, this view is not shared by everyone. CM. Rubashev (1928) denies the presence of the Clado ligament in women. According to B.V. Ognev (1926), it is found on the section in 33% of all examined. A.P. Tsvetkova (1944), on the basis of the studies carried out, came to the conclusion about the impossibility of a normal lymphatic connection between the appendix and the right appendages, since these organs develop from different embryonic rudiments.

At present, according to A.N. Strizhakova et al. (2004), in the etiology of acute appendicitis, the leading role belongs to the opportunistic aerobic and anaerobic flora that vegetates in the intestine. A special place is given to bacteroids, anaerobic cocci and Escherichia coli. The sudden manifestation of the pathogenic properties of microorganisms can be explained by excessive proliferation of bacteria in violation of evacuation and stagnation of the contents in the process due to a decrease in the motor function of the intestine.

During pregnancy, there is a weakening of the regulation of motor function of the intestine due to an increase in the sensitivity threshold

specific chemoreceptors for biologically active substances. From the first weeks of pregnancy, the intestine becomes tolerant to chemical irritants - prostaglandins, acetylcholine, serotonin and others. In addition, during pregnancy, hypotonic state smooth muscle gastrointestinal tract is supported by increased secretion of progesterone. A decrease in the tone of the smooth muscles of the intestine, pathological kinks of the appendix resulting from a change in its usual location during pregnancy, compression of the intestine by an enlarged uterus lead to a delay in the emptying of the appendix, stagnation of the contents, impaired blood circulation in the intramural vessels, multiplication of bacteria, their penetration into the wall of the appendix and the development of inflammation.

Without dwelling on all the known shortcomings and advantages of numerous classifications of acute appendicitis, for practical activities, the classification of V.M. Sedov (2002), based on the principles of classification by V.I. Kolesov (1972):. Acute appendicitis.

1.Superficial (simple) appendicitis.

2.Destructive appendicitis:

A) phlegmonous (with perforation, without perforation);

b) gangrenous (with perforation, without perforation).

3.Complicated appendicitis:

A) peritonitis (local, diffuse, diffuse);

b) appendicular infiltrate;

V) periappendicitis (typhlitis, mezenteriolitis);

G) periappendicular abscess;

e) abdominal abscesses (subdiaphragmatic,

subhepatic, interloop, recto-uterine

space);

e) abscesses and phlegmon of the retroperitoneal space;

g) pylephlebitis;

h) abdominal sepsis.

II. Chronic appendicitis.

1.Primarily chronic.

2.Chronically relapsing.

2.2 Clinical picture of acute appendicitis in pregnant women

There is no consensus on the impact of pregnancy on the occurrence, clinical course of appendicitis in pregnant women. In general, the clinical picture of acute appendicitis in pregnant women consists of many-sided symptoms, which also change under the influence of the characteristics of pregnancy, its timing and course.

Clinical symptoms

Pregnancy makes it difficult to diagnose appendicitis for the following reasons.

Anorexia, nausea, vomiting are regarded as signs of pregnancy, not appendicitis.

The appendix rises upward as the gestational age increases, which leads to a change in the localization of the pain syndrome.

Moderate leukocytosis is always noted in normal pregnancy.

Particularly difficult is the differential diagnosis of acute appendicitis with diseases such as acute pyelonephritis, renal colic, placental abruption, malnutrition of the myomatous node.

A pregnant woman, especially in late pregnancy, may not have symptoms that are considered "typical" of non-pregnant women. Pain in the right lower or middle quadrant of the abdomen is almost always present, but during pregnancy it is sometimes regarded as a round ligament sprain or infection. urinary tract. During pregnancy, the appendix moves upward and outward. After the first trimester of pregnancy, the process is significantly displaced from the McBurney point with horizontal rotation of its base. This rotation continues until the 8th month of pregnancy, when more than 90% of the appendixes are located above the iliac crest and 80% are rotated anteriorly to the right hypochondrium. An important role is played by the tendency to constipation during pregnancy, which causes stagnation of the intestinal contents and an increase in the virulence of the intestinal flora, as well as hormonal shifts leading to functional restructuring of lymphoid tissue.

The most constant clinical symptom in pregnant women with appendicitis is pain in the right abdomen, although the pain is often localized atypically. Muscle tension and symptoms of peritoneal irritation are less pronounced, the longer the gestational age. Nausea, vomiting, anorexia - as in non-pregnant women. At the beginning of the disease, the temperature and pulse rate are relatively normal. High fever is not typical for the disease; in 25% of pregnant women with appendicitis, the temperature is normal. To establish the diagnosis, diagnostic laparoscopy is indicated, especially in early pregnancy.

Due to the atypical clinical picture, the time from the onset of the disease to surgical treatment in almost 80% of patients exceeds 12 hours, and in every fourth - more than a day (Fig. 1), which contributes to an increase in the frequency of complicated forms of acute appendicitis.

As the gestational age increases, the caecum and appendix are located high, the formation of adhesions and the restriction of infection by the greater omentum become unlikely, as a result of which the frequency of destructive forms (Fig. 2) and diffuse purulent peritonitis increases.

Clinical Analysis case histories of pregnant women with acute appendicitis, conducted by the staff of the department, showed a high frequency of destructive forms of acute appendicitis in pregnant women.

All pregnant women with acute appendicitis complain of abdominal pain, and all have local soreness. Nausea and vomiting in the first trimester do not have a large diagnostic value, as often these are manifestations of early toxicosis of pregnancy. In the II and III trimesters, as a rule, there are no manifestations of toxicosis, and these symptoms become more important in the diagnosis of acute appendicitis, occurring respectively: nausea - in almost 70%, vomiting - in about 50% of cases. Loose stools may appear in 20% of patients. Tension of the muscles of the anterior abdominal wall and symptoms of irritation of the peritoneum are observed mainly in the first trimester (up to 75%), and after the exit of the uterus from the small pelvis in the second trimester - in 30-50%, in the third trimester - only in 28% of patients. In the diagnosis of acute appendicitis, the symptoms of Rovsing and Sitkovsky are of great importance, especially in the second half of pregnancy. Quite often, one can see an increase in pain when the uterus is displaced towards the localization of the appendix (Brando's symptom).

Rice. 1. Time from the onset of the disease to the operation of appendectomy in pregnant women

Rice. 2. The frequency of occurrence of various forms of acute appendicitis depending on the duration of pregnancy

Temperature response occurs only in half of the patients, as well as leukocytosis more than 12,000. But almost all patients have tachycardia up to 100 beats per minute.

Clinical symptoms of acute appendicitis in pregnant women depending on the duration of pregnancy

Symptoms of acute appendicitisTrimester IIIIII Abdominal pain 100% 100% 100% Local tenderness on palpation 100% 100% 100% Nausea 83% 67% 71% Vomiting 25% 43% 53% Loose stools 8% 21% 18% Muscle tension 75% 51% 28% Symptoms: Shchetkin-Blumberg; 47% 3 0% 28% Rovzinga; 58% 87% 82% Sitkovsky; 50% 82% 76% Temperature > 37 ° C 67% 51% 41% Leukocytosis > 1200033% 41% 65% Tachycardia > 8092% 90% 100% Pyuria 010% 6%

3 Features of the treatment of acute appendicitis in pregnant women

Treatment of appendicitis in pregnant women involves two problems: surgical and obstetric.

At present, the question of the need for early surgical treatment of acute appendicitis in pregnant women, according to A. Fabricius (1935), N.A. Vinogradov (1941), B.I. Efimov (1959), I.L. Braude (1957), L.S. Persianinov (1973), G.I. Ivanov (1961), I.P. Korkan (1990), is considered already solved for both surgeons and obstetrician-gynecologists.

B.I. Efimov (1959) showed that putting into practice - early appendectomy in pregnant women reduced the frequency of postoperative abortions to 5.75%, and maternal mortality to 1.09%.

The question of choosing a surgical approach for appendectomies and tactics of pre- and postoperative management pregnancy remains the subject of debate to date.

According to S.S. Pevzner (1926), E.G. Dekhtyar (1971), the least traumatic and best access to the caecum in pregnant women gives an oblique incision according to Volkovich-Dyakonov. Taking into account the displacement of the caecum in the second half of pregnancy, N.A. Vinogradov (1941) recommends making an incision 3-4 cm above the anterior superior iliac spine, calling it a “pre-calculated oblique incision”.

