Appendicitis in Pregnancy: A Post-Hoc Analysis of an EAST Multicenter Study

Abstract

Objective:

To compare the presentation, management, and outcomes of appendicitis in pregnant and non-pregnant females of childbearing age (18–45 years).

Methods:

This was a post-hoc analysis of a prospectively collected database (January 2017–June 2018) from 28 centers in America. We compared pregnant and non-pregnant females' demographics, clinical presentation, laboratory data, imaging findings, management, and clinical outcomes.

Results:

Of the 3,597 subjects, 1,010 (28%) were of childbearing age, and 41 were pregnant: The mean age of the pregnant subjects was 30 ± 8 years at a median gestational age of 15 (range 10–23) weeks. The two groups had similar demographics and clinical presentation, but there were differences in management and outcomes. For example, in pregnant subjects, abdominal ultrasound scans (US) plus magnetic resonance imaging (MRI) was the most frequently used imaging method (41%) followed by MRI alone (29%), US alone (22%), computed tomography (CT) (5%), and no imaging (2%). Despite similar American Association for the Surgery of Trauma Emergency General Surgery Clinical and Imaging Grade at presentation, pregnant subjects were more likely to be treated with antibiotics alone (15% versus 4%; p = 0.008). Pregnant subjects were less likely to have simple appendicitis and were more likely to have complicated (perforated or gangrenous) appendicitis or a normal appendix. With the exception of index hospital length of stay, there were no significant differences between the groups in clinical outcomes at index hospitalization or at 30 days.

Conclusion:

Almost 1 in 20 women of childbearing age presenting with appendicitis is pregnant. Appendicitis most commonly affects women in early to mid-pregnancy. Compared with non-pregnant women of childbearing age, pregnant women presenting with appendicitis undergo non-operative management more often and are less likely to have simple appendicitis. Compared with non-pregnant patients, they have similar clinical outcomes at both index hospitalization and 30 days after discharge.

Appendicitis is a common cause of acute abdominal pain in the general population [1] and a common non-obstetric emergency in pregnant women [2,3]. Its diagnosis and management in pregnant women differ from that in the general population, as common diagnostic modalities such as computed tomography (CT) scan are not recommended during pregnancy. In pregnant women, diagnosis is based largely on magnetic resonance imaging (MRI), as it has high specificity, negative predictive value, and positive predictive value [4], although the sensitivity is less robust [5]. Also, treatment of appendicitis in pregnant women is more controversial than in non-pregnant patients. For example, the superiority of laparoscopic over open appendectomy reported in other populations has not been demonstrated clearly in pregnant patients [6 –8]. Additionally, apart from the usual surgical appendectomy-related complications, pregnant women are at risk for maternal and fetal peri-operative complications [9,10]. Current recommendations state that the choice should be made after a thorough discussion of the risks and benefits with the patient [11].

Many studies investigating appendicitis in pregnancy utilize retrospectively collected data and thus are susceptible to data loss and biases inherent in the study design. Our aim was to compare the differences in presentation and outcomes of appendicitis in pregnant and non-pregnant women using multicenter prospectively collected data and to describe the current practices of surgeons in the United States.

Patients and Methods

This was a post-hoc analysis of the Eastern Association for the Surgery of Trauma (EAST) multicenter observational study of appendicitis (“MUSTANG”) of prospectively enrolled adults (≥18 years) presenting with suspected or confirmed appendicitis between January 2017 and June 2018. Most participating sites were granted a waiver of informed consent, although some centers did obtain informed consent according to their local institutional review board requirements. For the purposes of this secondary analysis, we included only female patients of childbearing age (18–54 years), pregnant and non-pregnant.

The data collected included demographics (age and Body Mass Index [BMI]); clinical presentation (symptoms, signs, Alvarado score, American Association for the Surgery of Trauma (AAST) Emergency General Surgery (EGS) Score Clinical Grade); laboratory and imaging results (white blood cell count, percent polymorphonuclear cells, imaging technique, AAST EGS Score Imaging Grade); management (initial treatment modality, operative duration, AAST EGS Score Operative Grade); index hospitalization outcomes (pathology findings, AAST EGS Score Pathology Grade, secondary intervention, hospital length of stay [LOS], and Clavien-Dindo complications [12]); and 30-day post-discharge outcomes (emergency department [ED] return, re-admission, and Clavien-Dindo complications). The original data collection tool had separate items for categorization of the AAST EGS Clinical, Imaging, and Operative Grades. If the appendix was considered normal during the operation, it was not assigned an Operative Grade. The AAST EGS Pathology Grade was assigned retrospectively by the coordinating center (University of Miami).

