Appendicitis and pregnancy

During pregnancy, increasing in volume womb gradually moved from the small pelvis in a large and, in the end, fills in the abdominal cavity. As a result of this internal abdominal organs (stomach, intestines, liver, pancreas, kidneys, urinary bladder) in more or less crushed. Particularly dramatic changes occur in the internal organs to the end of pregnancy, when the bottom of the uterus reaches the level of the epigastric area.
All kinds of excessive reduction of the capacity of the abdominal cavity whether it comes by a large stretch of the uterus (polyhydramnios, multiple births) or due to the growth of the uterus for a small amount of the abdominal cavity (for example, kyphosis), to an even greater extent, affects the state of the woman's body and contributes to the emergence of certain complications, such as appendicitis, intestinal obstruction, etc.
Bowel mobility allows it to escape from squeeze growing gravid uterus, but at the same time drags him up towards the camera slightly to the left (uterus spins around its axis to the right side abdominal wall). In individuals offset the caecum up can reach a high level, especially when the mobile blind intestine (coecum mobile), vermiform process may move to the edge of the liver (Fig. 69), in some cases vermiform process, rising together with coecum up, you may be behind a pregnant uterus. C. Century Polikarpov at all appendectomia made to them during pregnancy, found a blind gut located considerably higher than usual. P. A. Vinogradov indicates that the cecum, as a rule, is shifted upward, starting from the 5th month of pregnancy and a maximum shift happens at the 7th month of pregnancy, and for 10 months it is omitted. However, the situation of the caecum pregnant woman, being in vertical position, is more consistent, and in the horizontal more volatile. Offset blind gut ordinary localization of the Appendix, and therefore typical of appendicitis point of pain is not detected. Only 21 % of women cecum has no free mobility.


Fig. 69. The offset of the gravid uterus blind gut with vermiform process.

Thus, the peculiarity of the anatomic topographic relations, emerging during pregnancy, especially in the recent period, is generated, mainly, due to the special location of the intestine. As already noted, the entire small intestine is usually one's pressing away gravid uterus backwards. The fundus of the uterus covered with the seal and the transverse colon rectum. Ascending part of the colon is covered by the gravid uterus shifted backwards and right from the middle line. Well seen descending colon, and the sigmoid colon. As a result of rotation of the uterus around its axis, right appendages and right round ligament are shifted to the right and slightly backwards. In this regard, access to the Appendix, naturally, will not always be the same and the surgeon should always remember.
Usually, the body adapts to the new requirements that apply to him pregnancy. In some cases the pregnancy exacerbates existing disease or promotes occurrence of those or other complications. It is observed mainly in cases where the bowel is fixed old growths or abdominal wall, or to the adjacent organs (uterus and its appendages) or it's a fusion between separate loops of intestine.
The presence of adhesions around the vermiform process calls its offset, inflection and a delay in it's content. Under the influence of displacement creates favourable conditions for disorders of blood circulation, as well as for the emergence of stagnation in the abdominal cavity, in particular in the intestine.
Due to hyperemia the mucous membrane of the intestine becomes swollen, distended, vulnerable and accessible for penetration of microbes. However, the worsening of chronic appendicitis occurs not only in the increase of the uterus and its displacement. Pregnancy, according to the remark N. A. Vinogradova, "contributes to the exacerbation of the process due to the presence of hipopotamo dyskinesia of intestines. He set hypomotor dyskinesia radiographically. "Lowering activity of sympathetic nervous system as a result of violations of colloidal equilibrium leads to a decrease motility and sluggishness of the bowels; creates a stagnant fecal masses. It changes the environment, and permanently contained in the intestine infection is particularly virulent. However, some clinicians, midwives with such interpretation does not agree. They believe that the blood of the pelvis during pregnancy, on the contrary, favorable resolution of inflammatory lesions. To deny the positive impact of congestion on the resolution of the inflammatory infiltrate not necessary; but found that simultaneously with hyperemia sick organ is required known peace. Meanwhile, occurring during pregnancy, with the growth of the uterus, offset and break inflamed and fixed the vermiform process does not ensure the necessary rest. Therefore, the delimitation of the inflammatory process in the right iliac fossa, which usually occurs outside of pregnancy, during the last missing. Therefore, the conditions for the spread of infection from the local focus.
However, not only progressing pregnancy adverse effect on for appendicitis. Emptying the gravid uterus and reduction of its volume (abortion, childbirth can also cause rupture of the walls of the encapsulated hearth and lead to peritonitis, as fights inevitably violated spikes and concretions and vermiform process often fails.


Thus, during pregnancy creates a number of adverse conditions, complicating the course of appendicitis. These include: 1) displacement blind gut with vermiform process; 2) the displacement of the packing - natural "patch", limiter inflammatory foci; 3) the obstacles created by the gravid uterus for the accumulation and osmawani pus in dopasowa space, and other
The absence of these anatomical-topographical features outside of pregnancy and in early terms makes the best outcome of appendicitis, than in a later time, and especially at the end of pregnancy.
Appendicitis in the second half of pregnancy often leads to occurrence of premature delivery, which, in turn, negatively affect the flow of appendicitis, causing the occurrence of serious complications and sometimes result in the death of a woman.
The question of the disease appendicitis in pregnancy large literature that shows its prevalence in women aged 20-30 years, i.e. in the period of childbirth, within 2% (N. A. Vinogradov). This appendicitis more likely to occur in the first half of pregnancy (71%. A. Vinogradov, 72,6% - A. A. Zykov, and others).
Clinically there are three stages of inflammation of the vermiform process: acute, subacute and chronic. Changes in appendicitis can be various, depending on the nature of the infection, extent of the inflammatory process and the individual characteristics of the organism, its reactivity. In connection with the foregoing, in the development of acute appendicitis clinically should distinguish between three main stages, due to the condition of the body's reactivity. At the first stage of development of the pain in the vermiform Appendix inflammatory process is limited within the process of the so-called endo-appendicitis. Here should be referred: appendicular colic, catarrhal or phlegmonously form of appendicitis, empyema process. The frequency of individual clinical forms of appendicitis, A. A. Zykova, is as follows: acute catarrhal form - 78,9%, acute flegmona form - 14,4%, acute gangrenous - 6,7%.
In the second phase of the inflammatory process has already spread outside the Appendix, and being involved in the peritoneum, omentum and intestinal loops. Clinically, this condition is known under the name of periappendicitis, or appendiceal infiltrate (destructive appendicitis, covered with a perforation of the Appendix). And finally, at the third stage of development of appendicitis prevalent phenomenon of General peritonitis (I. D. Anikin).
The difficulty of diagnosis increases with the duration of pregnancy. Up to 16 weeks of pregnancy diagnosis more or less simple. In the later stages of pregnancy diagnosis is difficult, because by that time cecum with vermiform process usually move up, in the area of right rib; the exception to this would be cases of so-called pelvic provisions of the vermiform process that determines the peculiarities of clinical picture of the disease and creates difficulties of diagnostics, and also affects the technique of surgery and the postoperative course.
If the symptomology of acute appendicitis outside of pregnancy is well developed, in the presence of the latter, as noted above, it is volatile and recognition difficult. Hence the number of diagnostic error is relatively large. The reason for this is that specific signs of appendicitis that is often not available. Many of the symptoms observed in women with appendicitis, characteristic of the pregnancy (nausea, vomiting, constipation, and so on). Hence it is clear how you should carefully evaluate the symptoms you have sick, especially because they do not always occur at the same time. Usually only some of them, and then not always equally expressed. For detection of appendicitis are essential medical history and data of laboratory researches. However, the main place in the diagnosis of appendicitis should be given clinical observation.