I.I. Grekov (1952) recommends using an oblique incision before 12 weeks of pregnancy, and a pararectal incision at a later date. N.S. Luros (1940), N.A. Panchenko (1948), I.I. Yakovlev (1953) consider the median lower laparotomy to be the most optimal.

In contrast, such researchers as A.L. Pkheidze (1963), E.L. Vovchenko (1963), E.M. Kostyuchenko (1963) believe that the choice of surgical access is of no fundamental importance.

E.E.Rpgash (1922), G.Dorzak (1929), K.K.Vvedensky (1944) believe that the pararectal incision, which gives the widest access, is the best. G.I. Ivanov (1968) notes that the pararectal incision, as giving the widest surgical access, is not always convenient due to the displacement of the appendix by the pregnant uterus, in addition, postoperative hernias are more often observed with it, which finds an explanation in the studies of A.I. the course of the so-called Langer lines is taken into account. G.I. Ivanov (1965) notes that the choice of surgical access to the caecum and appendix must be strictly individual and should be carried out taking into account the timing of pregnancy, the configuration of the abdominal wall and the alleged pathological changes in the appendix and surrounding tissues.

According to G.I. Ivanov (1965), in the first half of pregnancy, up to 20 weeks, a good surgical access for appendectomies gives an ordinary oblique incision according to Volkovich-Dyakonov. From 21-22 weeks of pregnancy to 32 weeks, the best surgical access is provided by a semi-transverse incision made along the skin fold 3-4 cm above the anterior superior iliac spine. During pregnancy at 39-40 weeks, the best surgical access is provided by a transverse incision in a slightly elevated medial direction, made 4-5 cm downward from the hypochondrium.

All three sections, according to G.I. Ivanov (1965), have a fundamental similarity: they are projected over the most frequent location of the caecum at different gestation periods and their direction corresponds to the course of the main aponeurotic, muscular and nerve formations anterior abdominal wall.

Thus, the usual oblique incision with an increase in the duration of pregnancy, rising after the caecum, unfolds like a fan in the medially-superior direction. This allows us to generalize the proposed incision into the term - a pre-calculated stepped incision for appendectomies in pregnant women. These incisions, as G.I. Ivanov (1965) writes, not only have the least trauma, but also create the widest operational access.

E.G. Dekhtyar (1971) believed that the oblique-pararectal incision, projected according to the zone of greatest pain, the so-called "migrating" oblique incision, is optimal. In her observations, only one median laparotomy was used in the third trimester of pregnancy. But it should be noted that in her data, the largest percentage of appendectomies occurred in the first trimester of pregnancy.

I.P. Korkan (1990) indicates that the method of choice is a right-sided, pararectal incision in conditions general anesthesia, the length of the incision depends on the prevalence of the process and the duration of pregnancy.

With widespread peritonitis in the II and III trimesters, E. Forsman (1990) suggests making a pararectal incision on both sides.

Thus, there is no consensus on the choice of surgical approach at different gestation periods, depending on the clinical morphological form acute appendicitis.

2.4 Complications of acute appendicitis in pregnant women

Regardless of the gestational age, acute inflammation of the appendix can lead to serious complications not only in the mother, but also in the fetus.

Postoperative infectious complications occur in 10-14% of cases. Most often (80-90%) infectious complications develop in pregnant women with process perforation. Maternal mortality ranges from 0% with uncomplicated appendicitis to 16.7% with perforation and peritonitis (Strizhakov A.N. et al., 2003). In the development of complications associated with acute appendicitis, the localization of the appendix is ​​of no small importance, especially in the third trimester of pregnancy.

Particular attention, both surgeons and obstetrician-gynecologists pay widespread peritonitis. This complication endangers the life of a woman, the fetus and is the main cause of their death in acute surgical diseases of the abdominal cavity.

The danger of peritonitis for pregnant women is explained by the anatomical physiological features.

Phenomena occur in the abdominal organs venous congestion, intestinal atony with a delay of its contents in the right half, there is a violation of the secretory function of the gastrointestinal tract, which contributes to the development of bacterial flora in the intestine.

Mechanical displacement of the intestine by the uterus leads to its compression and stagnation of the intestinal masses. When peritonitis occurs, the above factors lead to its rapid spread.

Therefore, the main factor in the pathogenesis of peritonitis in pregnant women is that it develops against the background of physiological venous congestion in the abdominal organs, intestinal atony and retention of its contents.

So, R.Wilson (1927) (cited by L.S. Persianinov, 1973) recommends delivery by operation in case of perforation of the appendix and the presence of local peritonitis caesarean section, and with diffuse peritonitis - extirpation of the uterus. M.Michel (1927) advocated supravaginal amputation after appendectomy for peritonitis at any time during pregnancy.

N.A. Vinogradov (1941) believes that with diffuse peritonitis, “emptying” of the uterus by the vaginal or abdominal route is indicated. According to the author, removal of the uterus should be resorted to in rare cases. E.G. Dekhtyar (1971) wrote: "Timely methods of dealing with peritonitis allow in most cases to avoid intervention on the uterus and carry out childbirth in a natural way."

“When it comes to the removal of the appendix at the end of pregnancy,” writes I.I. Yakovlev (1953), “especially with incipient peritonitis or with the pelvic position of the appendix, it is necessary to free the uterus from the fetal egg and drain the abdominal cavity through the posterior Douglas space with the output of the rubber tube into the vagina. With peritonitis that occurs with appendicitis at the end of pregnancy, you must first empty the uterus, and then remove the appendix. In exceptional cases, the operation of caesarean section has to be combined with the operation of supravaginal amputation of the uterus in order to create the best conditions for the outflow of pus from the abdominal cavity and create maximum opportunities for “rest” of the caecum with the appendix ”(Yakovlev I.I., 1953).

Operative delivery and removal of the uterus by the above authors were carried out in order to eliminate a possible subsequent focus of infection, which could be a potential cause of the onset or recurrence of sepsis.

Issues related to obstetric tactics in acute appendicitis continue to be discussed at the present time.

V.N. Serov et al. (1997) believe that in the presence of acute appendicitis, abdominal delivery can be performed only for health reasons on the part of the mother. At the same time, after performing a caesarean section, the volume of surgical intervention expands to the extirpation of the uterus with fallopian tubes. A. Sugkolyug (1996) indicates that hysterectomy after caesarean section is necessary in cases of complicated appendicitis. V.Birshak, Eloches (1996) admit the possibility of performing appendectomy and caesarean section (without subsequent removal of the uterus) in the absence of diffuse peritonitis.

G.M. Savelyeva et al. (2006) indicate that any form of appendicitis, including complicated by peritonitis, is not an indication for abortion.

According to A.N. Strizhakov et al. (2004), the principles of surgical tactics should be maximum activity in relation to peritonitis and maximum conservatism in relation to pregnancy. In the short term of pregnancy, the treatment of peritonitis should be carried out against the background of an ongoing pregnancy in order not so much to prolong it, but to preserve reproductive function. After appendectomy, long-term therapy is necessary to maintain pregnancy with sedative, antispasmodic, tocolytic and other drugs, in case of development labor activity childbirth through natural birth canal. The issue of the scope and nature of the intervention in destructive appendicitis against the background of long gestation periods should be decided together with the obstetrician-gynecologist, preferably with his direct participation in the surgical intervention. Cesarean section should be performed only by absolute indications.

Observations by A.N. Strizhakov et al. (2004) show that vaginal delivery in the presence of an "acute abdomen" is optimal. Even with perforated appendicitis and diffuse peritonitis, it is necessary to sanitize the abdominal cavity, remove the process, then carry out dynamic prolonged sanitation using a laparoscopic cannula and refuse a caesarean section followed by extirpation of the uterus with fallopian tubes.

It remains an open question whether to drain the abdominal cavity with diffuse peritonitis. L. Site (1947), N. A. Vinogradov (1941), N. N. Mezinova (1982), I. P. Korkan (1990) suggest draining the abdominal cavity. However, B.I. Efimov (1959), I.I. Grekov (1952), P.S. Suleymanov (1960), M.F. Bogatyreva (1961) categorically oppose drainage of the abdominal cavity. In their opinion, in the second half of pregnancy, a tampon or drainage are additional irritating factors for the uterus.

For the prevention of infectious complications after appendectomy in pregnant women, A.C. (1992) recommend antibiotics for all operated women. According to A.N. Strizhakov (2003), in order to prevent postoperative purulent-septic complications and infection of the fetus in pregnant women operated on for destructive forms of appendicitis, antibiotic therapy is indicated.

