The American Journal of Surgery xxx (xxxx) xxx

Contents lists available at ScienceDirect

The American Journal of Surgery

journal homepage: www.americanjournalofsurgery.com

Is neutrophilia the key to diagnosing appendicitis in pregnancy?

J. Quinn Gentles a, Gabriela Meglei b, Leo Chen a, Cameron J. Hague b, Adrienne L. Melck c, *
a
Department of Surgery, University of British Columbia, 2775 Laurel Street 11th Floor, Vancouver, BC, V5Z 1M9, Canada
b
Department of Radiology, Providence Healthcare, St. Paul’s Hospital, Vancouver, BC, V6Z 1Y6, Canada
c
Division of General Surgery, Providence Health Care, St Paul’s Hospital, Room C303-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada

a r t i c l e i n f o a b s t r a c t

Article history: Background: The diagnosis of acute appendicitis (AA) in pregnancy remains challenging. We investigated
Received 6 November 2019 which preoperative clinical factors are most predictive of AA in pregnant women.
Received in revised form Methods: 164 pregnant patients undergoing magnetic resonance imaging for suspected AA were retro-
18 March 2020
spectively reviewed. Logistic regression was used to compare those with pathologically confirmed AA
Accepted 20 March 2020
and those without.
Results: 28 patients (17.1%) had pathologically confirmed AA. 42.9% (n ¼ 12) were perforated at the time
Keywords:
of operation. Factors associated with AA included history of emesis (p ¼ 0.005), migratory abdominal
Acute appendicitis
Pregnancy
pain (p ¼ 0.006), rebound tenderness (p ¼ 0.01), elevated white blood cell count (p ¼ 0.003), elevated
Diagnosis Alvarado Score (p < 0.001), elevated neutrophil count (p ¼ 0.021), and left shift (p ¼ 0.001). As a
Neutrophilia screening test, a left shift with neutrophils >70% provided a sensitivity and negative predictive value of
Left shift 100.0%.
Discussion: Every patient in our series with AA had a left shift. Neutrophil count and percentage should
be considered in the diagnostic evaluation of these patients to better guide resource utilization and
treatment.
© 2020 Published by Elsevier Inc.

1. Introduction no history or physical exam findings consistently predictive of

appendicitis in pregnancy.7,8
Acute appendicitis (AA) is the most common non-obstetrical Given the inconsistency of history, physical, and laboratory
surgical condition during pregnancy, effecting approximately 1 in findings, clinicians often rely on imaging to guide treatment, but
1500 pregnant women.1,2 The diagnosis is particularly challenging this also presents a challenge in pregnancy. Ultrasound has tradi-
as pregnancy-related symptoms and a gravid uterus can confound tionally been routine, however concerns regarding its low sensi-
the clinical presentation.2e4 Furthermore, physiologic leukocytosis tivity,9 particularly later in pregnancy,10 have led to
and C-reactive-protein (CRP) elevation seen in pregnancy may recommendations that magnetic resonance imaging (MRI) be
make these investigations less sensitive. Due to the difficulty of adopted as the preferred first line imaging modality with a reported
differentiating pregnant women who truly have AA from those sensitivity of 81.3e100% and specificity of 93e99.2%.11e13 While
with alternate diagnoses, there is no defined consensus on the ideal promising, MRI is not available in all centers, and its use may be
diagnostic pathway for this patient population.3 The literature limited by resource constraints. Ideally, better initial diagnostics
evaluating diagnostic algorithms for appendicitis in pregnancy has would aid in triaging which patients might be best served by this
been conflicting. A recent study has suggested the Alvarado score5 imaging modality. It is vital that appendicitis be diagnosed and
can be efficacious in this population,6 however others have found managed rapidly, as a missed diagnosis and/or delayed treatment
can result in significant maternal and fetal morbidity and mortal-
ity.14 Increased risk of poor outcomes with AA in pregnancy can
result in these patients being treated more aggressively than their
* Corresponding author. Division of General Surgery, St Paul’s Hospital, University
non-pregnant counterparts, and this is reflected in higher negative
of British Columbia Faculty of Medicine, Room C303, 1081 Burrard Street, Van-
couver, BC V6Z 1Y6, Canada. appendectomy rates in this population.14e18
E-mail addresses: [email protected] (J.Q. Gentles), [email protected] Following work done at our institution by Burns et al.12 MRI has
(G. Meglei), [email protected] (L. Chen), [email protected] (C.J. Hague), become the standard of care for first line imaging of pregnant
[email protected] (A.L. Melck).

https://doi.org/10.1016/j.amjsurg.2020.03.018
0002-9610/© 2020 Published by Elsevier Inc.

