Gebelerde Akut Apandisit
Özet
Gebelerde akut apandisit, obstetrik olmayan en yaygın cerrahi acil durum olup, gebelikteki fizyolojik ve anatomik değişiklikler nedeniyle tanı ve tedavi açısından ciddi zorluklar barındırır. İkinci trimesterde insidansı daha yüksek olan bu hastalıkta, büyüyen uterusun apendiksi yukarı ve yana itmesi ağrının klasik sağ alt kadran yerine farklı lokalizasyonlarda hissedilmesine yol açabilir. Gebelikteki fizyolojik lökositoz tanısal doğruluğu azaltırken, teşhiste yüksek sensitivite ve spesifiteye sahip ultrasonografi (USG) ve iyonize radyasyon riski taşımayan manyetik rezonans görüntüleme (MRG) tercih edilir. Akut apandisitin kesin tedavisi cerrahi müdahaledir; konservatif tedavi yöntemleri daha yüksek sepsis ve peritonit riski taşır. Tanı ve tedavide yaşanacak gecikmeler perforasyon, peritonit ve sepsis riskini artırarak erken doğum ile komplike vakalarda %20'ye varan fetal ölümlere yol açabilir. Cerrahi yaklaşımda açık veya laparoskopik appendektomi uygulanabilmektedir. Laparoskopik yöntem hastanede kalış süresi ve yara yeri enfeksiyonu açısından avantajlar sağlasa da, yüksek fetal risk ve mortalite ilişkilendirmeleri nedeniyle benimsenmesi hala tartışmalıdır; bu yüzden gebelik sürecinde kadın doğum uzmanının yakın takibi büyük önem taşır.
Acute appendicitis in pregnant women is the most common non-obstetric surgical emergency, presenting serious challenges in diagnosis and treatment due to physiological and anatomical alterations during pregnancy. In this disease, which has a higher incidence in the second trimester, the growing uterus shifts the appendix upward and laterally, causing pain to be felt in different locations rather than the classic right lower quadrant. While physiological leukocytosis in pregnancy reduces diagnostic accuracy, ultrasonography (USG), which has high sensitivity and specificity, and magnetic resonance imaging (MRI), which carries no risk of ionizing radiation, are preferred for diagnosis. The definitive treatment for acute appendicitis is surgical intervention, as conservative treatment methods carry a higher risk of sepsis and peritonitis. Delays in diagnosis and treatment increase the risks of perforation, peritonitis, and sepsis, which can lead to preterm labor and fetal mortality reaching up to 20% in complicated cases. Open or laparoscopic appendectomy can be performed as the surgical approach. Although the laparoscopic method offers advantages regarding hospital stay and wound infections, its adoption remains controversial due to associations with high fetal risk and mortality; therefore, close monitoring by an obstetrician during the pregnancy process is of great importance.
Referanslar
Augustin G, Majerovic M. Non-obstetrical acute abdomen during pregnancy. Eur J Obstet Gynecol Reprod Biol. 2007;131(1): 4–12.
Malangoni MA. Gastrointestinal surgery and pregnancy. Gastroenterol Clin North Am. 2003;32(1): 181–200.
Zingone F, Sultan AA, Humes DJ, et al. Risk of acute appendicitis in and around pregnancy: a population-based cohort study from England. Ann Surg. 2015;261: 332–7.
Wilasrusmee C, Sukrat B, McEvoy M, et al. Systematic review and meta-analysis of safety of laparoscopic versus open appendicectomy for suspected appendicitis in pregnancy. Br J Surg. 2012; 99: 1470–8.
Kirshtein B, Perry ZH, Avinoach E, et al. Safety of laparoscopic appendectomy during pregnancy. World J Surg. 2009;33: 475–80.
Walker HG, Al Samaraee A, Mills SJ, et al. Laparoscopic appendicectomy in pregnancy: a systematic review of the published evidence. Int J Surg. 2014;12: 1235–41.