The anatomical and topographic proximity of the internal organs and the appendix creates favorable conditions for hematogenous and descending (through the fallopian tubes) penetration of microbes.

According to 1. Ayb (1992), antenatal fetal death was noted in 14% of cases after appendectomy.

When studying the course of the outcome of pregnancy and childbirth after appendectomy, S.F. Kiriakidi (1996) found an increase in the frequency of preeclampsia in 52.4%, fetal hypoxia in 16.7%, anemia in 23.8%. At the same time, there is a clear trend towards an increase following complications: untimely discharge of water (26.6%), pathological preliminary period (7.14%), primary weakness of labor activity (7.1%), partial dense attachment of the placenta (12%), complete dense attachment of the placenta (2.4%), delayed involution of the uterus (2.4%).

Many authors note that the rate of postoperative complications in pregnant women who underwent appendectomy is higher than in non-pregnant women. According to I.P. Korkan (1991), this once again indicates the instability of the compensatory capabilities of the pregnant woman's body and the need for more thorough therapeutic and preventive measures.

Important for the diagnosis of acute appendicitis in pregnant women are percussion and palpation of the abdomen. Regardless of the gestational age, the study begins with the left iliac region, then smoothly moves to left hypochondrium, upper abdomen and finally the point or zone of greatest pain is determined. In the first trimester of pregnancy, with a typical location of the appendix, its localization corresponds to that in non-pregnant women. Starting from 20-21 weeks of pregnancy, due to changes in the topography of the caecum, pain sensitivity shifts upward and becomes dull or pulling.

It should be noted that palpation of the abdomen should be done not with the fingertips, but with a “flat hand”, since in acute appendicitis they do not look for a specific painful point, but rather a vast area without clearly defined boundaries.

Difficulties in examining the ileocecal angle arise from the second half of pregnancy, when the pregnant uterus not only shifts the ileocecal angle upwards, but also covers it. The variable position of the caecum and appendix places them in the projection of other organs, which in itself can become a source pathological process, and hence the area of ​​pain.

When examining the abdomen, it is necessary to identify a number of symptoms that allow diagnosing acute appendicitis:

occurrence of pain mechanical action on the appendix, parietal and visceral peritoneum of adjacent organs;

the presence of protective tension in the muscles of the abdominal wall in response to inflammation of the peritoneum.

However, during pregnancy, these symptoms lose their significance due to the presence of a pregnant uterus in the abdominal cavity.

The most important, characteristic, early and persistent local symptom of acute appendicitis is pain.

For an adequate assessment of the specifics of pain syndrome in pregnant women, it is necessary to take into account:

variability in the position of the appendix in the 1st, 11th, and 3rd trimesters of pregnancy;

the presence of a mediated (secondary) pain syndrome associated with intestinal hypermotility in conditions of inflammation;

a high frequency of symptoms of a threatened abortion, often combined with acute appendicitis or masking its clinical picture.

In the second half of pregnancy, the clinical manifestations and course of the disease have significant differences and are due to a number of reasons:

with an increase in the gestation period, the caecum with the appendix moves upward, is located behind the pregnant uterus and reaches the right hypochondrium by the end of pregnancy;

due to the displacement of the greater omentum by the pregnant uterus, the possibility of delimiting the inflamed appendix from the free abdominal cavity by the omentum is excluded, while in destructive forms of acute appendicitis, peritoneal complications in pregnant women develop much more often and faster than outside pregnancy;

changes in the topography of the pelvic organs and floors of the abdominal cavity with an increase in the gestational age, mainly due to the closure of the entrance to the small pelvis by the pregnant uterus, makes it difficult to localize the peritoneal effusion in the right iliac fossa and small pelvis, which often occurs with destructive forms of acute appendicitis complicated by local peritonitis. In this connection, the peritoneal effusion spreads up the right lateral canal to the subdiaphragmatic space and along the left lateral

channel, which leads to rapid development common forms appendicular peritonitis in the second half of pregnancy;

violation venous circulation, caused by increased intra-abdominal pressure and compression of blood vessels by an enlarged pregnant uterus, contributes to a more rapid development destructive changes in the process, the frequency of gangrenous-perforative forms of acute appendicitis increases;

stretching of the muscles of the anterior abdominal wall leads to the disappearance of the clinical symptom of acute appendicitis - protective tension of the abdominal muscles;

the propensity of pregnant women to coagulopathy, the presence of chronic DIC contribute to thrombosis, which must be taken into account when draining the abdominal cavity.

To determine the zone of the most pronounced pain sensitivity in the abdominal cavity, we used the "index finger" method.

We have not identified any pattern of localization of pain depending on the duration of pregnancy, since the displacement of the caecum and appendix in each pregnant woman is individual and depends on many reasons, which cannot be taken into account in each individual case: the constitution, the size of the pelvis, the number of pregnancies, the tone of the anterior abdominal wall, previously transferred inflammatory diseases of the abdominal cavity, surgical interventions.

Table 1 shows the localization of pain at different stages of pregnancy.

In the first trimester of pregnancy, the zone of greatest pain in acute appendicitis in pregnant women is projected into the right iliac region, as in non-pregnant patients. Pregnant women point to a painful point in the abdomen, located on the right, slightly higher (14 cm) of the anterior superior iliac spine. However, with an increase in the gestational age, the pain shifts upward, localizing at the level of the right iliac crest or in the right lateral canal, lateral to the right uterine rib. All patients noted that the pain syndrome in late pregnancy often does not have a clear localization, is less pronounced, recedes into the background, which may be due to a change in the location of the appendix and the topography of the abdominal cavity with a large uterus.

Table 1

Pain localization Term of pregnancy% ratio to the total number of women I trnmestre II trimester III trimester Postpartum period 4.86/35.14 Left iliac region Umbilical region 2/412/51/1-8.11/5.4 In the lower abdomen 2/421/192/51/114.05/15.67 Throughout the abdomen 1/28/185/10-7.57/16.22 No clear localization-9/1215/4-12.97/8, 65 In the lumbar region-2/0---Total patients41116262185

When a pain syndrome appears, initially in the epigastric or paraumbilical regions, after 3-6 hours the pain shifts down and to the right, localizing in the right iliac region, and is still aching in nature. It should be noted that pain migration occurs after a longer period of time, after 4-5 ± 0.31 hours, than outside pregnancy.

Localization of pain in acute appendicitis at different stages of pregnancy

The symptom of Kocher-Volkovich was detected in 32.97% of cases. Most often found in the first trimester of pregnancy - 46.34% of observations, and tends to decrease with increasing gestational age, in the second trimester - 21.08% of observations, in the third trimester - 7.69%. Since the occurrence of the Kocher-Volkovich symptom is due to reflex irritation of the superior mesenteric and celiac plexuses involved in the innervation of the ileocecal intestine, a decrease in the frequency of this symptom during pregnancy may be due to mechanical compression of these plexuses by the pregnant uterus and impaired impulses. Such migration of pain, provided that they are dull, aching in nature, is pathognomonic for acute appendicitis during pregnancy. When the Kocher-Volkovich symptom is detected in conjunction with other symptoms of acute appendicitis, histological examination of the diagnosis of the phlegmonous form of acute appendicitis is confirmed in 100%.

It should be noted that the frequency of occurrence of the Kocher-Volkovich symptom, like other symptoms, depends not only on the gestational age, but also on the clinical and morphological form of acute appendicitis.

In addition to the topography of the pain zone in acute appendicitis in pregnant women, it is essential to clarify the nature of the irradiation of the main pain symptoms.

In the study of the Kocher-Volkovich symptom, G.I. Ivanov (1965) revealed the most common symptom in pregnant women - a symptom of otresh / hay pain. This symptom is characterized by the fact that during palpation of the ileocecal region in the first half of pregnancy in the position of the patient on the back, and in the second half - on the left side, the pregnant woman notes pain in the uterus and navel, up and down from it. G.I. Ivanov (1965) explains the occurrence of this symptom by reflex transmission of irritation from the inflamed appendix along the neuroreflex arcs to the peritoneum and the root of the mesentery of the small and large intestines and, possibly, to the uterus (Fig. 3).

