Aim. Our objective was to demonstrate the impact of appendix removal on the obstetric outcome of the next pregnancy. Materials and method. A questionnaire for the survey of the impact of appendix removal on the obstetric outcome of subsequent pregnancy was applied in 52 and 79 women, who were the study and the control cases, respectively. Pre-pregnancy complaints, such as pelvic or abdominal discomfort and back pain, were recorded together with the pregnancy outcome, delivery findings and the maternal risk factors for adverse gestational outcome. Results. The rate of pelvic complaints was 67.3% (35/52) and 32.9% (26/79) in patients who were appendectomized or not, respectively. The gestational week at delivery and birth weight were lower in the patients who were appendectomized (p=0.240; p=0.003). The patients with an interval less than two years between appendix removal and pregnancy had lower birth weight and gestational week at delivery compared to the remainders (p=0.003; p=0.068). Moreover, patients who experienced pelvic complaints had lower birth weight and gestational week at delivery compared to the ones who did not experience pelvic complaint, despite the lack of statistical significance (p=0.238; p=0.238). Additionally, further analysis regarding the autoimmune diseases revealed that the rates of autoimmune diseases were 2.5% (2/79) and 32.6% (17/52) in patients without a history of appendectomy and in those with appendix removal, respectively. Conclusions. The long-term complications of appendix removal, such as adhesions and peritoneal irritations, must be considered, especially in the antenatal care of the next pregnancies. Appendectomized pregnancies should be evaluated for the presence of immune system problems.
appendix, appendectomy, pregnancy outcome
Scop. Am evaluat impactul apendicetomiei asupra prognosticului obstetrical al unei sarcini ulterioare. Materiale şi metodă. A fost realizat un studiu prospectiv, de tip caz-control, ce a inclus 52 de paciente în lotul de control şi 79 de paciente în cel al cazurilor. Toate pacientele au completat un chestionar. Au fost colectate date privind simptomatologia anterioară sarcinii (durere pelviană, disconfort abdominal, durere lombară) şi parametrii obstetricali (date privind sarcina şi naşterea). Rezultate. Simptomele pozitive au fost întâlnite la 67,3% (35/52) şi la 32,9% (26/79) dintre pacientele apendicetomizate, respectiv neoperate. Vârsta gestaţională şi greutatea la naştere au fost semnificativ mai mici la pacientele apendicetomizate versus cele neapendicetomizate (p=0,240; p=0,003). Asocierea a fost mai puternică dacă intervalul de la momentul intervenţiei de îndepărtare a apendicelui până la sarcină a fost sub doi ani (p=0,003; p=0,068). Pacientele cu simptomatologie dureroasă în intervalul de la apendicetomie la sarcină au avut o greutate şi o vârstă gestaţională la naştere mai mici comparativ cu cele asimptomatice, dar diferenţele nu au atins semnificaţia statistică (p=0,238; p=0,238). O analiză suplimentară a arătat că bolile autoimune au fost mai frecvent întâlnite la pacientele neapendicetomizate (2,5% – două paciente din 79, respectiv 32,6% – 17 paciente din 52). Concluzii. Complicaţiile pe termen lung ale apendicetomiei, cum ar fi sindromul aderenţial şi iritaţia peritoneală, sunt un aspect care trebuie luat în considerare în timpul supravegherii antenatale a sarcinilor. Pacientele apendicetomizate ar trebui să fie evaluate în ceea ce priveşte potenţiale afecţiuni autoimune.
The appendix was previously believed to exist as a rudimentary organ with no known function. It has been thought of as an evolutionary artifact like wisdom teeth and the tailbone, good for nothing but a potential source for intestinal inflammation. The pooled incidence of appendix removal due to appendicitis was 100 per 100,000 person-years in Northern America, and this number is 160 per 100,000 person-years in Turkey(1).
On the other hand, some studies suggested its immunological importance in the maintenance of intestinal immune system, and it has been shown that appendix has a positive effect on intestinal flora(2-5). We must also keep in mind another evolutionary lymphoid organ which is thymus and its role on human health, and the possible synergism of thymus and appendix in some immunological processes(6). Therefore, the appendix might be considered as an essential part of intestinal health and intestine-based immunological system(2-4).
In this study, we tried to present the impact of appendix removal on the gestational outcomes of subsequent pregnancies. Postoperative adhesions, inflammatory events due to appendix-related immune system changes and the effect of these changes on pregnancy were the main concerns of this pilot study.
Materials and method
This questionnaire-based study was carried out at the Hacettepe University, Division of Perinatology, Ankara Oncology Hospital, Department of General Surgery, Turkey, and at the “Iuliu Haţieganu” University of Medicine and Pharmacy, Department of Obstetrics and Gynecology, in 2018. The questionnaire was applied in patients admitted to the involved polyclinics after the acquirement of the informed consents of the patients. The questionnaire was performed by the physicians working at these clinics. The acquired data were evaluated by a team consisted of perinatologists and general surgeons.
The questionnaire consisted of questions related to demographic information about the patients, including prior obstetric history (gravida, parity, abortus and living child), a history of appendectomy with the year performed, the interval between the first pregnancy after appendectomy, and any complaint in this interval (between appendectomy and forthcoming pregnancy). Pre-pregnancy complaints have been carefully questioned and a detailed anamnesis has been taken in order to exclude acute pains or any organic pain related to other possible pathologies. The patiens were questioned about history of pelvic inflammatory disease, existence of chronic abdominal discomfort, chronic pelvic complaints and back pain. Pelvic complaints were also questioned in more detail regarding the site of pain and the characteristics of pain (sporadic, with irregular intervals or continous). Patients with a history of any complaint before appendectomy surgery and those with any systemic disease that may be related to chronic abdominal pain were also excluded in order to prevent bias. The existence of one of the complaints questioned was recorded as existence of any complaint after surgery.
