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Abdominal Pain in a Pregnant Woman ▲ PHOTO ROUNDS Maria Muñoz, MD, and Abdominal pain Richard P. Usatine, MD University of Texas in a pregnant woman Health Sciences Center at San Antonio 24-year-old woman, pregnant with were normal, and there was no indication a fetus at 22 weeks gestational age, of contractions. Her abdomen was diffuse- A came to the OB triage area with ly tender, with significant tenderness to abdominal pain, nausea, and vomiting. deep palpation in the right upper quadrant She described a sharp pain that began the at first. There was no rebound or guard- night before, starting at the umbilicus and ing. The psoas sign was negative. The radiating toward her right side; she rated it obturator sign was positive, with increased 7 out of 10. pain 4 out of 10 in the right lower quad- The patient said there had been no con- rant. There were no abdominal masses. tractions, vaginal bleeding or fluid leaking, Digital rectal examination revealed no rec- or dysuria. She reported having GERD at tal masses, and a guaiac stool test result times. She experienced chills the day before, was negative. A few hours later, the tender- but no fever. She had similar pain 1 month ness seemed to move toward the right before that resolved spontaneously, and for lower quadrant (FIGURES 1 AND 2). which a cause was never determined. She had nothing significant in her medical his- tory; family history was noncontributory. ■ What is the most likely On examination, she was afebrile, nor- diagnosis? motensive, and in no apparent distress. Her heart and lungs were normal. Her abdomen was soft and gravid with a fun- ■ How do the ultrasound dal height of 22 cm. Bowel sounds were images help you make present in all 4 quadrants. Fetal heart tones the diagnosis? FIGURE 1 Ultrasound of RLQ FIGURE 2 A second ultrasound of RLQ FEATURE EDITOR Richard P. Usatine, MD University of Texas Health Sciences Center at San Antonio CORRESPONDING AUTHOR Richard P. Usatine, MD, University of Texas Health Science Center at San Antonio, Department of Family and Community Medicine, MC 7794, 7703 Floyd Curl Drive, San Antonio, TX 78229-3900. E-mail: Ultrasound view of right lower quadrant with Second ultrasound view of the patient’s right [email protected] cecum labeled. lower quadrant. www.jfponline.com VOL 54, NO 8 / AUGUST 2005 665 PHOTO ROUNDS FIGURE 3 Appendix: Longitudinal view ■ Making the diagnosis We performed several laboratory analyses, including a complete blood count, chem- istry panel (including electrolytes and liver function studies), amylase, lipase, and a urinalysis. The test results were all normal. She had a white blood cell count of 15,000/µL, which can be normal in preg- nancy. The initial evaluating physician had obtained a right upper quadrant ultra- sound, which showed no gallstones or bilateral hydronephrosis; unfortunately, no attempt was made to visualize the right lower quadrant or appendix at that time. In light of the physical exam findings and the absence of gallstones, the patient Longitudinal view by ultrasound of enlarged appendix with diameter equal to 13 mm (normal was admitted to rule out appendicitis. The is less than 6 mm). surgery team at the university hospital was consulted. They requested a computed FIGURE 4 Appendix: Transverse view tomography (CT) scan of the abdomen with and without contrast. To avoid the risk of radiation to the fetus, the family medicine team spoke with Radiology to obtain another ultrasound. The ultrasound showed an enlarged and inflamed appendix with a transverse diameter of 13 mm (normal is <6 mm) (FIGURES 3 AND 4).1 A graded compres- FAST TRACK sion technique was used to assess the appen- Diagnosis of dix. This involves using pressure of the ultrasound probe starting above the area of appendicitis tenderness and working toward the tender is difficult area while scanning for the appendix. This because many showed obvious peristalsis in the cecum and of the symptoms Transverse view of inflamed appendix by ultra- no movement within the appendix, indicat- sound with wall thickening. ing obstruction or inflammation. occur normally in pregnancy ■ Differential diagnosis The differential diagnosis of abdominal ■ Patient management pain in a gravid patient includes placental and outcome abruption, cholecystitis, pancreatitis, An open appendectomy was performed. appendicitis, intussusception, pyelonephritis, The appendix was inflamed and enlarged round ligament syndrome, hydro- as suspected. The histology showed neu- nephrosis, ovarian torsion, uterine fibroid trophilic infiltration of mucosa, muscle, degeneration, ovarian cysts or tumors, and serosa (FIGURE 5). Postoperatively, the intra-abdominal and rectus muscle patient recovered in Labor and Delivery to abscesses, and Crohn’s disease with diffuse monitor for possible preterm labor. She did peritoneal inflammation. Given the loca- not develop any signs or symptoms of tion of the pain and the lack of vaginal preterm labor, and was transferred to a bleeding, the most likely diagnoses are regular antepartum floor after being cholecystitis and appendicitis. observed for 6 hours. 