Fig.3. The direction of reflected pain in appendicitis in pregnant women (according to Ivanov G.I. 1965). a, b, c, d - direction of reflected pain

In late pregnancy, reflected pain is more common in the right hypochondrium, as well as in the umbilical and lumbar areas. Attention is drawn to the predominance of the symptom of referred pain in the II trimester of pregnancy, which amounted to 29.2%. A change in the localization of reflected pain with an increase in the duration of pregnancy indicates a change in the topography of the appendix.

Consequently, almost half of pregnant women (52.97%) with appendicitis have reflected pain.

In typical observations, pain in acute appendicitis does not radiate, with the exception of those observations when the process is closely related to others. internal organs(gallbladder, rectum, ureter, urinary bladder). The involvement of the walls of these organs in the inflammatory process with atypical localization of the inflamed process causes reflected pain for these organs. Thus, reflected pain in pregnant women with acute appendicitis is much more common than in non-pregnant women (15-25%), and is diverse.

The presence of a symptom of reflected pain can not only serve as an indirect explanation of the sometimes encountered difficulties in diagnosing acute appendicitis in pregnant women, but to some extent allows us to understand the frequency of their diseases - “companions”.

Of the other symptoms caused by increased pain with additional irritation of the mechanoreceptors of the ileocecal angle in the appendix in the second half of pregnancy, the sensation of pain in the right side of the abdomen in the position of the patient on the right side (Mikhelson's symptom) also deserves attention. This symptom occurs in 54.05% of cases and is most typical for destructive forms of acute appendicitis (in the phlegmanous form of acute appendicitis it occurs in 76.29% in the II trimester, in 40% of the total number of pregnant women), when the uterus, with its weight, presses on the destructively altered process and thereby enhances the reflex.

The Bartholomew-Michelson symptom occurs in 47.03% during pregnancy, but most often in the second trimester of pregnancy (38.92%o). Increased pain on palpation in the position on the left side occurs due to the displacement of the cecum medially, the pregnant uterus also deviates, and the appendix, located in the lateral canal and previously covered by the cecum and the pregnant uterus, is more accessible to palpation.

Starting from 24 weeks of pregnancy, when the ileocecal angle cannot be palpated because of the uterus adjacent to the anterior abdominal wall, it was examined according to the method proposed back in 1891 by G.F. Frenkel, that is, in the position of the pregnant woman on the left side. In this position, the uterus deviates to the left, and thus the access for palpation of the caecum is "opened" to a greater extent. In the study of this symptom, it must be taken into account that starting from the 28-29th week of pregnancy, if the patient is laid on the left side, then the right iliac fossa and the right lateral canal of the abdominal cavity become inaccessible for palpation, due to the fact that the uterus that has shifted to the left contributes to the tension of the right half of the abdominal wall, creating a false impression of muscular protection. To this end, in order to eliminate and weaken the tension of the abdominal wall, we conducted a study of this symptom as follows: a roller was placed under the left side of the pregnant woman, then the uterus, shifting to the left, rested on the roller, the tension of the muscles of the right half of the abdominal cavity decreased.

In the position lying on the left side, under the force of gravity, the caecum with the appendix is ​​displaced in the medial direction, the pregnant uterus also deviates to the left. Pain in the right iliac region is aggravated by the movement of the inflamed organs. Sitkovsky's symptom was detected in 60.54% of cases.

Most patients paid attention to the increase in pain symptoms when coughing, which is a manifestation of the Cheremsky-Kushnirenko symptom (increased pain in the right iliac region when coughing), the incidence rate was 51.35%. The appearance and intensification of pain in the right iliac region when coughing occurs due to jerky contraction of the diaphragm and muscles of the anterior abdominal wall and the transmission of concussion to the area of ​​​​the inflamed appendix. This symptom can be called characteristic of acute appendicitis during pregnancy, especially in the phlegmonous form of acute appendicitis - in 41.62% of the total number of patients. However, this symptom is not always determined by surgeons; when it is detected, it makes up 79.2% of cases.

Rizvan's symptom was also quite often detected, characterized by increased pain in the right iliac region with deep breath. Rivzan's symptom was studied in 84 patients and amounted to 67.85%, with a predominance in the II trimester.

Quite often, with superficial palpation, it was not possible to localize the pain or clarify where they are more pronounced. To clarify the localization of pain, they resorted to percussion of the abdominal wall at symmetrical points on the right and left sides. Razdolsky's symptom (with percussion of the abdominal wall, the greatest pain in the right iliac region) was detected in 29.19%. This symptom has less diagnostic significance from 20 weeks of pregnancy.

Rovsing's symptom (appearance or intensification of pain in the right iliac region during compression sigmoid colon and jerky pressure on the descending colon) was detected quite often - in 57.3%, which is due to the displacement of the intestinal loops and the greater omentum in relation to the appendix and leads to increased pain where palpation is performed. Thus, this symptom does not lose its significance during pregnancy.

Other symptoms, often found in non-pregnant women, were extremely rare.

It should be noted a high percentage of detection of Brando's symptom in pregnant women, characterized by pain on the right when pressing on the left rib of the pregnant uterus - 37.3%. Symptom Brando was not always determined by surgeons. This symptom is not determined in the first trimester of pregnancy, and in the study of this symptom in 100 pregnant women, it was detected in 69% in the II and III trimester of pregnancy.

The "key" to the diagnosis of acute appendicitis, "a symptom that has saved the lives of millions of patients," is the protective tension of the muscles of the abdominal wall. It is necessary to distinguish between the degree of tension in the muscles of the abdominal wall: from slight resistance to pronounced tension and, finally, a “plank-shaped stomach”. The symptom of protective tension of the abdominal muscles occurs reflexively (visceromotor reflex) as a result of irritation of the parietal peritoneum by the inflammatory process. Its location corresponds to the localization of the inflamed process. In the case of a typical location of the appendix, the symptom of local muscular protection is detected only in the right iliac region. This symptom occurred in 62.16%, while most often in the phlegmonous form of acute appendicitis - 48.11% of the total and in 91.75% with this histological form. A more extensive zone of muscle tension indicates the spread of inflammation in the peritoneum.

The appearance of protective tension in the muscles of the anterior abdominal wall, if the appendix is ​​typically located in the right iliac fossa, can be noted with visual inspection belly. When breathing, there is a lag in the right half of the abdominal wall due to muscle tension. Sometimes it is possible to note a slight asymmetry of the abdomen due to muscle tension.

It is necessary to pay attention to Obraztsov's symptom - increased pain with pressure on the caecum and simultaneous lifting and straightening in the knee joint of the right leg, which is often found in non-pregnant women with a retrocecal location of the appendix. In our study, Obraztsov's symptom was detected in 33.51%. Wherein significant difference according to the frequency of occurrence in the I and II trimester and dependence on the histological form of acute appendicitis was not revealed. This is due to the fact that the appendix is ​​compressed between back wall caecum and sh. Peorzosh, followed by contraction of the latter, and the posterior surface of the uterus. Due to the contact of the inflamed process with the moving muscle in the iliac region, pain occurs. This symptom was detected in the retrocecal location of the appendix, and in non-pregnant women.

The so-called phrenicus syndrome, which in case of appendicitis in non-pregnant women, according to N.M. Volkovich and I.M. Ishchenko (1929), occurs in 74-85.6%, according to our data, was detected in 1.62% in the first trimester, in 6.48% in the second half of pregnancy (mainly with phlegmonous forms of acute appendicitis). The frequency of the phrenicus symptom grows in parallel with the timing of pregnancy, that is, the degree with the approach of the ileocecal angle to the liver.

The combination of pain in the right iliac region, local tension of the muscles of the anterior abdominal wall and local tenderness are combined into the Dieulafoy triad, the presence of which makes the diagnosis of acute appendicitis in non-pregnant women probable. It remains significant in pregnant women only in the first trimester of pregnancy.

Continuing to characterize the pain syndrome, it is necessary to dwell on cramping pains.

The presence of cramping pain for acute appendicitis is uncharacteristic, although it is not completely excluded.

If there are complaints of pain of a cramping nature, in the first place differential diagnosis was carried out with the threat of abortion, as well as with a number of diseases in which pain is not caused by inflammation, but by ischemia of the organ, spasm of smooth muscles (renal, biliary colic, etc.).

At the onset of the disease, against the background of abdominal pain, the appearance of such subjective symptoms as dry mouth, weakness, and nausea is extremely characteristic. These sensations can be of varying severity, but are almost never the leading complaints.