More questions were asked about the outcomes of the first pregnancy after appendectomy. Gestational week at birth, birth weight, route of delivery and admission to neonatal intensive care unit have also been recorded. The possible relevant maternal risk factors such as diabetes mellitus, hypertension and autoimmune diseases were also recorded.
Patients with conflicting or unclear answers and patients with a history of other non-obstetric surgery were also excluded from the study. We have also included only the pregnancies reaching 32 weeks in order to see the neonatal and obstetric outcomes in terms of gestational week and birth weight more clearly.
The statistical analyses were carried out by SPSS V23.0 (2015, IBM SPSS Statistics for Windows, Version 23.0 Armonk, NY: IBM Corp.) software. The descriptive analyses were performed for characteristic information. The comparison between the appendectomized and non-appendectomized patients was performed using the Mann-Whitney U test and the Chi-Suqare test, according to data structure. A p value less than 0.05 was considered statistically significant.
This questionnaire study was approved by the Hacettepe University Ethics Committee (Ethical Board Approval Number: GO 18/885-10).
This questionnaire study consisted of 131 patients who were eligible for study and had a clear anamnesis related to questions. The study consisted of 52 patients with a prior appendectomy and 79 patients without a history of appendectomy. The characteristic information about the patients were summarized in Table 1. The median age of the patients was 28 years old (18-43). The median gestational week at delivery was determined as 39 years old (32-41), while the birth weight was 3100 g (1900-4750). The caesarean section rate was determined as 29%.
The questions related to maternal health status revealed diabetes mellitus, hypertensive disorders or any autoimmune disorder in 6 (4.6%), 2 (1.5%) and 19 (14.5 %) cases, respectively. Additionally, the further analysis revealed that the rates of autoimmune diseases were 2.5% (2/79) and 32.6% (17/52) in the patients without a history of appendectomy and with an existent appendectomy, respectively. According to patients’ answers, 61 out of 131 (46.6%) patients had experienced chronic pelvic complaints. The rate was 67.3% (35/52) and 32.9% (26/79) in patients who were appendectomized or not, respectively.
We have also compared patients in terms of obstetric outcomes regarding being appendectomized or not. The gestational week at delivery was lower in the appendectomized patients, despite the lack of statistical significance (p=0.240). On the other hand, birth weight was significantly lower in appendectomized patients (p=0.003).
The further analyses of the study included only appendectomized patients. The patients were classified according to time interval between appendectomy and forthcoming pregnancy. The patients with an interval less than two years had lower birth weight and gestational week at delivery compared to remainders (p=0.003; p=0.068). We have also compared appendectomized patients in terms of existence of any chronic pre-pregnancy pelvic complaint. The patients who experienced pelvic complaints had lower birth weight and gestational week at delivery compared to those who did not experience pelvic complaint, despite the lack of statistical significance (p=0.238; p=0,238) – Table 2.
Acute appendicitis is one of the most common surgical interventions, with a lifetime risk of 1 in 15(1,7). The interesting issue is the high frequency of appendectomy in terms of surgical procedures and the very limited amount of knowledge about the underlining pathophysiological rationales behind appendicitis(3,8).
The appendix is accepted as a vestigial organ in the traditional clinical practice. However, recent publications suggested that this lymphoid organ may have an important role in the intestinal immune system regulation(3). It has also been reported that it may be responsible for the organization of gut flora, biofilm formation and education of microorganisms in terms of their adaptations to intestinal environment(1,5). Other important finding is the possible role of appendix in the pathophysiology of autoimmune disorders(9,10). Additionally, it has been reported that appendix has an important role in the biology of chronic inflammatory diseases, such as ulcerative colitis(11-13). Appendix removal is considered to be beneficial for this type of diseases(14-16). In this preliminary questionnaire-based investigation, immune system problems and autoimmune disorders were found to be more frequent in appendectomized patients. Almost one third of the cases (32.6%) revealed immune system problems. More specific studies are necessary to support this finding because our surprising results might be due to the structure of our study. It is a questionnaire-based investigation and appendectomized cases were evaluated more intensively compared to the control cases.
The long-term complications of appendix removal might be responsible for the pelvic complaints most probably due to postoperative adhesion formations and peritoneal irritations. This type of mechanical factors and the tendency for immunological inflammations may be clinically important in certain periods of the lifetime of appendectomized patients. In this regard, we have searched the pregnancies with a history of appendix removal in terms of gestational outcomes and demonstrated that there is a tendency for earlier delivery and low birth weight, most probably due to the presence of mechanical reasons and/or upregulation of proinflammatory pathways. It has been reported that immune system disorders might influence the pregnancy outcomes(17-20). It has also been demonstrated that chronic inflammatory diseases and celiac disease might influence the gestational outcomes(21,22).
As far as we understand, this is the first study that investigated the role of appendix removal on subsequent pregnancy outcomes. The limitation of this preliminary report is the small number of the cases and the questionnaire-based structure. However, this report may be important because it may stimulate the design of further studies in this field.
In conclusion, appendectomized pregnancies should be considered specifically and these cases must be evaluated in terms of the presence of immune system problems. Moreover, previous appendectomy and its long-term complications might be the reason for pelvic complaints and triggering factors for earlier deliveries.
Conflict of interests: The authors declare no conflict of interests.
The study has no financial support.
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