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 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 that requires prompt diagnosis.

Key Considerations

• Abdominal ultrasound is the preferred initial imaging modality in pregnancy because 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 American College of Radiology recommends ultrasound or MRI abdomen and pelvis without IV contrast as the initial imaging for pregnant women with right lower quadrant pain, fever, leukocytosis, and suspected appendicitis 1.
• CT scan (option B) should be avoided if possible due to radiation risks to the fetus, although it may be necessary in certain cases where ultrasound and MRI are inconclusive or not available 1.
• While observation (option C) might be reasonable for milder presentations, this patient's guarding suggests peritoneal irritation requiring immediate diagnosis.
• Exploratory laparoscopy (option D) is too invasive as a first diagnostic step before attempting non-invasive imaging.

Diagnostic Approach

• The ultrasound can help identify the cause of her acute abdomen while maintaining fetal safety, allowing for appropriate surgical intervention if necessary based on findings.
• If the ultrasound is inconclusive, further imaging with MRI or CT may be considered, depending on the clinical suspicion and availability of imaging modalities 1.

Prioritizing Fetal Safety

• The primary concern in managing acute abdominal pain in pregnancy is to balance the need for prompt diagnosis and treatment with the need to minimize radiation exposure to the fetus 1.
• Abdominal ultrasound is a safe and effective initial imaging modality that can help achieve this balance.

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 physical examination findings, such as diffuse tenderness and guarding, suggest an acute abdominal condition that requires further evaluation.
• The use of abdominal X-ray series showed dilated bowel loops, which may indicate an obstruction or other bowel-related issue.

Diagnostic Approach

Considering the patient's pregnancy status and the need for a safe and effective diagnostic approach, the following options are available:

• Abdominal ultrasound (A) is a non-invasive and safe diagnostic tool that can be used to evaluate the patient's symptoms, as suggested by studies 2, 3, 4, 5, 6.
• Pelviabdominal CECT (B) may not be the best initial choice due to the patient's pregnancy status and the potential risks associated with radiation exposure.
• Admit and observation with serial abdominal exam (C) may be considered, but it is essential to have a diagnostic approach to guide management.
• Exploratory laparoscopy (D) is an invasive procedure that may not be necessary as an initial step.

Recommended Next Step

Based on the available evidence, the recommended next step in management would be to perform an abdominal ultrasound (A) to evaluate the patient's symptoms and guide further management, as suggested by studies 2, 3, 4, 5, 6. This approach is non-invasive, safe, and can provide valuable information to guide further management.