In the first trimester of pregnancy, the clinic of appendicitis is basically the same as in the absence of pregnancy, but it is often masked by an abundance of complaints in the early stages of pregnancy, including abdominal pain, constipation, nausea and vomiting - not so rare. “... Therefore, the data of the anamnesis and objective research obtained from pregnant women require a particularly thorough and in-depth analysis,” wrote N.A. Vinogradov.

Against the background of "abdominal discomfort" in most patients, nausea occurs, accompanied by one or two vomiting. Nausea and vomiting in patients with acute appendicitis occurs already against the background of abdominal pain. The appearance of vomiting before the development of pain makes the diagnosis of acute appendicitis unlikely.

Pregnant women are more likely to experience nausea, which is permanent, and sometimes increasing. Vomiting occurs in 22.7%, this is important differential sign, in the first trimester with early toxicosis, where nausea and vomiting are the main and main complaint of pregnant women. In late pregnancy, these symptoms, combined with pain in epigastric region may be a manifestation of a severe form of preeclampsia, which requires the use of additional diagnostic methods. In those clinical observations in the II and III trimesters of pregnancy, when there was a combination of nausea, vomiting with pain syndrome in the epigastric region in the absence of data for preeclampsia, phlegmonous form acute appendicitis.

Thus, in the absence of obstetric pathology, the presence of these three symptoms—nausea, vomiting, and the Kocher-Wolkovich sign—is a diagnostic criterion for acute appendicitis in late pregnancy. Mostly vomiting was observed in the first trimester with a gradual decrease in the frequency of occurrence and an increase in the gestational age. important and constant sign acute appendicitis is stool retention caused by intestinal paresis, due to the spread of the inflammatory process in the peritoneum.

pregnancy acute appendicitis

2.5 Postoperative period

Management of pregnant women in the postoperative period, prevention and treatment of complications of acute appendicitis are carried out according to the rules adopted in surgery, taking into account a number of features. After the operation, do not put weight and ice on the stomach (this can provoke pregnancy complications), be careful in expanding the regimen, in choosing means aimed at improving bowel function. Physiotherapy is used, which helps not only to improve bowel function, but also helps to maintain pregnancy. Use antibiotics that are not capable of harming the fetus. Prevention of premature termination of pregnancy after surgery consists in a longer bed rest and in the use of appropriate treatment: sedatives, with noticeable contractions of the uterus - suppositories with papaverine or magnesium sulfate, endonasal electrophoresis of vitamin B1 .

After discharge from the hospital, such pregnant women are included in the risk group for the threat of early termination of pregnancy, which can also occur in the long-term after the operation, therefore, preventive actions aimed at maintaining pregnancy.

The management of childbirth that occurred in the early postoperative period (1-3 days after the operation) is distinguished by care. Apply tight bandaging of the abdomen (to prevent the divergence of the seams), full anesthesia with the widespread use of antispasmodics. During childbirth, the prevention of intrauterine hypoxia (lack of oxygen) of the fetus is constantly carried out. The period of exile is shortened by dissecting the perineum, because with attempts, intra-abdominal pressure increases with a load on the anterior abdominal wall, which negatively affects postoperative sutures.

CONCLUSION

Acute appendicitis (AA) is the most common surgical disease in pregnant women, threatening the life of the mother and fetus.

For the diagnosis of acute appendicitis during pregnancy, it is necessary to use complex clinical, laboratory and high-tech research methods (sonography, dopplerometry, laparoscopy, cardiotography).

Diagnosis of acute appendicitis in the initial stages of pregnancy differs little from that of non-pregnant women, but it can also be difficult: the abundance of complaints in women during these periods leads to the fact that they are often not given due attention. Therefore, nausea and vomiting in appendicitis are sometimes attributed to toxicosis, abdominal pain - threatening abortion, overstretching of the peritoneum, round ligaments, etc.

Currently, two methods are used to remove the appendix: the traditional operation, performed through an incision, and endoscopic surgery, which is done through punctures under the control of the TV.

In an appendectomy performed through an incision, an incision 8-10 cm long is made through the skin and layers of the abdominal wall above the area where the appendix is ​​located. The surgeon examines the appendix. After examining the area around the appendix to make sure there are no other diseases in this area, the appendix is ​​removed. If there is an abscess, it can be drained with drains (rubber tubes) that come from the abscess and exit through the incision. The incision is then sutured.

New way removal of the appendix involves the use of a laparoscope - this optical system, connected to a video camera that allows the surgeon to look inside the abdomen through a small puncture hole (instead of a large incision). If appendicitis is detected, the appendix is ​​removed using special instruments that are inserted into the abdominal cavity, like a laparoscope, through small holes. Benefits of using laparoscopy: reduced postoperative pain (since pain is mostly due to incisions) and faster recovery, and excellent cosmetic effect. Another advantage of laparoscopy is that it allows the surgeon to look into the abdominal cavity and make an accurate diagnosis in cases where the diagnosis of appendicitis is in doubt. Laparoscopic method removal is best method surgical treatment, especially for pregnant women.

Thus, after discharge from the hospital, such pregnant women are included in the risk group for the threat of early termination of pregnancy, which can also occur in the long-term after the operation, therefore, preventive measures are taken to preserve the pregnancy.

The fetus in these women is considered as having had an intrauterine infection and the necessary measures are taken to monitor its development, the condition of the fetus and placenta - (ultrasound, hormonal research, Doppler). With manifestations of fetoplacental insufficiency (when the fetus receives less oxygen and nutrients), the woman is hospitalized and appropriate therapy is carried out.

The management of childbirth that occurred in the early postoperative period (1-3 days after the operation) is distinguished by care. Apply tight bandaging of the abdomen (to prevent the divergence of the seams), full anesthesia with the widespread use of antispasmodics. During childbirth, the prevention of intrauterine hypoxia (lack of oxygen) of the fetus is constantly carried out. The period of exile is shortened by dissecting the perineum, because with attempts, intra-abdominal pressure increases with a load on the anterior abdominal wall, which negatively affects postoperative sutures.

No matter how far in time the childbirth is from surgical intervention, they are always carried out with sufficient caution due to the tendency to complications: anomalies of the birth forces, bleeding in the afterbirth and early postpartum periods.

1.The risk factors for perioperative complications during appendectomy during pregnancy include not only the clinical and morphological form of appendicitis and the duration of pregnancy, but also the period from the onset of the disease to surgery, the age of the pregnant woman is less than 16 and more than 35 years, the presence of cardiovascular diseases, chronic inflammatory diseases of the abdominal organs, obesity, the severity of the initial endotoxemia and disorders in the hemostasis system. Importance have signs that are

2.in the postoperative period: the time of appearance of peristaltic noises, the level of peripheral vascular resistance and the resistance index uterine arteries

.on the 3rd postoperative day.

.The frequency of perioperative complications in pregnant women with acute appendicitis depends on the initial intra-abdominal pressure and the method of appendectomy. Potentiation of negative effects intra-abdominal hypertension caused by pregnancy, acute inflammatory process in the abdominal cavity and the creation of pneumoperitoneum during laparoscopic appendectomy, leads to significant systemic disorders, the severity of which depends on the outcome of the operation. The value of intra-abdominal pressure can serve as an additional diagnostic criterion for choosing a surgical approach for the treatment of acute appendicitis in pregnant women.

1.For the diagnosis of acute appendicitis during pregnancy, it is necessary to use complex clinical, laboratory and high-tech research methods (sonography, dopplerometry, laparoscopy, cardiotography).

2.For appendectomy during pregnancy, choose a surgical approach:

Itrimester of pregnancy (up to 12 weeks):

-a typical oblique variable incision in the right iliac region (according to the Volkovich-Dyakonov method);

-it is possible to use operative laparoscopy;

IItrimester of pregnancy (up to 28 weeks):

-pararectal access;

-performing an appendectomy from an oblique variable access in the right iliac region according to the Volkovich-Dyakonov method up to the 24th week of pregnancy (the access should be wide, 7-9 cm);

IIItrimester of pregnancy and complicated forms of acute appendicitis:

-median laparotomy.

3. In order to prevent postoperative purulent-septic complications and intrauterine infection of the fetus, pregnant women, regardless of the gestational age and clinical and morphological form of acute appendicitis, after appendectomy, antibiotic therapy is indicated, which is carried out in the first trimester with semi-synthetic penicillins, and in the II and III trimesters with semi-synthetic penicillins or cephalosporins.

