Acute appendicitis is the most common surgical emergency during pregnancy. The diagnosis is frequently delayed because of anatomic and other considerations in pregnancy, thus increasing the risk of significant morbidity or even mortality for the mother and fetus. In addition to concerns about the difficulty of making a prompt and accurate diagnosis, the displacement of the appendix by the gravid uterus has resulted in controversy about the optimal site of abdominal incision for appendectomy. Many surgeons believe that incisions above the classic McBurney's point facilitate easy location and removal of the inflamed appendix. Popkin and colleagues studied appendectomies in pregnant patients over a five-year period at a university teaching hospital to compare results of different surgical approaches.

They reviewed records of 23 pregnant women who underwent appendectomy. In 16 cases, acute appendicitis was confirmed by a pathology report. The mean age of the mothers was 26 years (range, 17 to 39 years). Six cases were in the first trimester, 13 in the second, and four in the final stage of pregnancy. McBurney's point was the site of incision in 18 cases and, in five cases, the incision was made superior to the classic point. In these five cases, the patients were in the first or second trimester. The appendix was easily located in 17 (94 percent) of the cases using McBurney's point and in four (80 percent) of the higher incisions.

The authors conclude that McBurney's point provides effective access for appendectomy throughout pregnancy, even during the third trimester. They point out that the belief that the appendix is displaced by a counterclockwise rotation out of the pelvis during pregnancy is based on a single study that cannot be replicated because of concerns about radiation exposure. They recommend that efforts continue to facilitate early diagnosis of appendicitis during pregnancy and advocate a surgical approach through a transverse incision at McBurney's point.

editor's note: Although acute appendicitis is the most common surgical emergency of pregnancy and must be recognized when it occurs, the incidence is approximately 1:1,500 births. In daily interaction with pregnant patients, the diagnosis is rare. Many more common conditions can cause fever, anorexia, and abdominal pain in pregnant women. These conditions too must be accurately diagnosed and effectively managed. As obesity becomes more common and more women undertake pregnancy at advanced ages, the rate of gallbladder problems in pregnancy could overtake that of appendicitis during pregnancy.—a.d.w.