Laparoscopic or open appendicectomy for suspected appendicitis in pregnancy and evaluation of foetal outcome in Australia

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Abdominal pain in pregnancy is a diagnostic challenge. Although there are many potential causes, the most common reason to consider abdominal surgery is acute appendicitis.1 The literature suggests that the rate of suspected appendicitis is approximately 1:635 to 1:500 pregnancies. The true incidence of pathologically proven appendicitis is in the order of 1:1440.3 The background rate of appendicitis during pregnancy is similar to that of non‐pregnant women; however, appendiceal perforation rates may be higher in the gravid population.4 With perforation, foetal loss occurs in 20% of cases, compared with 1.5% for uncomplicated appendicitis.5 Similarly, perforation can be associated with preterm labour and increased perinatal and maternal morbidity.6 The anatomical and physiological changes in pregnancy create challenges to clinical assessment, investigations and decision making. Due to these reasons, a more aggressive surgical strategy is often chosen, resulting in a higher negative appendicectomy rate in pregnant women (27% versus 18%).8
The safest surgical approach for suspected appendicitis in pregnancy remains controversial. Multiple large series attest to the safety of laparoscopic surgery in pregnancy, despite earlier concerns relating to changes in intra‐abdominal pressures and relative hypercarbia.9 Most previous studies looking at open versus laparoscopic appendicectomy (LA) in pregnancy were underpowered to detect any benefit of either surgical approach, resulting in conflicting conclusions. However, a recent systematic review by Wilasrusmee et al.10 pooled these studies and found that there was a statistically significant increase in the risk of foetal loss in the laparoscopic group compared with open surgery (relative risk (RR) 1.91). Preterm labour rates, hospital length of stay (LOS) and perinatal complications were similar.
The Wilasrusmee review was heavily influenced by one paper (contributing 87.65% of the data). This study was a retrospective analysis of case files from California, which did not account for maternal and gestational age – both independent determinants of foetal loss rates. Furthermore, gestational age is a likely determinant in surgical approach and hence a significant confounder in this study.
We hypothesized that the LA group would have an over‐representation of early gestational ages compared with the open appendicectomy (OA), and accordingly, the difference in risk of foetal loss between LA and OA may be explained by the inherently higher risks of foetal loss earlier in pregnancy. In order to more accurately determine the influence of surgical approach, we sought to evaluate the risks of foetal loss in pregnant woman following laparoscopic or OA for suspected appendicitis adjusting for these factors.

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