SA, aged 22 years, presented to the emergency department in her first pregnancy at 37 + 6 weeks of gestation. She gave a 4-day history of right sided
abdominal pain and feeling generally unwell. She had some nausea but no vomiting, bowel or urinary symptoms. On examination she was
normotensive at 100/50 mmHg, with a pulse of 80 beats per minute and a temperature of 38.1°C. Her abdomen was soft, with a gravid uterus
appropriate for dates and right iliac fossa tenderness with localised guarding but no rebound. Urinalysis was negative. Blood analysis showed a
C-reactive protein of 20 mg/L, white cell count of 12x109/L with a neutrophilia, normal liver function tests. She was thought to have appendicitis, was
commenced on intravenous amoxicillin and metronidazole and transferred to the nearest obstetric unit with surgical cover. She was given appropriate
analgesia. Cardiotocography (CTG) was normal.
On arrival she was reviewed by the general surgeons on call who felt she was likely to be suffering from acute appendicitis. She was booked for
surgery the following morning. The plan from the surgical registrar was that she should have a caesarean section (CS) prior to the appendicectomy so
that the same incision could then be used. This was outlined to the patient and her family.
Later that evening she was reviewed by the obstetric team. It was felt that there was no indication for caesarean section. The plan was changed so
that the surgery should start with appendicectomy. If the appendix appeared infected then the uterus would be left intact, baby undelivered. If the
appendix appeared normal then a CS would be considered. The rationale was that if there was appendicitis it would be better not to open the uterus for
risk of introducing infection with possible deleterious effects on future fertility. Instead the patient could recover from the surgery, await spontaneous
labour and ideally achieve a normal delivery weeks later.
If there was no appendicitis found, other intra-abdominal sources of sepsis would have to be excluded. If chorioamnionitis was thus diagnosed by
exclusion, then CS might be advisable. In that scenario a CS would be safer since there would be no intra-abdominal infection present.
The patient and family were extremely distressed to learn that they would not necessarily be getting their baby delivered that day. They demanded to
have a CS at the same time as the appendicectomy. The reasoning was repeated a number of times and eventually the patient agreed.
The patient underwent appendicectomy under spinal anaesthetic. A Lanz incision was made over the point of maximal tenderness. A swollen,
discoloured retroileal appendix was identified and excised, the stump ligated with 2.0 polyglactin (Vicryl, Ethicon Inc. Somerville, NJ, USA) and the
abdomen closed in layers. As the appendix was clearly inflamed a CS was not performed. The patient and her family were debriefed that she should now
make a full recovery. CTGs were performed postoperatively and were normal. SA went home on the second postoperative day. She was seen in
antenatal clinic weekly until she went into spontaneous labour at term plus 8. Labour was uneventful and she delivered a live male infant by
vacuum-assisted delivery under epidural anaesthesia. She was discharged home with her baby 3 days later and was extremely happy with the outcome