Perforated Appendix In Late Gestation.
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Acute abdominal pain in pregnancy is a challenging situation for the treating physician, given that the lives of the patient and the expected child are at risk. A quick and wise decision is imperative. A variety of pathologies could be responsible, whether related to pregnancy or not. Careful assessment and considering the anatomical and physiological changes associated with pregnancy certainly will avoid fetal and maternal morbidities and mortalities.

CASE PRESENTATION

A 28-year-old lady, previous caesarean section was admitted at her 36 weeks gestation with an acute onset of vague abdominal pain associated with nausea and vomiting of 4 days duration. Clinical examination revealed temperature was 36.8o C and blood pressure (BP) of 110/80 mm Hg. Abdominal tenderness was elicited all over with palpable uterine contractions . Vaginal examination revealed no cervical dilation or effacement. Abdominal and pelvic ultrasonography (USG) was performed by a radiologist who reported a single live intrauterine pregnancy of 36 weeks with normal intra abdominal organs

Biochemical tests revealed a hemoglobin value of 12.4 gms/dl and white blood cells of 7.9 x 109 /L which fall within the normal range. There was no evidence of urinary tract infection. Fetal monitoring by cardiotocography (CTG) showed pathological findings a couple of hours later.

Emergency caesarean section was carried out. A live male neonate was delivered weighing 2.160 kg with a good Apgar score. Turbid fluid was noticed upon opening the peritoneum, raising the possibility of coexisting inflammatory focus, thus pelvic and abdominal organs were explored. A seriously inflamed appendix with pus discharging from the same place of the perforation was found with no other organ morbities. Appendectomy and peritoneal lavage were performed by the surgical team with drain kept in situ. No other pathology was found.
Subsequent histopathology confirmed the intra operative findings.

The patient had a smooth and complete postpartum course in spite of this serious intraoperative finding and discharged on the 9th postoperative day, after completing full course of broad-spectrum antibiotics.

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