Peritoneovaginal Fistula and Appendicitis-Related Pelvic Abscess in Pregnancy

Abstract

Appendicitis in pregnancy is the most common nonobstetric surgical emergency. Pregnancy causes changes in anatomy, which could lead to uncertainty regarding the diagnosis of appendicitis. This case report describes a case of appendicitis presenting with peritoneovaginal fistula in a pregnant woman in the second trimester, with interesting finding of isolated appendiceal endometriosis on pathology. The importance of complete physical examination, including speculum examination, is emphasized in the pregnant patient presenting with acute-onset abdominal pain. Imaging criteria for diagnosis of appendicitis should be adjusted to account for the gravid uterus, which may cause appendiceal abscess to appear in a variety of locations, such as posterior to the cervix, as in this case.

Keywords: acute appendicitis during pregnancy; appendiceal abscess; appendiceal endometriosis; peritoneovaginal fistula.

Fig. 1

5x2cm complex collection in posterior cul-de-sac, consistent with multiloculated abscess, seen here in 2 views.

Fig. 2

Histopathological appearance of the appendix. Haematoxylin and eosin staining. Low power view (20X) of the appendix. The lumen was show on the left (labeled with star). Decidulized endometriosis was present in the lamina propria, muscularis mucosa, submucosa and muscularis propria (labled with arrow heads).

Fig. 3

High power power view (200X) showing endometrial glands (black arrow) and decidualized stroma (blue arrow). Acute inflammatory infiltrates with numerous neutrophils are present (angled arrow).