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Ruptured Appendicitis in the Parturient
Abstract Number: RF6AI-124
Abstract Type: Case Report Case Series
Acute appendicitis occurs in approximately 1/500 pregnancies, making it the most common non-obstetric surgical problem encountered in pregnancy. Of these patients, 20% will develop peritonitis, which increases their risk of preterm delivery to 34.5%. This is a report of a 32 year old parturient with successful VBAC whose pregnancy was complicated by antepartum surgical treatment for ruptured appendicitis at 31 weeks gestation. In addition to purulent peritonitis, her clinical course was significant for metabolic acidosis (pH 7.02) consistent with a state of starvation in the setting of acute abdomen.
At 31 weeks gestation patient presented to an outside hospital with abdominal pain and was discharged with diagnosis of gastritis. Three days later she returned with worsening symptoms. Upon diagnosis of appendicitis she was transferred to our tertiary medical center. Assessment was concerning for ruptured appendicitis. Symptoms included chills, nausea, vomiting, and abdominal pain due to irregular contractions. History significant for poorly controlled reflux, tobacco use, and palpitations with no formal diagnosis due to lack of insurance. Obstetric history included two spontaneous vaginal deliveries and one cesarean delivery for prolapsed umbilical cord. Physical exam notable for a Mallampati III. Pulse 92, blood pressure 127/72, afebrile. Initially, the general surgery team planned for non-operative management with intravenous antibiotics. After discussion with the obstetric team, it was later agreed that she should go to the operating room for an open appendectomy with continuous monitoring of fetal heart rate and uterine activity. Obstetrics and NICU were on standby in case fetal status was non-reassuring and a stat cesarean section was indicated. Anesthetic plan included a rapid sequence induction with 200 mg propofol (titrated), 250 mcg fentanyl, and 100 mg succinylcholine. Video laryngoscopy was performed with a D blade, arytenoids visualized. 6.5 mm endotracheal tube placed. Maintained with sevoflurane (0.5 MAC) with 50:50 nitrous oxide and oxygen, and rocuronium; BIS was 36-42. Following intubation, ETCO2 21 mmHg; tidal volume 490 mL, respiratory rate 14. Radial arterial line placed for lab draws. Initial intraoperative labs significant for pH 7.02, base deficit 20.8, consistent with metabolic acidosis. During the 2.5 hour procedure, urine output 30 mL, EBL minimal, crystalloid 2.8 L. Surgical findings consistent with ruptured appendicitis, accounting for sepsis. The patient was transferred to the SICU intubated and sedated. Post operative labs significant for lactic acid of 0.7 mmol/L and beta hydroxybutyric acid 4.6 mmol/L revealing a mixed acidosis secondary to a combination of sepsis and starvation ketoacidosis. Transferred out of SICU POD# 1, discharged from hospital POD# 12; returned six days later in preterm labor at 33 weeks 5 days for uncomplicated spontaneous vaginal delivery of healthy neonate.