After appendectomy, complex therapy is carried out aimed at prolonging pregnancy in the first trimester of pregnancy:

-psychotherapy, sedatives: decoction of motherwort, valerian;

-antispasmodic therapy: no-shpa 0.04 g 3 times a day, suppositories with papaverine hydrochloride 0.02 mg 3-4 times a day;

-with the appearance of clinical symptoms of a threatened abortion and echographic signs of increased myometrial tone after 7-8 weeks of pregnancy, the use of progestogens (utrogestan, duphaston) is indicated. In the presence of spotting spotting and ultrasound signs of partial detachment of the chorion after the 5th week of pregnancy, small doses of estrogen should be used.

In the II and III trimesters of pregnancy, tocolytic therapy is performed, including:

-conducting infusion therapy 25% magnesium sulfate on the operating table during surgery, followed by continuation in the postoperative period;

-at the end of infusion magnesia therapy, the use of tablet forms r 2- adrenomimetics in a daily dose of 3 mg (hexoprenaline) in combination with blockers calcium channels;

-when stopping the symptoms of a threatened abortion, the use of tablet forms r 2- adrenomimetics within 21-30 days;

-with the development of preterm labor in the early postoperative period, prevention of respiratory distress syndrome in newborns with glucocorticoid drugs is indicated;

-physical rest, observance of the "bed rest" mode;

-p application 2- adrenomimetics and progestogens according to the scheme:

o utrozhestan 400 mg once, immediately after surgery + infusion tocolytic therapy p 2- adrenomimetics in 6-8 hours;

o on the 1st day, taking utrozhestan every 6 hours + tablet forms p 2- adrenomimetics, in subsequent combination; o 2nd day - every 8 hours; o 3rd day - 300 mg every 8 hours;

additional corrective agents for the threat of abortion - antispasmodic and sedative drugs (according to the scheme, as in the first trimester of pregnancy);

5.The method of choice of delivery in the early postoperative period is the management of childbirth through the natural birth canal.

6.Pregnant women after appendectomy in order to prevent the development of fetoplacental insufficiency are shown to be treated with actovegin 200 mg 3 times a day, in combination with chimes or trental 100 mg 3 times a day for three weeks.

BIBLIOGRAPHY

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2.Grekov I.I. About appendicitis and pregnancy. In the book of I.I. Grekov. Selected Works. L.-1952 - S. 187.

.Dekhtyar E.G. Acute appendicitis in women. M., Medicine, 1971 - S.192.

.Efimov B.I. Appendicitis and pregnancy. Diss… cand. honey. Sciences. - M., 1959.

.Ivanov G.I. Pregnancy and acute appendicitis. Diss...doc.med.sci. M., 1965.

.Korgan I.P. Acute surgical diseases of the abdominal organs in pregnant women. Diss…candidate of medical sciences. M., 1991.

.Kulik I.P., Sedov V.M., Strizheltsky V.V. / Pregnancy and acute appendicitis // Bulletin of Surgery, 1998 T155. - No. 3. - S. 31-33.

8.Kriger D.G., Fedorov A.V., Voskresensky P.K. Acute appendicitis. - M.: Medicine, 2007 - S. 234.

9.Livadny, G.V. The choice of surgical access and method of anesthesia for appendectomy in pregnant women / G.V. Livadny, D.V. Marshalov, A.P. Petrenko, Yu.G. Shapkin / Anesthesia and resuscitation in obstetrics and neonatology: Proceedings of the IV All-Russian Educational Congress. - M., 2011. - S. 63-65.

.Livadny, G.V. Features of the cytokine profile in acute appendicitis in pregnant women depending on the level of intra-abdominal hypertension / G.V. Livadny, D.V. Marshalov, A.P. Petrenko, Yu.G. Shapkin / Anesthesia and resuscitation in obstetrics and neonatology: Proceedings of the IV All-Russian Educational Congress. - M., 2011. - S. 65-66.

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./ Yu.G. Shapkin, G.V. Livadny, D.V. Marshalov, A.P. Petrenko, M.E. Davydov / Mother and Child: Proceedings of the XII All-Russian Scientific Forum. - M., 2011 - S. 236-237.

.Livadny, G.V. The state of regional microhemodynamics in pregnant women with acute appendicitis in conditions of carboxyperitoneum / Yu.G.Shapkin, G.V. Livadny, D.V. Marshalov, A.P. Petrenko, M.E. Davydov / Mother and Child: Proceedings of the XII All-Russian Scientific Forum. - M., 2011 - S. 237-238.

.Livadny, G.V. Surgical tactics in acute appendicitis in pregnant women / Yu.G. Shapkin, D.V. Marshalov, G.V. Livadny, A.P. Petrenko // Annals of Surgery. - 2011. - No. 5. - S. 24-27.

.Livadny, G.V. Influence of the level of intra-abdominal hypertension on the outcomes of appendectomy in pregnant women / Yu.G. Shapkin, D.V. Marshalov, G.V. Livadny, A.P. Petrenko // Basic Research. - 2012. - No. 5. - S. 374-378.

.Livadny, G.V. Forecast of the complicated outcome of appendectomy in pregnant women / Yu.G. Shapkin, D.V. Marshalov, G.V. Livadny, A.P. Petrenko // PhD student. - 2012. - No. 3.1 (52). - S. 140-149.

.Livadny, G.V. Influence of the operation method on the outcomes of appendectomy in pregnant women / Yu.G. Shapkin, I.E. Rogozhina, D.V. Marshalov, G.V. Livadny, A.P. Petrenko // Fundamental research. - 2012. - No. 8 (2). - S. 452-457.

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.Strizhakov A.N., Baev O.R., Cherkezova E.I. Pregnancy and acute appendicitis. - Herald Russian Association obstetricians and gynecologists, 1999 - No. 1. - S. 123-129.

It would be naive to assume that pregnancy protects women from any pathology not related to obstetrics.

Some diseases even occur much more often during this period, since there are many predisposing factors to the appearance of a particular pathology.

Enough is a good example high incidence acute appendicitis during pregnancy, in about 0.3% of cases.

In other words, 3 out of 1000 women have this pathology. In addition, according to statistics, it is the removal of the appendix that is the most common surgical intervention during pregnancy.

The most popular classification this disease morphologically:

• catarrhal.

It is characterized by superficial inflammation of the mucosa of the appendicular process;

• Phlegmonous.

Outwardly, the appendix looks significantly enlarged, edematous, becomes red, on its walls you can see a plaque of fibrin threads;

• Gangrenous.

The appendix has a very dark color, almost black, tissue necrosis occurs;

• Perforated.

The most severe form, because as a result irreversible changes in the tissue of the appendix, its rupture (or perforation) occurs, the contents enter the abdominal cavity and cause widespread peritonitis.

There is also a division of acute appendicitis into two forms: uncomplicated (when there is no rupture) and complicated (with the development of peritonitis).

It must be remembered that the final morphological diagnosis is made by a histologist when examining the removed tissue under a microscope!

Symptoms of appendicitis in pregnant women

There are significant differences in the clinical manifestations of this disease in the first and second half of pregnancy, which is primarily due to the displacement of the abdominal organs by the growing uterus.

Acute appendicitis that occurs before 20 weeks has certain symptoms.

• , vomit.

This sign of appendicitis is present in 90% of women, but the difficulty lies in the fact that it is in the first trimester of pregnancy that most women suffer from toxicosis, which manifests itself with the same signs. For this reason, this symptom is not the leading and fundamental in the diagnosis of this pathology.

In acute appendicitis, a gradual increase in temperature is characteristic, ranging from subfebrile figures (37.5 ° C), in rare cases to severe fever (40 ° C). However, this symptom is also very controversial, because during pregnancy there is an increased production of the hormone progesterone, which has many biological properties.

One of them is the effect on the thermoregulation point in the hypothalamus of the brain and an increase in body temperature.

It is with this that the fact that most pregnant women have a temperature in the range of 37.1-37.5 ° C is connected.

In addition, during the period of bearing a child, the mother's immune response is suppressed. In this regard, the body of a pregnant woman rarely reacts to acute inflammation. high fever. Thus, slight increase temperature is also not a reliable sign of acute appendicitis.

• Pain in the stomach.

Few people know that appendicitis at the very beginning is manifested by pain in the projection of the stomach, only after a couple of hours the pain migrates to the right iliac region. This diagnostic feature is called "Kocher's symptom".

