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. 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, as recommended by the American College of Radiology 1. CT scan (option B) should be avoided if possible due to radiation risks to the fetus. While observation (option C) might be reasonable for milder presentations, this patient's guarding suggests peritoneal irritation requiring immediate diagnosis rather than watchful waiting. Exploratory laparoscopy (option D) is too invasive as a first diagnostic step before attempting non-invasive imaging. The ultrasound can help identify the cause of her acute abdomen while maintaining fetal safety, allowing for appropriate surgical intervention if necessary based on specific findings, and is supported by recent studies such as the 2022 update of the ACR Appropriateness Criteria for right lower quadrant pain 1. Key points to consider in the management of this patient include:
- The importance of avoiding radiation exposure to the fetus whenever possible
- The need for prompt diagnosis and treatment of acute abdominal conditions in pregnancy
- The role of abdominal ultrasound as a safe and effective initial imaging modality in pregnancy
- The potential for other diagnostic modalities, such as MRI, to be used if ultrasound is inconclusive or if further evaluation is needed, as suggested by studies such as Vasileiou et al 1.
From the Research
Patient Assessment and Management
The patient presents with acute onset of abdominal pain, fever, and vomiting, which are concerning symptoms for several abdominal conditions, including appendicitis. Given the patient's 24 weeks pregnancy, it's crucial to consider the risks and benefits of various diagnostic approaches.
Diagnostic Considerations
- The patient's symptoms and physical examination findings, such as diffuse tenderness with guarding throughout the abdomen, suggest an acute abdominal condition.
- Laboratory results, including a white blood cell count of 15,000, support the presence of an inflammatory process.
- Abdominal X-ray series showed dilated bowel loops but no other findings, which may indicate an obstruction or ileus.
Imaging Options
- Abdominal Ultrasound (A): According to 2, point-of-care abdominal ultrasound can be useful in evaluating acute abdominal pain and detecting conditions such as appendicitis, small bowel obstruction, and gastrointestinal perforation.
- Pelviabdominal CECT (B): While CT scans are highly sensitive for detecting appendicitis, as discussed in 3, they involve radiation, which may be a concern in pregnant patients.
- Admit and Observation with Serial Abd Exam (C): This approach may be considered if the diagnosis is unclear, but it may delay definitive treatment.
- Exploratory Laparoscopy (D): This is a more invasive approach that may be considered if other diagnostic methods are inconclusive or if the patient's condition worsens.
Next Steps
Given the patient's pregnancy and the need for a timely diagnosis, an abdominal ultrasound (A) may be the most appropriate next step, as it is a non-invasive, non-radiation-based imaging modality that can help diagnose appendicitis and other abdominal conditions, as discussed in 2 and 4. If the ultrasound is inconclusive, other imaging modalities, such as MRI, may be considered, as discussed in 4 and 5.