From the Guidelines
The next best step for a 29-week pregnant woman with right lower quadrant pain, leukocytosis (WBC 22,000), vomiting, and diarrhea when ultrasound cannot visualize the appendix is to proceed with MRI imaging of the abdomen and pelvis without gadolinium contrast. This approach is supported by the most recent guidelines, including the American College of Radiology (ACR) Appropriateness Criteria for right lower quadrant pain, which suggests that MRI abdomen and pelvis without IV contrast is usually appropriate for the initial imaging of a pregnant woman with suspected appendicitis 1.
While awaiting imaging, the patient should receive supportive care, including:
- IV fluids for hydration
- Antiemetics as needed for vomiting
- Appropriate pain management
Surgical consultation should be obtained early, as appendicitis in pregnancy requires prompt intervention to prevent complications such as preterm labor and maternal sepsis. If MRI confirms appendicitis, laparoscopic appendectomy is generally recommended regardless of gestational age, as the risks of delaying surgery typically outweigh the risks of the procedure itself. The high white blood cell count, persistent right lower quadrant pain, and gastrointestinal symptoms strongly suggest appendicitis, which remains the most common non-obstetric surgical emergency during pregnancy.
It's worth noting that the ACR Appropriateness Criteria also discuss the use of ultrasound as the primary imaging modality in pregnant patients with nontraumatic abdominal pain, including appendicitis 1. However, in this case, since ultrasound is unlikely to visualize the appendix, MRI is the preferred next step.
From the Research
Next Best Steps for Diagnosis and Treatment
Given the symptoms of a 29-week pregnant woman with right lower quadrant (RLQ) pain, leukocytosis (white blood cell count of 22), vomiting, and diarrhea, and considering that ultrasound is unlikely to visualize the appendix, the following steps can be considered:
- Prompt Surgical Consultation: The clinical presentation of appendicitis in pregnancy can be misleading, and given the high white blood cell count and symptoms suggestive of appendicitis, early surgical consultation is recommended 2.
- Diagnostic Approach: While ultrasound may not be definitive, it should still be performed as part of the diagnostic approach, as it was useful in guiding the diagnosis in a significant number of cases in previous studies 3.
- Laparoscopy or Laparotomy: The decision between laparoscopy and laparotomy should be made on a case-by-case basis. Laparoscopy is an option, especially in early pregnancy, but the difficulty of operating under laparoscopy increases with the pregnancy term, leading to a higher risk of conversion to open surgery 3, 4, 5.
- Multidisciplinary Team Approach: Management of acute appendicitis in pregnancy should be prompt and undertaken by a multidisciplinary team approach to minimize risks to both mother and fetus 4.
Considerations for Pregnancy
- Gestational Age: The incidence of perforation may increase with gestational age, but this does not necessarily result in increased fetal mortality 6.
- Symptoms and Physical Examination: Abdominal pain is a common symptom, and physical examination findings such as rebound and guarding can be reliable diagnostic tools 6.
- Maternal and Fetal Risks: Acute appendicitis poses significant risks to both maternal and fetal health, emphasizing the need for prompt and accurate diagnosis followed by appropriate surgical intervention 3, 4, 5.