Unfortunately, pain in the epigastric region is very often present in many pregnant women, which is associated with heartburn, dyspeptic symptoms in toxicosis.

• Pain in right iliac region.

Such pain is classically a sign of acute appendicitis. But even here the doctor has a very thorny path to the correct diagnosis. After all, it is known that during pregnancy there is an active growth of the uterus, sprain. And some women with a history of previous operations may even have adhesions that cause a pain symptom in this area.

• Symptom of Obraztsov.

It consists in a pronounced increase in the intensity of pain when the patient, located in a horizontal state, raises his right leg.

• When you press on the abdominal wall, and then with a sharp removal of the hand, the pain increases significantly. This sign indicates local irritation of the peritoneum. In advanced cases, with a belated diagnosis, a woman may have signs of diffuse peritonitis. This usually happens when the appendix ruptures.

Symptoms of acute appendicitis after 20 weeks of gestation:

• Appearance of nausea and vomiting.

This symptom in this period of pregnancy is very informative, since during this period there should no longer be. In rare cases, in some pregnant women, these phenomena are present throughout pregnancy, but this usually indicates a problem with the abdominal organs (ulcer, erosion of the stomach, duodenum, chronic pancreatitis, cholecystitis, etc.);

• An increase in temperature is also not a reliable sign, since the effect on thermoregulation processes extends to the entire pregnancy: from the moment of conception to childbirth;
• A feature of the clinical picture of acute appendicitis after 20 weeks of gestation is the distortion of the pain syndrome.

This mechanism is associated with an increase in the uterus in the abdominal cavity. The growing uterus begins to shift and compress the organs, thereby the appendix begins to be located above the right iliac region.

In this case, the following pattern is observed: the longer the gestational age, the higher the pain will be localized.

For example, at a period of 28-30 weeks, pain can be on the same horizontal line with the navel on the right side, but at a period of 39-40 weeks - almost in the right hypochondrium.

• The tension of the muscles of the anterior abdominal wall is very difficult to assess, as it is overstretched.

What are the diagnostic methods?

Due to the controversial, ambiguous clinical picture, additional research methods are indispensable:

• Blood study.

It is known that inflammatory changes appear in the blood with appendicitis: an increase in the total number of leukocytes, an acceleration of the ESR (erythrocyte sedimentation rate), a shift of the leukocyte formula to the left (the appearance of young, immature forms of neutrophils). But even here diagnostic “scissors” may arise, because some pregnant women are characterized by a physiological increase in leukocytes, as well as an acceleration of ESR.

• Ultrasonography.

With a good expert-class apparatus, inflammation and enlargement of the appendix can be detected. However, during pregnancy, this is extremely difficult to do, since the enlarged uterus occupies a large part of the abdominal cavity and significantly worsens the visualization of other organs.

For this reason, an indirect sign of appendix inflammation is evaluated during ultrasound: the presence of fluid (effusion) in the abdominal cavity.

Presence a large number exudate may indicate an inflammatory process.

• In rare cases with confusing symptoms, a diagnostic laparoscopy can be resorted to in order to correctly determine the cause, and if necessary, perform surgery and remove the inflamed appendix.

What complications can be in acute appendicitis in mother and fetus?

With this disease, inflammation occurs in the appendix. If left untreated, the inflammatory process may spread to the abdominal cavity with peritoneal phenomena up to sepsis (blood poisoning). All these toxic agents, getting into the bloodstream of the mother and fetus, can cause irreversible processes.

Mortality from acute appendicitis and its complications is still high even today, as many people turn to the doctor for help very late. In other words, the complications of this disease are very dangerous for the mother and child, sometimes threatening their lives.

However, even with timely treatment, the risk of the following conditions is dangerous:

• infection of the fetus;
• inflammation of the membranes (chorioamnionitis);
• as a result of an infection;
• toxic damage vital important organs fetus (kidney, liver);
• prenatal rupture of amniotic fluid;
• intrauterine fetal death.

What to do with acute appendicitis during pregnancy?

If you suspect this disease, then you must adhere to the following rules:

• immediately call an ambulance;
• take a horizontal position, you can not do anything. Ask someone to pack your bag for the hospital.
• in no case do not take any painkillers, as they can cause a distortion of the clinical picture.
• the only thing that can be done is an injection "" intramuscularly.
• Do not eat or drink anything until the ambulance arrives.
• necessarily among collected documents must have a passport, policy and your exchange card, as well as all ultrasound protocols.

Features of surgical intervention

The most important question in such a situation for patients is: how will they operate (open access or laparoscopically)? And what about pregnancy?

Up to the 20th week of pregnancy, a woman can be operated on using a laparoscopic technique. However, it is very problematic to do this at a later date, since the large uterus interferes with the full access of the instruments to the appendix.

Thus, in the second half of gestation, it is preferable to use the open method.

The question of pregnancy and its further "fate" must be approached individually:

• If acute appendicitis occurs before 37 weeks, then it is necessary to maintain the pregnancy.
• If an attack of appendicitis appeared later than 37 weeks, then a woman can be delivered by caesarean section.

How to manage the period after the operation?

A woman who has undergone surgery during pregnancy should be observed by a surgeon and a gynecologist.

In the postoperative period it is necessary:

• bed rest on the first day;
• the appointment of tocolytics (drugs that relax the tone of the uterus): "" intravenously drip.
• monitor the condition of the fetus (if necessary, registration of a cardiotocogram, auscultation of the heartbeat with a stethoscope, in very early stages of pregnancy - you need to investigate).
• be careful when prescribing antibacterial drugs. Cephalosporin antibiotics and penicillins are allowed.
• should not be administered after the operation "Cerukal" with nausea and vomiting, as this drug can cause malformations of the neural tube of the fetus in the first trimester.

What to do if appendicitis occurs during childbirth?

It is important to remember that appendicitis is a disease in which delay is very dangerous. Therefore, when a symptom of this disease appears, it is impossible to continue childbirth in a natural way, since during attempts the intra-abdominal pressure rises significantly, and the appendix may rupture.

Therefore, in this situation, it is necessary to urgently deliver the woman by, and then, through the same surgical access, remove the inflamed appendix. The operating team should consist of surgeons and obstetrician-gynecologists. In this case, it is very important to follow the sequence: first, the removal of the child and the suturing of the incision on the uterus, and then the appendectomy. In such a situation, doctors must act quickly and efficiently.

case from practice

A pregnant woman was admitted to the department for a period of 18-19 weeks. The patient complained of pain in the stomach, fever up to 38°C, general malaise, weakness.

On general examination: the uterus was enlarged up to 18 weeks, on palpation the pain was localized in the epigastric region.

At vaginal examination: the cervix is ​​closed, the length of the vaginal part is 3 cm.

An ultrasound was performed: the fetal heartbeat was clear, the rhythm was 140 per minute, the development of the fetus was without pathology. The fluid in the volume of 20 ml was revealed in the abdominal cavity.

In the blood test: the level of leukocytes is almost twice the norm, the ESR is 40 mm/h, the shift of the leukocyte formula.

A surgeon was invited to clarify the diagnosis.

After a joint examination, a presumptive diagnosis was made: acute appendicitis.

It was decided to perform a diagnostic laparoscopy.

During the operation, an appendix with inflammatory changes, edematous, with hyperemia was found.

An appendectomy was performed.

After the operation, pregnancy-preserving drugs were administered, and a short course of antibiotic therapy with Ceftriaxone was performed.

The state of the fetus was observed in dynamics.

On the 7th day the patient was discharged from the department.

The patient subsequently delivered a successful spontaneous delivery. healthy baby for a period of 38-39 weeks without any complications.

Of course, acute appendicitis during pregnancy makes adjustments to the tactics of management, and in some cases even to the method of delivery of the patient.

In addition, a very confusing clinical picture, the absence of reliable symptoms complicate the diagnosis. But delay in this case is even more dangerous. Therefore, when the first signs appear, it is necessary to consult a doctor so that the outcome is favorable for everyone.

Diagnosis is based on clinical manifestations; CT or ultrasound is often done for confirmation.

In the US, acute appendicitis is the most common cause acute pain in the abdomen, in which there is a need for surgical treatment. In the population, the incidence of appendicitis exceeds 5%. It is most often observed in adolescents and during the 3rd decade of life, but can be recorded at any age.