Descriptive analysis was used, and the results are reported as mean ± standard deviation or median (interquartile range) for continuous variables on the basis of parametric or non-parametric distribution. Categorical variables are reported as counts and frequencies. The Student t-test and Wilcoxon signed rank test were used for continuous variables as appropriate. The χ² test and Fisher exact test were used for categorical variables. Statistical analysis was carried out with StataCorp. 2015 (Stata Statistical Software Release 14, StataCorp LP, College Station, TX). All p values <0.05 were considered statistically significant.

Results

Initial presentation and work-up

From the original MUSTANG cohort of 3,597 patients, 2,587 were excluded: 1565 were men, and 1022 were females of non-childbearing age. Of the remaining 1,010 patients, 41 (4%) were pregnant. Table 1 summarizes the information on the demographics, presentation, laboratory data, and imaging differences between the groups. The mean age was 30 ± 8 years, and the median gestational age was 15 (range 10–23) weeks. The BMI was not significantly different in the pregnant and non-pregnant women (27 [23–33] vs. 27 [23–32] kg/m², respectively; p = 0.34). Pregnant and non-pregnant women had similar clinical presentations, with nausea being the most common symptom, followed by migration of pain to the right lower quadrant, vomiting, and anorexia. The duration of symptoms was <24 hours for the majority of patients in both groups and was not significantly different. The mean Alvarado score was 6 ± 2 for both groups, and the most common finding on physical examination was right lower quadrant tenderness, followed by the Rovsing sign and diffuse abdominal tenderness. Based on the AAST EGS Score for Clinical Grade, nearly all women (98% overall) in both groups were in Grade 1–3.

Table 1.

Demographics, Clinical Presentation, Laboratory Data, and Imaging Findings

	All (N = 1,010)	Non-pregnant (N = 969)	Pregnant (N = 41)	p
Age^a	30 ± 8	30 ± 8	29 ± 7	0.34
Body Mass Index^b (range)	27 (23–32)	27 (23–32)	27 (23–33)	0.77
Symptoms and signs (%)
Nausea^c	819 (81)	783 (81)	36 (88)	0.26
Vomiting^c	507 (50)	480 (50)	27 (66)	0.04
Anorexia^c	510 (52)	489 (50)	21 (51)	0.77
Diarrhea^d	188 (19)	184 (19)	4 (10)	0.16
Migration of pain to RLQ^c	763 (76)	733 (76)	30 (73)	0.83
Duration of symptoms <24 h^c	545 (54)	521 (54)	24 (59)	0.54
RLQ tenderness^c	986 (98)	948 (98)	38 (93)	0.03
Diffuse abdominal tenderness^d	140 (14)	134 (14)	6 (15)	0.82
Rovsing sign^c	306 (38)	295 (30)	11 (27)	0.58
Obturator sign^d	110 (15)	108 (11)	2 (5)	0.29
Psoas sign^d	111 (15)	110 (11)	1 (2)	0.11
Alvarado Score^a	6 ± 2	6 ± 2	6 ± 2	1.0
AAST EGS Score Clinical Grade (%)^d				0.10
1,2,3	993 (98)	954 (98)	39 (96)
4	5 (1)	4 (1)	1 (2)
5	8 (1)	7 (1)	1 (2)
White blood cell count (10³/mcL)^a	13.5 ± 4.5	13.5 ± 4.4	14.0 ± 5.6	0.45
% polymorphonuclear cells^b (range)	80 (72–85)	79 (72–85)	82 (76–87)	0.05
Imaging (%)^c				<0.001
CT	820 (81)	818 (84)	2 (5)
MRI	13 (1)	1 (<1)	12 (29)
None	5 (1)	4 (<1)	1 (2)
US and CT	104 (10)	104 (11)	0
US and MRI	19 (2)	2 (<1)	17 (41)
US	49 (5)	40 (4)	9 (22)
AAST EGS Score Imaging Grade (%)^d	(n = 930)	(n = 902)	(n = 28)	0.82
1	689 (68)	669 (74)	20 (71)^e
2	24 (2)	24 (3)	0 (0)
3	132 (13)	127 (14)	5 (18)
4	68 (7)	65 (7)	3 (11)
5	17 (2)	17 (1)	0 (0)

Student t-test.

