by 
Adamina M, Andreou A, Arezzo A, Christogiannis C, Di Lorenzo N, Gioumidou M, et al. EAES rapid guideline: systematic review, meta-analysis, GRADE assessment, and evidence-informed European recommendations on appendicitis in pregnancy. Surg Endosc. 2022;36:8699–712. https://link.springer.com/10.1007/s00464-022-09625-9.
Recommendations
•We recommend operative treatment over conservative management in pregnant patients with complicated appendicitis or appendicolith on imaging studies. (strong recommendation)
•We suggest operative treatment over conservative man- agement in pregnant patients with uncomplicated appen- dicitis and no appendicolith on imaging studies. (weak recommendation)
• We suggest laparoscopic appendectomy* in patients with acute appendicitis until the 20th week of gestation, or when the fundus of the uterus is below the level of the umbilicus. (weak recommendation)
•We suggest laparoscopic* or open appendectomy in patients with acute appendicitis beyond the 20th week of gestation, or when the fundus of the uterus is above the level of the umbilicus, depending on the expertise and preference of the surgeon. (weak recommendation)
*Laparoscopic appendectomy with open establishment of pneumoperitoneum.
Explication/Comments
Acute appendicitis occurs in 1 out of 1000 pregnancies for 6.3 cases per 1000 patient years.
Evidence to decision considerations for Q1: surgery versus conservative management
The panel agreed that the evidence was extremely scarce. Appendectomy was associated with increased risk of minor complications, and conservative management was associated with increased risk of fetal loss. Recent evidence suggests that failed non-operative management is associated with higher odds of preterm delivery, preterm labor, or abortion (odds ratio, 1.45; 95% confidence interval, 1.24–1.68), antepartum hemorrhage (odds ratio, 1.56; 95% confidence interval, 1.05–2.31), (odds ratio, 3.44; 95% confidence interval, 1.56–7.61), amniotic infection (odds ratio, 4.74; 95% confidence interval, 2.76–8.13), pneumonia (odds ratio, 2.01; 95% confidence interval, 1.37–2.94), and sepsis (odds ratio, 1.58; 95% confidence interval, 1.25–1.99).
Evidence to decision considerations for Q2: Laparoscopic versus open surgery
Summary evidence suggests an increased risk of fetal loss for laparoscopic compared to open appendectomy. However, the panel considers that this is likely due to residual confounding. Most studies did not define the distribution of patients receiving laparoscopic or open surgery among trimesters. It can be well hypothesized that laparoscopic surgery was more often practiced in the first half of pregnancy, an open surgery in the second half of pregnancy. The baseline risk of fetal loss is substantially higher in the 1st trimester compared to the 2nd and 3rd trimesters, which likely resulted in identifying a spurious effect in favor of open surgery Indeed, in a post hoc review of the data, 6 out of 22 studies
reported on the trimester of pregnancy in the event of fetal loss, and in only 3 the distribution of events was similar between groups. Sensitivity analysis of these studies did not suggest superiority of either approach with regard to fetal loss, albeit with very wide confidence interval. Under consideration of the above, the panel considered that there is no reliable information on this outcome The risk of preterm delivery and minor complications were lower with laparoscopic surgery.