Other disease processes that can occur in the appendix are carcinoid, cancer, villous adenomas, diverticula. The appendix can also be affected in Crohn's disease and ulcerative pancolitis.

Causes of appendicitis

Appendicitis (inflammation of the vermiform appendix of the caecum) is more common in children and adolescents - about 50% of all cases fall before the age of 20 years; however, appendicitis may first occur in the elderly.

In the origin of the disease, the most important are: a violation of the emptying of the process and a bacterial infection (due to blockage foreign body, fecal stone, as well as with anomalies of positions); autoinfection from the intestine (E. coli, streptococcus, enterococcus, staphylococcus, anaerobes, proteus); the introduction into the process of worms - whipworm, pinworms, contributing bacterial infection. Less commonly, the appendix is ​​affected by specific infections - tuberculosis, actinomycosis, spreading from neighboring foci. Streptococci and other bacteria can enter the process rich in lymphatic tissue from distant foci (tonsillitis, etc.), and through the blood.

Pathologically distinguish:

1. acute catarrhal appendicitis with plethora and infiltration of mucosal leukocytes, as well as an inflammatory reaction of lymphatic follicles and submucosal tissue;
2. chronically recurrent appendicitis with formed scar tissue, disfigurement and overgrowth of the appendix;
3. purulent appendicitis with intraparietal abscess formation, necrosis, massive gangrenization and perforation, or the development of acute periappendicitis.

Symptoms and signs of appendicitis

Classical manifestations of acute appendicitis include pain, nausea, vomiting, and anorexia. Additional Features- increasing pain during passive extension in the right hip joint, which is accompanied by stretching of the iliopsoas muscle, as well as pain caused by passive rotation of the flexed thigh inwards (a symptom of the obturator muscle). Low-grade fever is often noted.

Unfortunately, classic manifestations occur with frequency< 50%. Наблюдается вариабельность симптоматики. Боль может не иметь локализованного характера, особенно у детей. Пальпаторная болезненность может иметь разлитой характер и в отдельных случаях отсутствовать; при наличии диареи необходимо заподозрить ретроцекальное расположение аппендикса. В моче могут выявляться эритроциты или лейкоциты. У пожилых и беременных не-редки атипичные проявления; в меньшей степени выражены боль и местная пальпаторная болезненность.

Appendicitis begins with sudden pains in the right iliac region, often at first in the epigastric region (due to reflex spasm of the pylorus) or at the navel. Pain can spread to the perineum, testis, or have the character of colic (appendicular colic-colica appendicularis) from partial closure and violent peristalsis of the process, resembling renal or hepatic colic. Pain can be minor, even with the development of gangrene, especially in children. Nausea, vomiting are observed at the beginning of the disease, but usually persistent; for the most part there is constipation, even with a polyp of gas retention, but in children appendicitis may begin with diarrhea. Fever without initial chills, moderate, accompanied by a slight neutrophilic leukocytosis. At severe course, even gangrene of the process, and with general peritonitis the temperature may remain unincreased when other severe phenomena (adynamia, tachycardia) speak for the progression of the process. The general condition is severe, the face is pale; a typical position in bed on the back with the right leg bent (irritation m. psoas), although some patients can remain on their feet for a long time.

The abdomen is swollen, especially on the right: hypersensitivity skin in the region of the X-XII thoracic segment. Deep constant pressure with one finger in the area of ​​​​the process causes pain, sometimes very strong. Soreness during the rapid removal of the finger (Shchetkin B. Tyumberg's symptom) speaks for the involvement of the peritoneum in the process. Usually there is muscular protection varying degrees in the lower quadrant of the abdomen. Soreness is sometimes detected. It is better when examining through the rectum. Characterized by an increase in pain in the region of the appendix when the patient is positioned on the left side (Sitkovsky's symptom) or when pressure is applied to the left side of the non-going intestine (push with gases).
When the process is located behind the ascending colon, appendicitis can simulate a lesion of the gallbladder with a sharp tension of the flank. There may be pelvic and bladder symptoms when the effusion moves downward or when the process is appropriately located; pains can be left-sided, especially when located from the digging kn closer to the middle write.

In addition to local pain, it is often possible to palpate in the process area both through the abdominal wall and through the rectum, and in women through the vagina, an inflammatory tumor (infiltrate), initially without clear boundaries, and then limited, indicating the formation of a periappendicular abscess.

Course, forms and complications of appendicitis

Superficial inflammation of the appendix may soon end in recovery. However, a deceptive decrease in complaints does not always exclude the progression of the process. The spread of the infiltrate towards the bladder, into the small pelvis, to the kidney or liver accordingly changes the picture of the disease.

Pernapendicular abscess, breaking into the cavity of the peritoneum, gives rise to violent perforated peritonitis; if the abscess breaks into the process, intestine, bladder, vagina, gradual recovery may occur or a subdiaphragmatic abscess, paranephritis, cholangitis and liver abscess, pyemia with jaundice develop. After acute or recurrent appendicitis, cicatricial changes in the process, peritoneal adhesions, often interpreted as chronic appendicitis, may remain.

Chronic appendicitis as a chronic inflammatory process is rarely observed, in particular, an unfilled appendix with a contrast non-mass on radiography is not equivalent to a diagnosis of chronic inflammation.

Diagnosis of appendicitis

• Clinical assessment.
• If necessary, CT scan of the abdomen.
• Ultrasound is an alternative to CT.

In the presence of classical manifestations, diatonic is based on clinical data. And in such cases, delaying surgery due to the use of imaging techniques only increases the risk of perforation and subsequent complications. For atypical or questionable manifestations, imaging should be sought immediately. Contrast-enhanced CT has sufficient accuracy in the diagnosis of appendicitis. Ultrasound with dosed compression is easy to perform and does not carry radiation exposure; however, in some cases, its use is limited by the presence of gases in the intestine, it is also less informative in recognizing non-appendicular causes of pain. The diagnosis of appendicitis remains predominantly clinical. Selective and reasonable use of methods of radiation diagnostics helps to reduce the frequency of unjustified laparotomy.

Laparoscopy is performed for the purpose of diagnosis, as well as therapeutic intervention; this intervention is especially valuable for pain of unknown origin in the lower abdomen in women. A typical laboratory sign is leukocytosis, but this figure can vary significantly; with a normal content of leukocytes in the blood, the presence of appendicitis cannot be excluded.

Appendicitis prognosis

Forecast serious even though apparently easy course, as perforation may occur unexpectedly.

Without surgery and administration of antibiotics (based on observations in remote areas and observations of past years), the death rate is > 50%.

Early surgical intervention has a mortality rate of< 1%, восстановление протекает полно и без осложнений. При наличии осложнений (разрыв с развитием абсцесса или перитонита) и/или у больных пожилого возраста прогноз ухудшается: могут потребоваться повторные оперативные вмешательства, период восстановления затягивается.

Treatment of appendicitis

• Surgical removal of the appendix.
• Intravenous administration of solutions and antibiotics.

Treatment of acute appendicitis involves open or laparoscopic appendectomy; because delay increases frequency deaths, a 15% incidence of unreasonable appendectomy is considered acceptable. As a rule, even a perforated appendix can be removed. In some cases, the location of the appendix is ​​difficult to establish. Contraindication to appendectomy - an inflammatory disease with damage to the caecum. However, in the presence of terminal ileitis and no changes in the caecum, the appendix should be removed.

Appendectomy is preceded by the administration of antibiotics. Assign cephalosporins of the 3rd generation. In appendicitis without perforation, further administration of antibiotics is not indicated. In case of perforation of the appendix, the administration of antibiotics is continued until the temperature and leukocyte count normalize, or a course of a fixed duration is carried out according to the preference of the surgeon. When surgical intervention is not possible, the introduction of antibiotics significantly increases survival, although it does not allow to achieve a cure. If a large inflammatory infiltrate with the involvement of the appendix, it is preferable to resect the entire mass formation with the imposition of an ileostomy. In advanced cases, when the formation of a pericolic abscess is completed, it is drained through a catheter by percutaneous access under ultrasound control or by an open method (followed by a delayed appendectomy).

Key points

• In classical presentations, laparotomy should be preferred, without recourse to additional methods visualization.
• In case of insufficient information content of the data, one should resort to visualization of the process using CT or, especially in children, ultrasound.
• Before surgical treatment, a 3rd generation cephalosporin should be prescribed and, if appendix perforation has occurred, continue its administration after surgery.