Wilcoxon signed rank test.

Chi-square test.

Fisher exact test.

Patients who received CT or MRI.

AAST = American Association for the Surgery of Trauma; CT = computed tomography; ED = emergency department; EGS = emergency general surgery; LOS = length of stay; MRI = magnetic resonance imaging; RLQ = right lower quadrant; US = ultrasound scan.

Significant differences were noted in the imaging method chosen for the pregnant and non-pregnant women. Pregnant women were more likely to undergo imaging with a minimal radiation burden, as 17 (41%) had US and MRI compared with 2 (<1%) of non-pregnant women, followed by MRI alone (12 [29%] versus 1 [<1%], respectively) and US alone (9 [22%] versus 40 [4%], respectively). There were 2 pregnant women (5%) who underwent CT alone, compared with 814 non-pregnant women (84%), and very few women in either group had no imaging work-up (1 pregnant woman [1%] versus 4 non-pregnant women [<1%]). The AAST EGS Score for Imaging Grade showed that in both groups, grade 1 was the most common with 20 pregnant women (71%) and 669 non-pregnant women (74%) in this grade, followed by grade 3 (5 [18%] and (127 [14%], respectively), grade 4 (3 [11%] and 65 [7%], respectively), grade 2 (0 and 24 [3%], respectively), and grade 5 (0 and 17 (1%), respectively). No imaging grade was assigned to three pregnant women because of inconclusive imaging (n = 2) and no description of appendiceal inflammation (n = 1). For non-pregnant women, there were 67 patients for whom no Imaging Grade could be assigned: 40 underwent US only and 23 underwent either CT scan alone (n = 16) or CT and US (n = 7). Of the 23 with CT imaging, eight had inconclusive results, five had normal findings, five had inadequate imaging of the appendix, and five had unrelated findings. There were four non-pregnant women having no imaging.

Management and outcomes

The results for the management and outcomes of both groups are presented in Tables 2 and 3. Whereas appendectomy was the most common treatment for both pregnant and non-pregnant women (35 [85%] and 919 [95%], respectively), pregnant women were significantly more likely to be treated with antibiotics alone (6 [15%]) than were non-pregnant women (31 [3%]). For those undergoing operative management or percutaneous drainage, the time to intervention was <24 hours for both most pregnant (33 [94%]) and non-pregnant (895 [95%]) women. The median operative duration was similar (55 minutes [range 37–67 minutes] for pregnant and 53 minutes [range 39–71 minutes] for non-pregnant women).

Table 2.

Management and Outcomes

	All (N = 1,010)	Non-pregnant (N = 969)	Pregnant (N = 41)	p
Initial treatment (%)^a				0.01
Appendectomy	954 (95)	919 (95)	35 (85)
Antibiotics	37 (4)	31 (3)	6 (15)
Percutaneous drainage	18 (1)	18 (2)	0
Other	1 (<1)	1 (<1)	0
Time to Intervention <24 h	928 (95)	895 (95)	33 (94)	0.75
Operative duration (min) (range)^b	53 (39–71)	53 (39–71)	55 (37–67)	0.90
AAST EGS Score Operative Grade (%)^a	(n = 915)	(n = 883)	(n = 32)	0.001
1	769 (76)	748 (81)	21 (60)
2	38 (4)	34 (4)	4 (11)
3	54 (5)	53 (6)	1 (3)
4	34 (3)	28 (3)	6 (17)
5	20 (2)	20 (2)	0
Pathology Findings (%)^a				0.005
Acute appendicitis	774 (81)	753 (78)	21 (60)
Gangrenous appendicitis	45 (5)	40 (4)	5 (14)
Perforated appendicitis	74 (8)	70 (7)	4 (11)
Normal appendix	36 (4)	33 (3)	3 (9)
Other	21 (2)	19 (2)	2 (6)

Index hospitalization outcomes
Secondary intervention (%)^a	15 (2)	15 (2)	0 (0)	1.0
Hospital LOS^b (range)	1 (1–2)	1 (1–2)	2 (1–3)	<0.001
Clavien-Dindo complications (%)^a	49 (5)	47 (5)	2 (5)	1.0

30-day outcomes	All (N = 966)	Non-Pregnant (N = 828)	Pregnant (N = 34)
ED return (%)^a	111 (13)	109 (13)	2 (6)	0.30
Re-admission (%)^a	34 (4)	33 (4)	1 (3)	1.0
Clavien-Dindo complications (%)^a	54 (6)	53 (6)	1 (3)	0.72

Fisher exact test.

