Arch Gynecol Obstet DOI 10.1007/s00404-014-3276-7
Maternal-Fetal Medicine
Evaluation of obstetrical and fetal outcomes in pregnancies complicated by acute appendicitis Nimrah Abbasi · Valerie Patenaude · Haim A. Abenhaim
Received: 18 February 2014 / Accepted: 28 April 2014 © Springer-Verlag Berlin Heidelberg 2014
Abstract Purpose The purpose of our study was to evaluate obstetrical and fetal outcomes in pregnancies complicated by acute appendicitis, and to specifically evaluate the impact of peritonitis. Methods We conducted a population-based cohort study using the Healthcare Cost and Utilization Project-Nationwide Inpatient Sample from 2003 to 2010 to evaluate perinatal outcomes in pregnant patients with appendicitis and delivery in the same admission compared to women delivering without appendicitis. Logistic regression was used to calculate the odds ratio (OR) and corresponding 95 % confidence intervals (CIs) for variables and outcomes of interest. Results Among seven million maternities, there were 1,203 women with appendicitis who delivered in the same admission. Pregnant women with appendicitis were more likely to deliver preterm OR 2.68 (95 % CI 2.31–3.11) and had an increased risk in abruptio. Among the 27 % of patients with peritonitis, the rate of preterm birth was fourfold higher, and the caesarean section rate was almost doubled. Conclusions Although rare, appendicitis in pregnancy is associated with adverse maternal outcomes and worsened in cases of peritonitis. Measures to decrease risk of
N. Abbasi · H. A. Abenhaim (*) Department of Obstetrics and Gynecology, Jewish General Hospital, 5790 Cote‑Des‑Neiges Road, Pav H, Room 325, Montreal, QC H3S 1Y9, Canada e-mail: [email protected] V. Patenaude · H. A. Abenhaim Centre for Clinical Epidemiology and Community Studies, Jewish General Hospital, Montreal, QC, Canada
peritonitis should be taken in order to limit associated morbidities. Keywords Appendicitis · Maternal outcomes · Fetal outcomes · Peritonitis · Pregnancy
Introduction Abdominal pain is a frequent yet difficult symptom to decipher in pregnancy due to the numerous physiological and anatomical changes that occur as well as the vast obstetrical and non-obstetrical differential diagnosis of abdominal discomfort in pregnancy. Appendicitis, the most common cause of an acute abdomen pain in pregnancy, is among the most challenging diagnoses to make with confidence, due to the limited radiological techniques available in pregnancy, as well as the non-specific associated signs and symptoms. However, appendicitis can have severe consequences on both mother and fetus if missed or if diagnosis is delayed. Multiple studies, generally case series and a small number of population-based studies, have illustrated an increased risk of preterm birth [1–3], small for gestational age [2, 3], and some have noted an increase rate of fetal loss [1, 4] in pregnancies complicated by appendicitis. However, the number of cases has been small, and thus our ability to draw meaningful associations has been limited. Given the sparse data available, we decided to further investigate perinatal outcomes associated with appendicitis, as a means to better quantify the impact of appendicitis on the mother and fetus and enable clinicians to make appropriate decisions based on objective risks and outcomes. The primary purpose of our study was to evaluate obstetrical and fetal outcomes of pregnancies complicated by acute
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appendicitis by conducting a population-based study in the United States (US).
Materials and methods Data obtained from the Health Care Cost and Utilization Project, Nationwide Inpatient Sample (HCUP-NIS) were used to carry out a population-based cohort study. The NIS contains data on US hospital inpatient stays from states participating in the Healthcare Cost and Utilization Project from 2003 to 2010, inclusively, and approximates 20 % of US hospital admissions. These include admissions to rural and urban, teaching and non-teaching hospitals. The database includes clinical and resource use information during hospitalization for delivery, including demographic information, duration of admission, comorbidities, up to 15 discharge diagnoses, procedures categorized according to the International classification of Diseases, ninth revision, clinical modification (ICD-9-CM), as well as maternal death, if present. Our cohort was obtained by isolating all patients with a pregnancy and delivery-related discharge code obtained from the NIS database (ICD-9 code 650–659 and V-27). Cases of appendicitis were isolated using the following ICD-9 codes 540.9, 541 and 542, and cases of appendicitis with peritonitis were identified using ICD-9 codes 540.0 and 540.1. Our cases were all pregnant patients with a diagnosis of appendicitis and a delivery in the same admission, which were identified by pregnancy and delivery codes with an appendicitis-related code. Appendicitis-related death during admission was identified when “died” was indicated under disposition of patient in the NIS database, combined with any of the appendicitis codes and a pregnancy and delivery code. Controls were identified as delivering pregnant females without appendicitis. Baseline characteristics were identified either as independent variables within the database or using ICD-9 codes. These included age, race, income, type of insurance, hospital type and obesity (codes 649.1x, 278.01, V85.3–4; defined as BMI greater than 30). All outcomes of interest were identified using ICD-9 codes as follows: threatened preterm labor with subsequent term delivery (codes 644.0, 644.1), preterm birth (code 644.2; defined as birth at