Please cite this article as: Gentles JQ et al., Is neutrophilia the key to diagnosing appendicitis in pregnancy?, The American Journal of Surgery,
https://doi.org/10.1016/j.amjsurg.2020.03.018
Downloaded for FK UMI Makassar ([email protected]) at University of Muslim Indonesia from ClinicalKey.com by Elsevier on April 25, 2020.
For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.
2 J.Q. Gentles et al. / The American Journal of Surgery xxx (xxxx) xxx

patients with suspected AA at our institution since 2008. MRI is not 0.05. All statistical analyses were performed using R software
available at many of our regional hospitals, thus many pregnant version 3.6.1.
patients suspected to have AA are transferred to our center solely
for the purpose of obtaining an MRI. The purpose of this study is to 3. Results
identify which clinical factors are most predictive of AA in the
pregnant patient to better inform resource utilization associated 164 pregnant patients underwent a total of 179 MRIs during our
with transporting patients to obtain an MRI. study period for suspected AA. 10 patients underwent repeat MRI
evaluation on the same admission, and 5 patients underwent
2. Material and methods repeat MRI during a separate admission within the study period.
The mean age was 31.7 years (range 18e43 years). 22.4% were in
Patients were identified by searching for the key word(s) their first trimester (n ¼ 35), 48.1% were in their second trimester
“appendicitis” in the radiology information system among all pa- (n ¼ 75), and 29.5% were in their third trimester (n ¼ 46). There
tients who underwent an MRI examination between the years were 10 cases where gestational age could not be recovered from
2008e2018. MRI reports were retrospectively reviewed to identify the records.
patients who were pregnant at the time of the study. All MRI scans Of the 164 patients, 28 (17.1%) had pathologically confirmed AA.
were performed on General Electric Signa HD 1.5 F system (GE There were no differences between the AA and non-AA groups in
Healthcare, Milwaukee, WI). MRI findings including whether the terms of age, gestational age or BMI (Table 1). Comparing history
appendix was visualized, the cross-sectional diameter, the presence features between the groups, only emesis (p ¼ 0.005) and migra-
or absence of surrounding inflammatory changes such as fat tory abdominal pain (p ¼ 0.006) were significantly associated with
stranding and free fluid, ancillary features, and the presence of an a diagnosis of AA (Table 2).
alternative diagnosis were obtained from the radiology report. The Table 3 shows objective data including physical exam features
MRI diagnosis of acute appendicitis was categorized based on the and laboratory investigations. Rebound tenderness (p ¼ 0.010) was
final impression of the radiologist as positive (>7 mm diameter and the only objective finding on physical examination to reach statis-
inflammation), negative (appendix < 7 mm and no inflammation, tical significance. Several laboratory investigations were signifi-
or appendix not seen and no inflammation), equivocal (>7 mm cantly associated with AA including elevated WBC (p ¼ 0.003),
diameter and no inflammation, equal to 7 mm diameter and elevated neutrophil count (p ¼ 0.021) and elevated neutrophil
inflammation, or appendix not seen but presence of inflammation), percentage (p ¼ 0.001). NLR, PLR, and CRP were not associated with
and non-diagnostic (incomplete study). For a complete description AA. The mean Alvarado score was significantly higher among the
of the MRI acquisition protocol please refer to Burns et al.12 All AA compared to the non-AA patients (6.5 vs. 4.3, p < 0.001). After
studies were interpreted by a staff radiologist. multivariate analysis, the only variables to remain significant were
A thorough chart review was then performed using the patient’s the Alvarado score (p ¼ 0.021) and neutrophilia (p ¼ 0.003). Of all
electronic medical record to collect demographic, clinicopatho- variables significantly associated with pathology proven AA,