Wilcoxon signed rank test.

AAST = American Association for the Surgery of Trauma; ED = emergency department; EGS = emergency general surgery; LOS = length of stay.

Table 3.

Index Hospitalization and 30-Day Outcome According to Management

Index hospitalization outcomes
Non-interventional management
	All (N = 37)	Non-pregnant (N = 31)	Pregnant (N = 6)	p
Secondary Intervention (%)^a	6 (<1)	6 (<1)	0 (0)	0.31
Hospital LOS (IQR)^b	3 (2–4)	2 (1–4)	3 (2–5)	0.32
Clavien-Dindo complications (%)^a	4 (<1)	4 (<1)	0 (0)	0.48

Interventional management
	All (N = 973)	Non-pregnant (N = 938)	Pregnant (N = 35)	p
Secondary Intervention (%)^a	9 (1)	9 (1)	0	0.72
Hospital LOS (IQR)^b	1 (1–2)	1 (1–2)	1 (1–3)	0.003
Clavien-Dindo complications (%)^a	45 (5)	43 (5)	2 (6)	0.49

30-Day outcomes
Non-interventional management
	All (N = 28)	Non-pregnant (N = 23)	Pregnant (N = 5)	p
ED return (%)^a	8 (29)	8 (35)	0	0.16
Re-admission (%)^a	4 (14)	4 (17)	0	0.43
Clavien-Dindo complications (%)^a	3 (11)	3 (13)	0	0.54

Interventional management
	All (N = 834)	Non-pregnant (N = 805)	Pregnant (N = 29)	p
ED return (%)^c	103 (12)	101 (13)	2 (7)	0.28
Re-admission (%)^a	30 (4)	29 (4)	1 (3)	0.72
Clavien-Dindo complications (%)^c	51 (6)	50 (6)	1 (3)	0.46

Fisher exact test.

Wilcoxon signed Rank test.

Chi-square test.

AAST = American Association for the Surgery of Trauma; ED = emergency department; EGS = emergency general surgery; IQR = Interquartile range; LOS = length of stay.

There were significant differences noted between the groups for the AAST EGS Score for Operative Grade. Three pregnant women were not assigned an Operative Grade because of an intra-operative finding of a normal appendix. Of note, two were subsequently assigned grade 1 in the Pathologic subscale. In non-pregnant women, 36 were not assigned an Operative Grade: 31 had a normal appendix; three had findings unrelated to appendicitis; in one subject, the appendix could not be identified; and one subject had missing data. According to the pathology reports, 21 pregnant women (60%) and 753 non-pregnant women (81%) had acute appendicitis (Grade 1), five pregnant women (14%) and 40 non-pregnant women (4%) had gangrenous appendicitis (Grade 2), and four pregnant (11%) and 70 non-pregnant (6%) women had perforated appendicitis (Grades 3, 4, and 5). Of note, there were three pregnant women (9%) who had a normal appendix on pathologic review compared with 33 non-pregnant women (3%). Two pregnant women (6%) and 20 non-pregnant women (2%) had findings other than appendicitis, such as tumors, lymphoid hyperplasia, or pelvic inflammatory disease. Additionally, there were three non-pregnant women with missing data on pathology report.

The duration of post-operative antibiotic treatment was similar for the two groups. Non-pregnant women received 6 (range 4–9]) days of post-operative antibiotics, and pregnant women received 6 (range 4–10) days. The duration of antibiotic treatment in those women who underwent non-operative management was not recorded on the original data collection sheet. The antibiotic regimen used in both groups and based on interventional or non-interventional management is presented in Table 4.

Table 4.

