What is the best course of action for a 26-year-old pregnant female presenting with sharp pain in the lower right quadrant of her abdomen?

Management of Pregnant Patient with Right Lower Quadrant Abdominal Pain

For a 26-year-old pregnant female presenting with sharp right lower quadrant abdominal pain, ultrasound should be performed as the first-line imaging modality, followed by MRI if ultrasound is inconclusive, while continuing IV fluids, labs, and OB/GYN consultation. 1

Initial Assessment and Stabilization

• Vital signs monitoring: Assess for fever, tachycardia, hypotension
• IV access and labs: Continue with IV placement and obtain:
  • Complete blood count (leukocytosis may indicate infection/inflammation)
  • Comprehensive metabolic panel
  • C-reactive protein
  • Urinalysis
  • Type and screen
  • Beta-hCG (to confirm pregnancy if not previously documented)

Imaging Algorithm

1. Ultrasound (first-line) 2, 1

   • Abdominal and pelvic ultrasound to evaluate:
     • Appendix (though visualization rates are only ~7-30%)
     • Gallbladder
     • Kidneys/ureters
     • Obstetric assessment (fetal viability, placental location)
     • Adnexal structures (ovarian torsion, cysts)

2. MRI without contrast (second-line) 2, 1

   • Indicated when ultrasound is inconclusive
   • High sensitivity (89-100%) and specificity (93-98%) for appendicitis
   • Can identify alternative diagnoses in up to 43% of cases
   • No radiation exposure to fetus

3. CT scan (third-line) 2, 1

   • Reserve only for when MRI is unavailable and diagnosis remains unclear
   • Consider low-dose CT with oral contrast if MRI unavailable
   • Use judiciously due to radiation exposure to fetus

Differential Diagnosis to Consider

• Appendicitis: Most common non-obstetric surgical emergency in pregnancy 2

  • Right lower quadrant pain remains the most common presenting symptom regardless of gestational age 3
  • Pregnant women more likely to present with complicated/perforated appendicitis 2, 1

• Obstetric causes:

  • Ectopic pregnancy (if early in pregnancy)
  • Round ligament pain
  • Placental abruption
  • Preterm labor

• Other surgical causes:

  • Ovarian torsion
  • Ovarian cyst rupture
  • Ovarian vein thrombosis 4
  • Urolithiasis
  • Inflammatory bowel disease

Management Approach

• OB/GYN consultation: Essential for joint management
• Surgical consultation: If appendicitis or other surgical pathology is suspected
• Antibiotics: If infection suspected, initiate broad-spectrum antibiotics covering gram-negative and anaerobic organisms 1
• Surgical intervention:
  • If appendicitis is confirmed, prompt surgical intervention within 24 hours is recommended 1
  • Laparoscopic approach is preferred when feasible 1

Important Considerations

• Fetal monitoring: Continuous electronic fetal monitoring if >24 weeks gestation
• Positioning: Left lateral decubitus position to avoid vena cava compression
• Thromboprophylaxis: Consider if hospitalization is prolonged 1

Common Pitfalls to Avoid

• Delaying imaging: Do not hesitate to use appropriate imaging when clinically indicated 1
• Attributing symptoms to normal pregnancy: Right lower quadrant pain warrants thorough evaluation 1, 3
• Delaying surgical intervention: Increased risk of maternal and fetal morbidity with delayed diagnosis and treatment 1
• Relying on fever and leukocytosis alone: These are not reliable indicators of appendicitis in pregnancy 3

Early diagnosis with appropriate imaging followed by prompt intervention represents the optimal management strategy for this patient, balancing the risks of delayed diagnosis against unnecessary surgical intervention 1.