logic, diagnostic, and operative data. Demographic variables neutrophil percentage >70% produced the best results as a
collected included age, gestational age, trimester, and body mass screening test with a sensitivity of 100% (Table 4).
index (BMI). History features collected included duration of Forty patients (24.4% of total) proceeded to operative inter-
symptoms, anorexia, nausea, emesis, right lower quadrant (RLQ) vention, 35 of whom underwent an appendectomy. 34.3% (n ¼ 12)
pain, and migratory pain. Physical exam features included presence of the appendectomies were performed laparoscopically while the
of fever (temperature >37.5 Celsius), tachycardia (heart rate >100 remainder (65.7%, n ¼ 23) were performed open via a McBurney’s
beats per minute), rebound tenderness, and McBurney’s point incision. Mean operative time was 54.3 min (range 16e120). 42.9%
tenderness. Laboratory variables included maximum preoperative of patients had perforated appendicitis by the time of operation
white blood cell (WBC) count (cells x 109/liter), maximum preop- (n ¼ 12) and 6 negative appendectomies were performed. Fig. 1
erative neutrophil count (cells x 109/liter), percent neutrophils demonstrates the final diagnosis of all patient presentations,
(neutrophil count/WBC), lymphocyte count (cells x 109/liter), which highlights the diversity of pathology that can lead to the
platelet count (cells x 109/liter), neutrophil-to-lymphocyte ratio suspicion of AA in pregnancy. Notably, 43% of patients (n ¼ 74) were
(NLR, neutrophil count/lymphocyte count), and platelet to discharged with no final diagnosis to explain their symptoms.
lymphocyte ratio (PLR, platelet count/lymphocyte count), and CRP
(mg/liter). Operative data included hours from triage to operative
4. Discussion
intervention, type of intervention (procedure and whether it was a
laparoscopic versus open approach), operative time, post-operative
Our study supports the finding that many traditional diagnostic
complications within the index admission, and final pathologic
features of acute appendicitis (duration of symptoms, anorexia, RLQ
diagnosis. An elevated WBC count was defined as a count >11 x
pain, fever, tachycardia, and McBurney’s Point tenderness) are
109 cells/liter, and an elevated neutrophil count was defined as a
unreliable in the pregnant patient. Improving our ability to reliably
count >8 x 109 cells/liter. AA was defined by a pathologist’s final
and efficiently establish this diagnosis is critical in mitigating the
report indicating inflammation or necrosis of the appendix.
Perforated appendicitis was defined in those cases where the sur-
geon documented perforation in their operative report. Ethical Table 1
approval of this study was obtained from the University of British Patient demographic data.
Columbia Providence Health Care Research Institute human ethics
Variable AA n ¼ 28 Non-AA P-Value
review board. N ¼ 136
The patients were then divided into two groups for analysis:
Age (mean, years) 32.1 31.6 0.712
those with pathologically confirmed AA and those without. Uni- GA (mean, weeks) 22.8 21.3 0.241
variate and multivariate logistic regression was used to determine BMI (mean kg/m2) 25.3 27.4 0.228
which associations between patient clinocopathologic variables Second Trimester (n, %) 12 (43%) 65 (48%) 0.729
were significantly associated with having AA. Findings were Third Trimester (n, %) 11 (39%) 35 (26%) 0.265

considered statistically significant if they had a p-value of less than AA (Acute Appendicitis), GA (Gestational Age), BMI (Body Mass Index).

Please cite this article as: Gentles JQ et al., Is neutrophilia the key to diagnosing appendicitis in pregnancy?, The American Journal of Surgery,
https://doi.org/10.1016/j.amjsurg.2020.03.018
Downloaded for FK UMI Makassar ([email protected]) at University of Muslim Indonesia from ClinicalKey.com by Elsevier on April 25, 2020.
For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.
 J.Q. Gentles et al. / The American Journal of Surgery xxx (xxxx) xxx 3

Table 2 Table 4
History features. Neutrophilia performance as a screening test.