Antibiotic Use in Pregnant and Non-Pregnant Women

Non-interventional management^a
Antibiotic used (%)	All (N = 37)	Non-pregnant (N = 31)	Pregnant (N = 6)
Penicillin	0	0	0
1^st generation cephalosporin	0	0	0
2^nd generation cephalosporin	5 (14)	5 (16)	0
3^rd generation cephalosporin	5 (14)	4 (13)	1 (17)
4^th generation cephalosporin	0	0	0
Beta-lactam	1 (3)	1 (3)	0
Fluoroquinolone	9 (24)	8 (26)	1 (17)
Vancomycin	0	0	0
Clindamycin	1 (3)	0	1 (17)
Macrolide	0	0	0
Aminoglycoside	1 (3)	0	1 (17)
Tetracycline	1 (3)	1 (3)	0
Sulfonamide	1 (3)	0	1 (17)
Piperacillin/tazobactam	19 (51)	15 (48)	4 (66)
Amoxicillin/clavulanic acid	16 (43)	14 (45)	2 (33)
Ampicillin/sulbactam	3 (8)	3 (10)	0
Metronidazole	15 (41)	13 (42)	2 (33)
Other	1 (3)	1 (3)	0

Interventional management^b
Antibiotic used (%)	All (N = 973)	Non-pregnant (N = 938)	Pregnant (N = 35)
Penicillin	5 (<1)	2 (<1)	3 (1)
1^st generation cephalosporin	75 (8)	73 (8)	2 (1)
2^nd generation cephalosporin	299 (31)	287 (31)	12 (3)
3^rd generation cephalosporin	227 (23)	219 (23)	8 (23)
4^th generation cephalosporin	6 (<1)	6 (<1)	0
Beta-lactam	134 (14)	131 (14)	3 (1)
Fluoroquinolone	75 (8)	74 (8)	1 (<1)
Vancomycin	8 (1)	7 (1)	1 (<1)
Clindamycin	10 (1)	9 (1)	1 (<1)
Macrolide	1 (<1)	0	1 (<1)
Aminoglycoside	2 (<1)	2 (<1)	0
Tetracycline	3 (<1)	0	3 (1)
Sulfonamide	0	0	0
Piperacillin/tazobactam	295 (30)	284 (30)	11 (31)
Amoxicillin/clavulanic acid	1 (<1)	1 (<1)	0
Ampicillin/sulbactam	29 (3)	26 (3)	3 (1)
Metronidazole	351 (36)	343 (37)	8 (23)
Other	20 (2)	20 (2)	0

Antibiotics only.

Appendectomy and percutaneous drainage.

During the index hospitalization, there was a significant difference in hospital LOS, with pregnant women staying 2 (range 1–3) days compared with 1 (range 1–2) day for non-pregnant women (p < 0.001). After separating the groups into those who received operative management and those who received antibiotics only, this difference was preserved only for the interventional group (p = 0.003), as shown in Table 3 above. There were no differences for secondary interventions or Clavien-Dindo complications. Similarly, there were no significant differences for 30-day post-discharge outcomes between pregnant and non-pregnant women: 2 pregnant (6%) and 109 non-pregnant (13%) women returned to the ED; and of those, 1 (3%) and 33 (4%), respectively, were re-admitted. Additionally, 1 pregnant (3%) and 53 non-pregnant (6%) women developed Clavien-Dindo complications by 30 days.

Discussion

Our findings show that pregnant women have higher rates of complicated appendicitis, despite similar clinical presentations and durations of symptoms. Additionally, pregnant women had higher rates of negative appendectomy, a finding supported by Won et al.², which represents an unnecessary risk for the pregnant woman and fetus. Pregnant patients were more likely to receive non-operative management than appendectomy. Not surprisingly, pregnant women are more likely to undergo imaging with a minimal radiation burden, such as US and MRI, which is consistent with recent studies and current guidelines [11]. It is unclear why two pregnant patients (at 13 and 23 weeks of gestation) underwent CT scanning, which is not recommended in these patients.

