Appendicitis is the most common cause of non-obstetrical operation. Its incidence is approximately one per 1500 patients, which is similar to the one in the non-pregnant population.
The diagnosis of acute appendicitis is more challenging during pregnancy . Up to 23% of appendectomies performed during pregnancy show normal appendices (versus 18% in non-pregnant patients, p < 0.05) . This observation is mainly related to underlying physiological and anatomical changes leading to atypical pain, both in intensity and location [3–6]. In addition, a physiological leucocytosis is present during pregnancy and urine analysis often shows the presence of red blood cells or positive cultures, which can be misleading .
Multiple investigations and/or false diagnoses can delay surgery and increase the risk of appendix perforation, which is associated with higher rates of maternal morbidity (52% versus 17% non-perforated appendicitis) and foetal mortality (24% versus 7%) . Conversely, performing an appendectomy for a false diagnosis of appendicitis is associated to at least similar rates of foetal loss and preterm delivery than regular appendectomies. Such complications may be related to the surgery itself and/or to the misdiagnosed disease [2, 7, 8].
Once the decision to operate has been made, the operative technique, open or laparoscopic surgery, must be decided. The laparoscopy is most often recommended during the first two trimesters, as alternative diagnoses can be evaluated in case of normal appendix [9–14]. During the third trimester, guidelines are less clear. Many speak for the open approach, especially after the 26th-28th week of amenorrhea, but an increasing number of publications now report series of successful laparoscopic appendectomies during the third trimester [7, 9, 10, 12–14].
The present case illustrates the risks and limitations of the laparoscopic approach during the third trimester of pregnancy and an algorithm based on the current literature is proposed for the management of appendicitis during pregnancy.