Variable AA n ¼ 28 Non-AA P-Value Group AA Non-AA Predictive Values

N ¼ 136
Neutrophils >70% True Positives False Positives PPV
Symptom Duration (days, range) 1.53 (0.5-9) 3.39 (0-150) 0.175 18 66 21%
Anorexia 9 (64.3%) 34 (45.9%) 0.215 Neutrophils <70% False Negatives True Negatives NPV
Emesis 20 (71.4%) 51 (41.1%) 0.005 0 20 100%
RLQ Pain 26 (89.7%) 105 (83.3%) 0.401 Sensitivity Specificity
Migratory Pain 15 (53.6%) 31 (26.1%) 0.006 100% 23%

AA (Acute Appendicitis), RLQ (Right Lower Quadrant). AA (Acute Appendicitis), PPV (Positive Predictive Value), NPV (Negative Predictive
Value.

increased maternal and fetal morbidity of AA in pregnancy.19,20 A

recent cohort study by Theilen et al.16 of 171 pregnant women There has been recent interest in evaluating the utility of
being evaluated for AA found no differences in presenting signs and neutrophil percentage, neutrophil-to-lymphocyte ratio (NLR) and
symptoms between pregnant patients with and without other inflammatory markers in the diagnosis of AA in non-pregnant
pathologically-confirmed AA except for WBC count. Similarly populations.21e23 While traditionally leukocyte count has been
Aggenbach et al.8 examined 21 pregnant women undergoing ap- regarded as the principal inflammatory marker, some studies have
pendectomy for suspected AA and found no significant differences found NLR achieves better sensitivity. Sahbaz et al.21 reported NLR
in presenting symptoms or laboratory investigations between sensitivity of 60.1% and specificity of 90.9% vs 67.5% and 36.3% for
those with histologic confirmation and those without. WBC in diagnosing AA in their series of 159 non-pregnant patients.
In our series a history of emesis, migratory abdominal pain, NLR has also been found to predict severe appendicitis, increased
rebound tenderness, leukocytosis, elevated Alvarado score, and postoperative complication rate, and increased length of hospital
neutrophilia were all significantly associated with AA by univariate stay.23 A recent systematic review and meta-analysis found that
analysis. The Alvarado score is a widely-used scoring system for the NLR of 4.7 conferred a sensitivity of 88.9% and specificity of 90.9%
diagnosis of acute appendicitis. It utilizes history features (migra- for AA and higher NLR values were predictive of complicated
tion of pain, anorexia, nausea), physical exam findings (RLQ appendicitis.22 Other inflammatory markers such as CRP and
tenderness, rebound pain, temperature greater than 37.30 Celsius) platelet-to-lymphocyte ratio (PLR) have also been investigated in
and lab values (leukocytosis >10,000/mm3 and neutrophilia >5%) the setting of AA. Yazar et al.24 performed a retrospective review of
to predict the likelihood of appendicitis.5 A recent study6 showed 640 patients undergoing appendectomy for suspected AA. They
the Alvarado score to be as efficacious in pregnant patients as non- found that WBC, neutrophil percentage, lymphocyte count,
pregnant patients, with a sensitivity and specificity of 79% and 80%, lymphocyte percentage, CRP, NLR, and PLR were all significantly
respectively. However, the study did not include pregnant patients associated with AA. However, in multivariate regression only
with right lower quadrant pain who did not undergo surgery, neutrophil percentage, CRP and NLR remained significant. In their
limiting the study’s generalizability. Our study supports the finding study a neutrophil percentage >75%, CRP >51 mg/L, and NLR of 4.64
that the Alvarado score is useful in pregnancy. In our study higher could be used in combination to accurately diagnose AA in 88.9% of
Alvarado scores were significantly associated with AA (<0.001), and cases. In our study we did not find that NLR, PLR, nor CRP were
this association remained significant on multivariate analysis significantly associated with AA, perhaps reflecting differences in
(p ¼ 0.021). the pregnant population. Encouragingly, neutrophil percentage and
In addition to the Alvarado score, neutrophil percentage >70% particularly a left shift of greater than 70% neutrophils provided a
also remained significant on multivariate analysis and produced negative predictive value of 100%. This finding suggests that
the best results as a screening test with a sensitivity of 100%. There neutrophil percentage may help to better direct which patients
was no patient in our series with pathologically confirmed need expedited imaging and further investigation.
appendicitis who did not have a left shift of at least 70%. As a test, Improved diagnosis in this population would help to avoid delay
neutrophil percentage is accessible, affordable, and objective, to definitive treatment, and just as importantly, reduce inaccurate
making it an ideal measure in the initial investigation of a pregnant diagnosis and unnecessary intervention. Our study is consistent
patient with signs suggestive of appendicitis. Its use may help to with previous literature reporting higher rates of perforation
better direct the use of MRI and other diagnostic modalities in this compared to non-pregnant individuals (14.9%e55% vs 4e19%
patient population. respectively2,7,8,13,17,18,25,26), in part from diagnostic and treatment

