What is the next step in managing a 32-year-old pregnant woman at 24 weeks gestation presenting with acute onset of abdominal pain, fever, vomiting, and leukocytosis (elevated White Blood Cell count), with normal fetal monitoring and no vaginal bleeding?

From the Guidelines

The next step in management for this 32-year-old pregnant woman at 24 weeks gestation with acute abdominal pain should be abdominal ultrasound (option A). This patient presents with concerning symptoms including acute onset of abdominal pain, fever, vomiting, and diffuse tenderness with guarding, suggesting an acute abdominal process requiring prompt diagnosis.

• The clinical presentation of this patient, including fever, leukocytosis, and abdominal pain, is highly suggestive of an acute abdominal process such as appendicitis, which requires prompt and accurate diagnosis.
• Abdominal ultrasound is the preferred initial imaging modality in pregnancy as it avoids radiation exposure to the fetus while still providing valuable diagnostic information about potential causes such as appendicitis, cholecystitis, or other surgical emergencies 1.
• The use of ultrasound in this context is supported by recent guidelines, which recommend ultrasound or MRI abdomen and pelvis without IV contrast as the primary modality for evaluating suspected appendicitis in pregnant patients 1.
• CT scan should be avoided when possible during pregnancy due to radiation risks to the fetus.
• While observation with serial abdominal exams may be appropriate in some cases, the presence of guarding suggests peritoneal irritation requiring more immediate evaluation.
• Exploratory laparoscopy is too invasive as an initial step before attempting non-invasive diagnostic methods. The ultrasound can help identify the cause of her acute abdomen while maintaining safety for both mother and fetus, allowing for appropriate surgical intervention if necessary based on findings.

From the Research

Next Steps in Management

The patient presents with acute onset of abdominal pain, fever, and vomiting, which suggests an acute abdominal condition. Given the patient's pregnancy status, it is essential to consider the safest and most effective diagnostic approach.

• The patient's symptoms and laboratory results, including diffuse tenderness with guarding throughout the abdomen and elevated WBCs, indicate the need for further evaluation.
• Abdominal X-ray series showed dilated bowel loops but no other findings, which may suggest a bowel obstruction or other abdominal pathology.

Diagnostic Considerations

• According to 2, MRI is the preferred imaging modality in pregnant women.
• However, considering the patient's acute presentation and the need for rapid diagnosis, abdominal ultrasound (US) may be a suitable initial imaging test, as stated in 3 and 4.
• US is non-invasive, portable, and does not require radiographic contrast material, making it a relatively safe option for pregnant women.
• Additionally, 5 highlights the importance of abdominal ultrasound in emergency and critical care medicine, emphasizing its ability to rapidly diagnose various abdominal pathologies.

Recommended Course of Action

• Given the patient's symptoms and pregnancy status, the most appropriate next step in management would be to perform an abdominal ultrasound (A) to evaluate for potential causes of acute abdominal pain, such as appendicitis, bowel obstruction, or other abdominal pathologies.
• This approach is supported by 2, which recommends US as the first-line imaging test in pregnant women, and 4, which highlights the utility of US in evaluating bowel disease and acute abdomen.