Maternal-Fetal Medicine
Evaluation of obstetrical and fetal outcomes in pregnancies complicated by acute appendicitis Nimrah Abbasi · Valerie Patenaude · Haim A. Abenhaim
Received: 18 February 2014 / Accepted: 28 April 2014 © Springer-Verlag Berlin Heidelberg 2014
Abstract Purpose The purpose of our study was to evaluate obstetrical and fetal outcomes in pregnancies complicated by acute appendicitis, and to specifically evaluate the impact of peritonitis. Methods We conducted a population-based cohort study using the Healthcare Cost and Utilization Project-Nationwide Inpatient Sample from 2003 to 2010 to evaluate perinatal outcomes in pregnant patients with appendicitis and delivery in the same admission compared to women delivering without appendicitis. Logistic regression was used to calculate the odds ratio (OR) and corresponding 95 % confidence intervals (CIs) for variables and outcomes of interest. Results Among seven million maternities, there were 1,203 women with appendicitis who delivered in the same admission. Pregnant women with appendicitis were more likely to deliver preterm OR 2.68 (95 % CI 2.31–3.11) and had an increased risk in abruptio. Among the 27 % of patients with peritonitis, the rate of preterm birth was fourfold higher, and the caesarean section rate was almost doubled. Conclusions Although rare, appendicitis in pregnancy is associated with adverse maternal outcomes and worsened in cases of peritonitis. Measures to decrease risk of
N. Abbasi · H. A. Abenhaim (*) Department of Obstetrics and Gynecology, Jewish General Hospital, 5790 Cote‑Des‑Neiges Road, Pav H, Room 325, Montreal, QC H3S 1Y9, Canada e-mail: [email protected] V. Patenaude · H. A. Abenhaim Centre for Clinical Epidemiology and Community Studies, Jewish General Hospital, Montreal, QC, Canada
peritonitis should be taken in order to limit associated morbidities. Keywords Appendicitis · Maternal outcomes · Fetal outcomes · Peritonitis · Pregnancy
Introduction Abdominal pain is a frequent yet difficult symptom to decipher in pregnancy due to the numerous physiological and anatomical changes that occur as well as the vast obstetrical and non-obstetrical differential diagnosis of abdominal discomfort in pregnancy. Appendicitis, the most common cause of an acute abdomen pain in pregnancy, is among the most challenging diagnoses to make with confidence, due to the limited radiological techniques available in pregnancy, as well as the non-specific associated signs and symptoms. However, appendicitis can have severe consequences on both mother and fetus if missed or if diagnosis is delayed. Multiple studies, generally case series and a small number of population-based studies, have illustrated an increased risk of preterm birth [1–3], small for gestational age [2, 3], and some have noted an increase rate of fetal loss [1, 4] in pregnancies complicated by appendicitis. However, the number of cases has been small, and thus our ability to draw meaningful associations has been limited. Given the sparse data available, we decided to further investigate perinatal outcomes associated with appendicitis, as a means to better quantify the impact of appendicitis on the mother and fetus and enable clinicians to make appropriate decisions based on objective risks and outcomes. The primary purpose of our study was to evaluate obstetrical and fetal outcomes of pregnancies complicated by acute
13
appendicitis by conducting a population-based study in the United States (US).
Materials and methods Data obtained from the Health Care Cost and Utilization Project, Nationwide Inpatient Sample (HCUP-NIS) were used to carry out a population-based cohort study. The NIS contains data on US hospital inpatient stays from states participating in the Healthcare Cost and Utilization Project from 2003 to 2010, inclusively, and approximates 20 % of US hospital admissions. These include admissions to rural and urban, teaching and non-teaching hospitals. The database includes clinical and resource use information during hospitalization for delivery, including demographic information, duration of admission, comorbidities, up to 15 discharge diagnoses, procedures categorized according to the International classification of Diseases, ninth revision, clinical modification (ICD-9-CM), as well as maternal death, if present. Our cohort was obtained by isolating all patients with a pregnancy and delivery-related discharge code obtained from the NIS database (ICD-9 code 650–659 and V-27). Cases of appendicitis were isolated using the following ICD-9 codes 540.9, 541 and 542, and cases of appendicitis with peritonitis were identified using ICD-9 codes 540.0 and 540.1. Our cases were all pregnant patients with a diagnosis of appendicitis and a delivery in the same admission, which were identified by pregnancy and delivery codes with an appendicitis-related code. Appendicitis-related death during admission was identified when “died” was indicated under disposition of patient in the NIS database, combined with any of the appendicitis codes and a pregnancy and delivery code. Controls were identified as delivering pregnant females without appendicitis. Baseline characteristics were identified either as independent variables within the database or using ICD-9 codes. These included age, race, income, type of insurance, hospital type and obesity (codes 649.1x, 278.01, V85.3–4; defined as BMI greater than 30). All outcomes of interest were identified using ICD-9 codes as follows: threatened preterm labor with subsequent term delivery (codes 644.0, 644.1), preterm birth (code 644.2; defined as birth at