Table 3
Physical exam, laboratory and imaging features.

Variable AA Non-AA P-Value

n ¼ 28 N ¼ 136

Fever 2 (7.1%) 13 (9.6%) 0.489

Tachycardia 6 (21.4%) 24 (17.7%) 0.759
Rebound Tenderness 13 (46.4%) 33 (24.3%) 0.010
McBurney’s Point Tenderness 11 (39.3%) 45 (33.1%) 0.235
WBC Elevation 24 (85.7%) 68 (50.0%) 0.003
Neutrophil Elevation 15 (53.6%) 52 (38.2%) 0.021
Neutrophil Percentage (mean, range) 84.9 (72.4e95.9) 76.9 (52.4e99.0) 0.001
NLR (mean, range) 12.7 (3.9e37.8) 9.07 (1.4e199.8) 0.960
PLR (mean, range) 193.4 (80.9e532.0) 186.7 (49.7e3300.0) 0.577
CRP (mean, range) 27.7 (3.2e76.5) 46.5 (1.3e220.8) 0.451
Alvarado Score (mean, range) 6.5 (2e8) 4.3 (0e9) <0.001

WBC (White Blood Cell), NLR (Neutrophil-to-leukocyte ratio), PLR (platelet-to-lymphocyte ratio), CRP (C-reactive protein).

Please cite this article as: Gentles JQ et al., Is neutrophilia the key to diagnosing appendicitis in pregnancy?, The American Journal of Surgery,
https://doi.org/10.1016/j.amjsurg.2020.03.018
Downloaded for FK UMI Makassar ([email protected]) at University of Muslim Indonesia from ClinicalKey.com by Elsevier on April 25, 2020.
For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.
4 J.Q. Gentles et al. / The American Journal of Surgery xxx (xxxx) xxx

5. Conclusions

Acute appendicitis in pregnancy remains a challenging diag-

nosis for the surgeon. Most pregnant women undergoing investi-
gation for suspected acute appendicitis have an alternate diagnosis.
High rates of appendiceal perforation and negative appendectomy
underscore the need for an improved treatment pathway. Our re-
sults are also consistent with other recent literature suggesting that
Alvarado score, neutrophil absolute count, and percentage may be
useful predictive factors in the diagnosis of acute appendicitis in the
pregnant patient. In our series a neutrophil percentage of less than
70% provided a 100% negative predictive value. This finding may be
Fig. 1. Final Diagnoses of pregnant patients presenting with suspected Acute Appen- used to better direct the use of MRI and other diagnostic in-
dicitis. terventions in this patient population and improve care for both
NYD (Not yet diagnosed), AA (Acute Appendicitis), UTI (Urinary Tract Infection), MSK
patients and the system.
(Musculoskeletal).

