Management and Communication Problems in a Patient With Succinyl-CoA Transferase Deficiency in Pregnancy and Labor

Abstract

A ppendicitis is the most common surgical problem in pregnancy (occurs in 1/1500 pregnancies) and requires emergent abdominal surgery. Complications can include peritonitis, sepsis, and abscess formation, particularly for appendiceal rupture. The physiologic changes of pregnancy can make the diagnosis of appendicitis difficult. If the appendicitis is uncomplicated, prompt surgery can avoid the complications of perforation. If the appendix has ruptured, increases in maternal and fetal morbidity and mortality occur, and the method of optimal treatment is unclear. This report presents data on 2 patients with ruptured appendicitis treated without surgery but with antibiotics, bowel rest, and intravenous fluids.The first patient, at 32 4/7 weeks of gestation, reported 1 week of intermittent diarrhea and abdominal cramping. The right lower quadrant examination showed tenderness with rebound and her WBC was 22 Â 10 9 /L. Magnetic resonance imaging (MRI) confirmed the diagnosis of ruptured appendix with a phlegmon measuring 7 cm. She was treated with intravenous ampicillin, gentamicin, and clindamycin. Her WBC count peaked at 33 Â 10 9 /L with 9% bands. She remained clinically stable despite the development of peritoneal inflammation and ileus. Although premature uterine contractions developed, tocolysis and steroids were not administered. Over 2 to 3 days, the patient's clinical status and laboratory studies improved, with resolution of her ileus and uterine contractions. Fetal heart rate tracings were reassuring. A repeat MRI on day 5 revealed no change in the phlegmon size. On day 11, she was discharged home with a normal WBC count. At 38 5/7 weeks of gestation, she had an uncomplicated vaginal delivery of a 3544 g girl with Apgar scores of 8 and 9. The postpartum course was uncomplicated, and 2 months after delivery the patient had an interval laparoscopic appendectomy. Pathologic examination showed xanthogranulomatous appendicitis with partial obstruction of the appendiceal lumen.The second patient presented at 26 6/7 weeks of gestation with an 8-day history of right upper and lower quadrant pain. Her WBC count was 19 Â 10 9 /L. Pelvic ultrasound showed a noncompressible appendix with a phlegmon measuring 1.4 cm. MRI confirmed the presence of a ruptured appendix. Medical management was provided with ampicillin, gentamicin, and clindamycin, bowel rest, and intravenous fluids. She became afebrile and the WBC count returned to normal. She was discharged to home on day 9. At 32 weeks of gestation, her right lower quadrant pain recurred and another MRI showed no change in the appendix or phlegmon. Medical management remained the same. Despite the onset of preterm labor at 33 6/7 weeks, steroids and tocolytic drugs were not administered. She had a cesarean delivery by low transverse uterine incision for breech presentation at that time. A male neonate with Apgar scores of 8 and 9 and weight of 2005 g was delivered. The appendix was removed during the cesarean surgery. The postoperative course was uneventful, and the newbo...