Gilo NB, Amini D, Landy HJ. Appendicitis and cholecystitis in pregnancy. Clin Obstet Gynecol. 2009;52: 586–96.
Pritchard JA, Baldwin RM, Dickey JC. Blood volume changes in pregnancy and the puerperium, II: red blood cell loss and changes in apparent blood volume during and following vaginal delivery, cesarean section, and cesarean section plus total hysterectomy. Am J Obstet Gynecol. 1962; 84: 1271.
Tan EK, Tan EL. Alterations in physiology and anatomy during pregnancy. Best Pract Res Clin Obstet Gynaecol. 2013;27(6): 791–802.
Theilen LH, Mellnick VM, Shanks AL, et al. Acute appendicitis in pregnancy: predictive clinical factors and pregnancy outcomes. Am J Perinatol. 2017;34: 523–8.
Soma-Pillay P, Nelson-Piercy C, Tolppanen H, et al. Physiological changes in pregnancy. Cardiovasc J Afr. 2016;27(2): 89–94.
Hodjati H, Kazerooni T. Location of the appendix in the gravid patient: a re-evaluation of the established concept. Int J Gynaecol Obstet. 2003; 81(3): 245–247.
Ross JT, Matthay MA, Harris HW. Secondary peritonitis: principles of diagnosis and intervention. BMJ. 2018;361: k1407.
Debnath J, George RA, Ravikumar R. Imaging in acute appendicitis: What, when, and why?. Medical Journal Armed Forces India. 2017;73(1): 74-79.
Ramalingam V, LeBedis C, Kelly JR, et al. Evaluation of a sequential multi-modality imaging algorithm for the diagnosis of acute appendicitis in the pregnant female. Emerg Radiol. 2015;22(2): 125-32. doi: 10.1007/s10140-014-1260-y.
Zachariah SK, Fenn M, Jacob K, et al. Management of acute abdomen in pregnancy: current perspectives. International journal of women's health. 2019;11: 119.
Konrad J, Grand D, Lourenco A. MRI: first-line imaging modality for pregnant patients with suspected appendicitis. Abdom Imaging. 2015;40(8): 3359–3364.
Yoo KC, Park JH, Pak KH, et al. Could laparoscopic appendectomy in pregnant women affect obstetric outcomes? A multicenter study. Int J Color Dis. 2016;31: 1475–81.
Cheng HT, Wang YC, Lo HC, et al. Laparoscopic appendectomy versus open appendectomy in pregnancy: a population based analysis of maternal outcome. Surg Endosc. 2015;29: 1394–9.
Peled Y, Hiersch L, Khalpari O, et al. Appendectomy during pregnancy--is pregnancy outcome depending by operation technique? J Matern Fetal Neonatal Med. 2014;27: 365–7.
Jung SJ, Lee DK, Kim JH, et al. Appendicitis during pregnancy: the clinical experience of a secondary hospital. J Korean Soc Coloproctol. 2012;28: 152–9.
Abbasi N, Patenaude V, Abenhaim HA. Management and outcomes of acute appendicitis in pregnancy-population-based study of over 7000 cases. BJOG. 2014;121: 1509–14.
Walsh CA, Tang T, Walsh SR. Laparoscopic versus open appendicectomy in pregnancy: a systematic review. Int J Surg. 2008;6: 339–44.
Frountzas M, Nikolaou C, Stergios K, et al. Is the laparoscopic approach a safe choice for the management of acute appendicitis in pregnant women? A meta-analysis of observational studies. Ann R Coll Surg Engl. 2019;101(4): 235-248. doi: 10.1308/rcsann.2019.0011.
Lee SH, Lee JY, Choi YY, et al. Laparoscopic appendectomy versus open appendectomy for suspected appendicitis during pregnancy: a systematic review and updated meta-analysis. BMC surgery. 2019;19(1): 41. https://doi.org/10.1186/s12893-019-0505-9