References
delay. Even in a center with a well-established protocol in the use of
1. Zingone F, Sultan AA, Humes DJ, West J. Risk of acute appendicitis in and
MRI as first line imaging for this condition in pregnancy, 43% of
around pregnancy. Ann Surg. 2015;261:332e337.
patients in our series had evidence of perforation by the time of 2. Pastore PA, Loomis DM, Sauret J. Appendicitis in pregnancy. J Am Board Fam
operation. Additionally the negative appendectomy rate in our Med. 2006;19:621e626.
study was 17%, in keeping with published figures of 17e33%,1,15e18 3. Flexer SM, Tabib N, Peter MB. Suspected appendicitis in pregnancy. Surgeon.
2014;12:82e86.
and much higher than published rates in the non-pregnant popu- 4. Franca Neto A H de, Amorim MMRD, No
brega BMSV. Acute appendicitis in
lation of 4.4%.18 This underscores the need to improve the reliability pregnancy: literature review. Rev Assoc Med Bras. 2015;61:170e177.
and efficiency of our diagnostic pathway to expedite definitive care 5. Alvarado A. A practical score for the early diagnosis of acute appendicitis. Ann
Emerg Med. 1986;15:557e564.
while avoiding unnecessary operative risk and healthcare resource 6. Tatli F, Yucel Y, Gonzeneli O, et al. The Alvarado Score is accurate in pregnancy:
utilization. a retrospective case-control study. Eur J Trauma Emerg Surg. 2019;45:411e416.
There was a relatively high rate of appendectomies performed 7. Tamir IL, Bongard FS, Klein SR. Acute appendicitis in the pregnant patient. Am J
Surg. 1990;160, 571e5e discussion 575e6.
via an open approach in our series (65.7%). While the majority of 8. Aggenbach L, Zeeman GG, Cantineau AEP, Gordijn SJ, Hofker HS. Impact of
these were via a McBurney’s incision, this still represents a devia- appendicitis during pregnancy: No delay in accurate diagnosis and treatment.
tion from the contemporary standard laparoscopic approach. Pre- Int J Surg. 2015;15:84e89.
9. Israel GM, Malguria N, McCarthy S, Copel J, Weinreb J. MRI vs. ultrasound for
viously it was thought that laparoscopic appendectomy may confer suspected appendicitis during pregnancy. J Magn Reson Imag. 2008;28:
a higher risk of fetal loss as compared to open appendectomy27 for 428e433.
AA. Subsequently an updated metaanalysis by Lee et al.28 has 10. Lehnert BE, Gross JA, Linnau KF, Moshiri M. Utility of ultrasound for evaluating
the appendix during the second and third trimester of pregnancy. Emerg Radiol.
suggested no difference in fetal loss rate between laparoscopic and
2012;19:293e299.
open appendectomy. Our high rate of open appendectomies, 11. Burke LMB, Bashir MR, Miller FH, et al. Magnetic resonance imaging of acute
particularly earlier in our study period may reflect this practice appendicitis in pregnancy: a 5-year multiinstitutional study. Am J Obstet
change. Additionally, one surgeon at our institution routinely per- Gynecol. 2015;213:693. e1e6.
12. Burns M, Hague CJ, Vos P, Tiwari P, Wiseman SM. Utility of magnetic resonance
forms appendectomies via the open approach as a matter of pref- imaging for the diagnosis of appendicitis during pregnancy: a Canadian
erence. This may account for the high proportion of open experience. Can Assoc Radiol J. 2017;68:392e400.
appendectomies in our study. 13. Pedrosa I, Lafornara M, Pandharipande PV, Goldsmith JD, Rofsky NM. Pregnant
patients suspected of having acute appendicitis: effect of MR imaging on
Our study has several limitations. Our review was retrospective negative laparotomy rate and appendiceal perforation rate. Radiology.
and performed at a single tertiary center. Our method of patient 2009;250:749e757.
identification relied on MRI requisitions, which could have led to 14. Al-Qudah S, M Amr A, Sroujieh AM. Appendectomy in pregnancy: the expe-
rience of a university hospital. Journal of Obstetrics and Gynaecology. 2009;19:
selection bias and an underestimation of pregnant AA cases. 362e364.
Additionally, as many patients were transferred from other in- 15. McGory ML, Zingmond DS, Tillou A, Hiatt JR, Ko CY, Cryer HM. Negative ap-
stitutions to receive their imaging we had limited access to follow pendectomy in pregnant women is associated with a substantial risk of fetal
loss. J Am Coll Surg. 2007;205:534e540.
up data, thus some complications and pregnancy outcomes could 16. Theilen L, Mellnick VM, Shanks AL, et al. Acute appendicitis in pregnancy:
not be captured. Finally, 21 patients in our study had insufficient predictive clinical factors and pregnancy outcomes. Am J Perinatol. 2017;34:
records to provide a final diagnosis potentially biasing our results. 523e528.
17. Segev L, Segev Y, Rayman S, Nissan A, Sadot E. Acute appendicitis during
In the future, we hope to use our findings to advocate for
pregnancy: different from the nonpregnant state? World J Surg. 2016;41:
expedited investigation of these patients towards operative deci- 75e81.
sion making given the high rate of perforation observed in our 18. Won RP, Friedlander S, Lee SL. Management and outcomes of appendectomy
study. We plan to perform a cost analysis that focuses on the re- during pregnancy. Am Surg. 2017;83:1103e1107.
19. Abbasi N, Patenaude V, Abenhaim HA. Management and outcomes of acute
sources required to facilitate the transfer of pregnant patients with appendicitis in pregnancy-population-based study of over 7000 cases. BJOG An
suspected AA for evaluation with MRI and how increasing access to Int J Obstet Gynaecol. 2014;121:1509e1514.
this modality might save unnecessary diagnostic delay and hospital 20. Wei P-L, Keller JJ, Liang H-H, Lin H-C. Acute appendicitis and adverse preg-
nancy outcomes: a nationwide population-based study. J Gastrointest Surg.
transfers without further intervention. We plan to use this work 2012;16:1204e1211.
towards the development of a care pathway that reliably identifies 21. Sahbaz NA, Bat O, Kaya B, et al. The clinical value of leucocyte count and
pregnant patients with acute appendicitis to expedite definitive neutrophil percentage in diagnosing uncomplicated (simple) appendicitis and
predicting complicated appendicitis. Ulus Travma Acil Cerrahi Derg. 2014;20:
treatment, while better directing diagnostic resource utilization for 423e426.
patients and providers. 22. Hajibandeh S, Hajibandeh S, Hobbs N, Mansour M. Neutrophil-to-lymphocyte

