Statistical analysis
The study data were analyzed statistically using the IBM SPSS Statistics version 21.0 software (IBM Corp., Armonk, NY). Descriptive statistics (mean, median, standard deviation, minimum, maximum, number, percentage) were used to depict data. The Chi-square Test and The Mann-Whitney U test were used to compare the two groups (since parametric assumptions were not met). The Kruskal Wallis Test was used to compare the three groups (since parametric assumptions were not met). Comparisons yielding p-values of <0.05 were defined to be statistically significant.
Results
A total of 11513 singleton pregnant women were evaluated, 6531 women delivered vaginally, and 4982 women delivered by CS. Thirty-two patients underwent appendectomy: 12 women during their pregnancies and 20 women during puerperium. The mean age of pregnant women who had appendectomy for AA was 31.5 ± 5.5 years. Five of these 12 pregnant women were in their first pregnancy. Two pregnant women have been submitted to appendectomy in the first trimester, 6 in the second trimester, and 4 in the last trimester of pregnancy. One pregnancy resulted in a stillbirth at the 22nd week of gestation, with signs of perforated AA and intra-abdominal sepsis. Other pregnancies treated by appendectomy resulted in live births, but two women in their second trimester and four women in their last trimester had a preterm delivery (Table 1). The mean week of gestation of 12 pregnant women at the time of appendectomy was 24.7 ± 9.5 weeks; with mean gestational age at birth was 35.5 ± 5.2 weeks, according to trimesters: 39 ± 1.4 weeks, 33.6 ± 7.0 weeks, and 36.7 ± 1.5 weeks, respectively. There was no statistical difference between the groups (p = 0.421). The mean birth weight was 2928 ± 871 grams, according to trimesters: 3667 ± 300 grams, 2625 ± 1083 grams, 3015 ± 491 grams, respectively. There was no statistical difference between the groups (p = 0.217). It was observed that five pregnant women had a vaginal birth, and seven pregnant women had CS. The mean gestational age at live birth of the healthy pregnant cohort was 38.4 ± 4.2 weeks, and the mean birth weight was 3091 ± 1458 grams. The difference between healthy pregnants and pregnants with appendectomy for the birth week and birth weight could not reach a statistical value (p>0.05 and p>0.05).
All of 20 patients operated by appendectomy in the puerperium had a singleton pregnancy which had resulted in a live birth. The average age of women who had undergone appendectomy for AA in the puerperium was 29.7 ± 5.8 years. Twelve women on 20 were multiparous. Seven puerperal women had a vaginal birth, and 13 puerperal women had CS. The mean postpartum appendectomy week was 3 ± 2.05. Eight women (40% of all puerperal appendectomies) have been operated on during the first postpartum week. Two of them had a vaginal birth, and six of them had CS. Two cases (25% of women who had undergone appendectomy during the first week) operated on during the first postpartum week were diagnosed with perforated AA. The mean gestational age at birth was 37.1 ± 5.7 weeks and the mean birth weight was 3296 ± 592 grams. There was no difference between healthy puerperal women and puerperal women with appendectomy for the birth week and birth weight (p>0.05 and p>0.05).
The majority of women who had an appendectomy for AA during pregnancy had an urgent CS (Table 2). Also, most women who had an appendectomy during puerperium had a CS (58% vs. 65%, p = 0.706). For comparison, the CS rate of the entire healthy pregnant population was 43.27%.
Discussion
This is the first study analyzing specifically the relationship between the timing of appendectomy and the type of delivery. It was observed that pregnants who underwent appendectomy during pregnancy and, especially in the second trimester, gave preterm birth and with smaller newborns. On the other hand, when AA occurs in the third trimester, prematurity is significantly reduced. One of the causes could be that during the second trimester, the woman reduces the caloric intake due to maternal illness with inflammation and stress from the operation due to AA. Only one operated patient in pregnancy developed sepsis after appendiceal perforation due to the inability to diagnose, resulting in the death of the fetus at the 22nd week of gestation, while six women had preterm delivery. The first important finding is that most women who had undergone appendectomy (in both groups) delivered by CS. In our series of pregnants, two pregnant women underwent concurrent appendectomy with urgent CS in the 36th gestational week and one pregnant woman underwent an appendectomy in her 34thgestational week and then had an urgent CS after two weeks later due to fetal distress related to persistent infection.
About 40% of postpartum women had undergone appendectomy within the first postpartum week, and 2/8 had perforative AA. Clinicians have conjectured that puerperal women may associate their complaints (such as localized pain) to the recent CS and use of analgesics; therefore, it could be the cause of the delay of diagnosis and treatment.
The second interesting finding is that puerperal appendectomy was mainly after a CS (65%), with most appendectomies during the first week after CS (75%). Concerning this evidence, any foci of infection that may develop due to a lack of compliance with asepsis during CS (open abdominal operation) and lack of preoperative antibiotic therapy or invasion of the amnion fluid may lead to AA.18 It is difficult to conclude the cause of AA. It could be AA (which starts from the appendiceal mucosa) or periappendicitis when a surrounding infection spreads to the appendix.19 Another potential cause of post-CS AA could be the change in the location of appendix during intraoperative uterine manipulation. If the appendix is partly fixed, manipulation can cause kinking producing partial or complete obstruction of the appendiceal lumen finally resulting in AA.
The first limitation is a relatively small number of cases for firm conclusions. There should be worldwide multicentric studies with more patients that could deliver firm conclusions. Although 11513 pregnancies were scanned in the last five years from hospital records, the number of appendectomies performed was only 32 overall. Another limitation could be the indications for CS which vary widely around the globe. Also, specific indications for CS and their relationship to postpartum appendicitis/appendectomy in multicentric studies could deliver firm conclusions.
In conclusion, Appendectomy for nonperforated AA in pregnancy does not increase severe fetal morbidities, except the possibility of urgent CS with all its consequences. However, considering the number of surgeries, authors’ opinion is that the protective effect of pregnancy on AA immediately ends in the early postpartum period. Therefore, it should be kept in mind that the cause of acute abdomen in the first six postpartum weeks, especially during the first week, could be AA. The incidence of AA is additionally increased in women delivered by CS, indicating that appendectomy should be made early in such cases.
Acknowledgments: We thank the general surgery team.
Disclosure statement: The authors declare that they have no conflict of interest. The authors alone are responsible for the content and writing of the article.
Author contributions: BŞ contributed to data collection and analysis, manuscript writing. AT contributed to study design, manuscript writing and revision. GA contributed to manuscript writing and revision. All authors approved the final version of the article for submission.
Funding: No funding.
Details of ethics approval: All procedures performed in this study were in accordance to the institutional ethical standards and the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. Approval was granted by the Ethics Committee of University Amasya (Date: 2020/9 / No: 98). Informed consent was obtained from the participants.