Previous investigators have examined appendicitis in the pregnant population. A retrospective analysis of 4,295 pregnant patients conducted on a national level in Taiwan between 2005 and 2010 demonstrated that, compared with pregnant patients without appendicitis, pregnant women with appendicitis were more likely to have complications such as pre-term labor, abortion, and cesarean section [6]. Pregnant women treated with antibiotics alone had a higher incidence of miscarriage than those women who underwent operative treatment. Furthermore, there was no difference between laparoscopic and open appendectomy for the aforementioned maternity outcomes, but pregnant women who underwent open appendectomy had a significantly longer hospital LOS. That study is limited by its retrospective nature, although the authors mention that their database has been used extensively and thus can be recognized as reliable. Another limitation of that study is that it was conducted in Taiwan, and its external validity might be limited, as practices among countries may differ significantly. For example, of the 781 pregnant women who underwent appendectomy, 653 had open appendectomy, and only 128 had laparoscopic appendectomy, which reflects differences in therapeutic approaches, as surgeons in the United States tend to prefer laparoscopic appendectomy to an open approach [13]. In our study, all 35 pregnant women who underwent surgery had laparoscopic appendectomy.

We report that pregnant women had a longer LOS at index hospitalization, but there were no differences in Clavien-Dindo complications nor secondary interventions between pregnant and non-pregnant women. Similarly, no differences were noted in 30-day outcomes in the two groups. Similarly, in a retrospective study, Sergev et al. compared 92 pregnant women with 494 non-pregnant women and reported that pregnant women were more likely to have a prolonged hospitalization, but there were no significant differences in operative duration or post-operative complications [14]. However, they found no differences in pathology reports, whereas we showed that pregnant women had higher rates of both complicated appendicitis and normal appendix.

This study has limitations that need to be mentioned. First, there were only 41 pregnant women in the cohort, a small number from which to draw strong conclusions. Although this study was conducted in a multi-center fashion, with 28 participating centers in the United States, 41 patients is a small number to use for describing current practices in pregnant women presenting with appendicitis.

Second, because the original study was not designed exclusively for pregnant patients, we cannot know why two women underwent CT scanning, whether the decision about management was made on the basis of gestation and specifically for non-operative management; if it was made by the pregnant patient, the treating physician, or both; and why three pregnant women who underwent appendectomy were treated with tetracyclines. Furthermore, the assignment of the AAST EGS Scores for appendicitis was performed by the investigators at each enrollment site, with the exception of the Pathology Grade, which was assigned by the investigators at the coordinating center (University of Miami). Despite a standardized definition and the principal investigator's overview of data entries for each individual record, there exists a possibility of inter-rater variability in grade assignment that cannot be estimated.

Another limitation is that this study analyzed data collected exclusively in the United States, thus reflecting only this country's practices. The results of this descriptive study might not represent current clinical practices in other countries. Finally, we have no information regarding the effects of each treatment on the fetus, as the original data collection tool did not specifically collect outcomes for pregnant women and outcomes not pertinent to appendicitis. Further studies with a targeted population of pregnant women could help illustrate the disease presentation in this cohort and identify the best treatment modalities and their outcomes in these women. Despite its limitations, this study illustrates the most current practices for appendicitis in pregnant women in the United States and contributes to the scant existing literature for appendicitis in these patients.

Conclusion

Almost one in 20 women of childbearing age presenting with appendicitis is pregnant. Appendicitis seems to affect women in early- to mid-pregnancy. Pregnant women presenting with appendicitis undergo non-operative management more often than do non-pregnant women and appear to have a more complicated presentation of the disease. Negative appendectomy rates are three times higher in pregnant patients. However, compared with non-pregnant patients, they have similar clinical outcomes at both index hospitalization and 30 days after discharge.

Footnotes

Acknowledgments

We are grateful to the following colleagues for their contribution to data collection in the original EAST Appendicitis Study. Without their work, this article would not have been possible (alphabetically by center):