Please cite this article as: Gentles JQ et al., Is neutrophilia the key to diagnosing appendicitis in pregnancy?, The American Journal of Surgery,
https://doi.org/10.1016/j.amjsurg.2020.03.018
Downloaded for FK UMI Makassar ([email protected]) at University of Muslim Indonesia from ClinicalKey.com by Elsevier on April 25, 2020.
For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.
 J.Q. Gentles et al. / The American Journal of Surgery xxx (xxxx) xxx 5

ratio predicts acute appendicitis and distinguishes between complicated and 2007;5:192e197.
uncomplicated appendicitis: a systematic review and meta-analysis. Am J Surg. 26. Ueberrueck T, Koch A, Meyer L, Hinkel M, Gastinger I. Ninety-four appendec-
2019;219:1e10. tomies for suspected acute appendicitis during pregnancy. World J Surg.
23. Kelly ME, Khan A, Mudassar R, et al. The utility of neutrophil-to-lymphocyte 2004;28:508e511.
ratio as a severity predictor of acute appendicitis, length of hospital stay and 27. Prodromidou A, Machairas N, Kostakis ID, et al. Outcomes after open and
postoperative complication rates. Dig Surg. 2015;32:459e463. laparoscopic appendectomy during pregnancy: a meta-analysis. European
24. Yazar FM, Urfalioglu A, Bakacak M, Boran OF, € Bülbülog lu E. Efficacy of the Journal of Obstetrics and Gynecology. 2018;225:40e50.
evaluation of inflammatory markers for the reduction of negative appendec- 28. Lee SH, Lee JY, Choi YY, Lee JG. Laparoscopic Appendectomy versus Open Ap-
tomy rates. Indian J Surg. 2018;80:1e7. pendectomy for Suspected Appendicitis during Pregnancy: A Systematic Review
25. Yilmaz HG, Akgun Y, Bac B, Celik Y. Acute appendicitis in pregnancy d risk and Updated Meta-Analysis. 2019:1e12. https://doi.org/10.1186/s12893-019-
factors associated with principal outcomes: a case control study. Int J Surg. 0505-9.

Please cite this article as: Gentles JQ et al., Is neutrophilia the key to diagnosing appendicitis in pregnancy?, The American Journal of Surgery,
https://doi.org/10.1016/j.amjsurg.2020.03.018
Downloaded for FK UMI Makassar ([email protected]) at University of Muslim Indonesia from ClinicalKey.com by Elsevier on April 25, 2020.
For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.