Baystate Medical Center: Reginald Alouidor and Kailyn Kwong Hing

Beaumont Hospital: Victoria Sharp and Thomas Serena

Boston Medical Center: George Kasotakis and Sean Perez

Carilion Clinic: Stacie L. Allmond and Bruce Long

Cooper University Hospital: Nadine Barth and Janika San Roman

Denver Health: Ryan A. Lawless and Alexis L. Cralley

Emory University: Rondi Gelbard and Crystal Szczepanski

Essentia Health: Steven Eyer and Kaitlyn Proulx

Geisinger Medical Center: Jeffrey Wild and Katelyn A. Young

Inova Fairfax: Erik J. Teicher and Elena Lita

Intermountain Medical Center: David Morris and Laura Juarez

Loma Linda University: Richard D. Catalano and David Turay

Marshfield Clinic: Daniel C. Cullinane and Jennifer C. Roberts

Massachusetts General Hospital: Haytham M.A. Kaafarani and Ahmed I. Eid

Mayo Clinic: Mohamed Ray-Zack and Tala Kana'an

Medical City Plano: Victor Portillo and Morgan Collom

Medical College of Wisconsin: Chris Dodgion and Savo Bou Zein Eddine

North Shore Medical Center: Maryam B. Tabrizi and Ahmed Elsayed Mohammed Elsharkawy

Ryder Trauma Center: D. Dante Yeh and Georgia Vasileiou

Ohio State University Wexner Medical Center: David C. Evans and Daniel E. Vazquez

St. Vincent Hospital Indianapolis: Jonathan Saxe and Lewis Jacobson

Oregon Health Sciences University: Brandon Behrens and Martin Schreiber

University of Arizona, Tucson: Bellal Joseph and Muhammad Zeeshan

University of California, Irvine: Jeffry Nahmias and Beatrice Sun

University of Florida, Jacksonville: Marie Crandall and Jennifer Mull

University of Maryland: Jason D. Pasley and Lindsay O'Meara

University of Southern California: Ali Fuat Kann Gok and Jocelyn To

Walter Reed National Military Medical Center: Carlos Rodriguez and Matthew Bradley

Author Disclosure Statement

D. Dante Yeh is receiving royalties from Shire/Takeda and obtained a research grant for a trial. The other authors have no conflicts of interest to declare.

References

Ferris

, Quan

, Kaplan

, et al. The global incidence of appendicitis: A systematic review of population-based studies. Ann Surg, 2017; 286:237–241.

Won

, Friedlander

, Lee

. Management and outcomes of appendectomy during pregnancy. Am Surg, 2017; 83:1103–1107.

Andersen

, Nielsen

. Appendicitis in pregnancy: Diagnosis, management and complications. Acta Obstet Gynecol Scand, 1999; 78:758–762.

Burke

LMB

, Bashir

, Miller

, et al. Magnetic resonance imaging of acute appendicitis in pregnancy: A 5-year multiinstitutional study. Am J Obstet Gynecol, 2015; 213:693.e1–693.e6.

Aguilera

, Gilchrist

, Farkas

. Accuracy of MRI in diagnosing appendicitis during pregnancy. Am Surg, 2018; 84:1326–1328.

Cheng

H-T

, Wang

, Lo

, et al. Laparoscopic appendectomy versus open appendectomy in pregnancy: A population-based analysis of maternal outcome. Surg Endosc, 2015; 21:1394–1399.

Wilasrusmee

, Sukrat

, McEvoy

, et al. Systematic review and meta-analysis of safety of laparoscopic versus open appendicectomy for suspected appendicitis in pregnancy. Br J Surg, 2012; 99:1470–1478.

Cox

, Huntington

, Blair

, et al. Laparoscopic appendectomy and cholecystectomy versus open: A study in 1999 pregnant patients. Surg Endosc, 2016; 30:593–602.

Abbasi

, Patenaude

, Abenhaim

. Management and outcomes of acute appendicitis in pregnancy: Population-based study of over 7000 cases. Br J Obstet Gynecol, 2014; 121:1509–1514.

10.

Theilen

, Mellnick

, Shanks

, et al. Acute appendicitis in pregnancy: Predictive clinical factors and pregnancy outcomes. Am J Perinatol, 2017; 34:523–528.

11.

Di Saverio

, Birindelli

, Kelly

, et al. WSES Jerusalem guidelines for diagnosis and treatment of acute appendicitis. World J Emerg Surg, 2016; 11:34.

12.

Dindo

, Demartines

, Clavien

P-A

. Classification of surgical complications: A new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg, 2004; 240:205–213.

13.

Yeh

, Sakran

, Rattan

, et al. A survey of the practice and attitudes of surgeons regarding the treatment of appendicitis. Am J Surg, 2019; 218:106–112.

14.

Segev

, Segev

, Rayman

, et al. Acute appendicitis during pregnancy: Different from the nonpregnant state?. World J Surg, 2017; 41:75–81.