666 VOL 54, NO 8 / AUGUST 2005 THE JOURNAL OF FAMILY PRACTICE Abdominal pain in a pregnant woman ▲ She did well during her hospitalization, FIGURE 5 Histology and was sent home on post-op day 2. Her abdominal pain had resolved, and she had very little post-op tenderness. ■ Discussion: Appendicitis in pregnancy Acute appendicitis is the most common condition requiring surgery during preg- nancy.2 Suspected appendicitis accounts for nearly two thirds of all nonobstetric exploratory laparotomies performed during pregnancy; most cases occur in the Pathologic specimens showing neutrophilic second and third trimesters. infiltration of mucosa, muscle, and serosa. The incidence of appendicitis is 0.4 to 1.4 per 1000 pregnancies.2 Although the The leukocytosis of pregnancy makes incidence of appendicitis in not increased it difficult to determine if there is an infec- during pregnancy, rupture of the appendix tion. Not all pregnant patients with appen- occurs 2 to 3 times more frequently in dicitis will have a white blood cell count pregnancy secondary to delays in diagnosis greater than 16,000/µL, but approximate- and operation. Maternal and perinatal ly 75% of them will have a left shift in the mortality and morbidity rates are greatly differential.2 A urinalysis may reveal increased when appendicitis is complicated pyuria and hematuria and can mislead the by peritonitis. physician to explain the symptoms as pyelonephritis.2 A difficult diagnosis Diagnosis is difficult because many symp- toms are considered to be normal during ■ Treatment: Appendectomy, FAST TRACK pregnancy. Many times, pain in the right antibiotics if needed Fetal loss is more lower quadrant of the abdomen may be Treatment of nonperforated acute appen- attributed to round ligament pain or uri- dicitis in pregnancy is appendectomy. In likely with severe nary tract infection. After the first the first trimester, a laparoscopic appen- appendicitis than trimester, the appendix is gradually dis- dectomy may be performed.2 Intravenous with intervention; placed above McBurney’s point, with hor- antibiotics are indicated with perforation, izontal rotation of its base. This upward peritonitis or abscess formation.2,5 evaluate displacement occurs until the eighth month Tocolysis is unnecessary in uncompli- abdominal pain of gestation, when more than 90% of cated appendicitis, but may be indicated if in all pregnancies appendices lie above the iliac crest, and the patient goes into labor after 80% rotate upward and toward the right surgery. In the late third trimester, with subcostal area.2,3 perforation or peritonitis, a cesarean The most consistent clinical symptom section is indicated. encountered in pregnant women with appendicitis is vague right-sided abdominal Evaluation is imperative pain.2 Depending on the gestation, muscle Fetal loss may occur in association with guarding and rebound tenderness may preterm labor and delivery or with gener- or may not be present. Nausea, vomiting, alized peritonitis and sepsis, and occurs and anorexia are usually present as in the only rarely in uncomplicated appendicitis. nonpregnant patient. Twenty-five percent Fetal loss appears to be more closely asso- of pregnant patients with appendicitis are ciated with severity of appendicitis than afebrile, as our patient was.2,4 with surgical intervention.2,5,6 www.jfponline.com VOL 54, NO 8 / AUGUST 2005 667 PHOTO ROUNDS TABLE itive predictive value was 90% and 87%; Ultrasound and CT and the negative predictive value was 8 in the diagnosis of appendicitis 64% and 65% (LOE=2a). In conclusion, it is reasonable to use TEST SN SP LR+ LR– graded compression ultrasonography in a pregnant woman with suspected appen- Ultrasound 0.86 0.81 5.8 .019 dicitis. If the suspicion for appendicitis is (0.83–0.88) (0.78–0.84) (3.5–9.5) (0.13–0.27) high, a negative result may still need fur- CT 0.94 0.95 13.3 0.09 ther evaluation with a CT or ultimately (0.91–0.95) (0.93–0.96) (9.9–17.9) (0.07–0.12) lead to abdominal surgery despite negative imaging studies. ■ Sn, sensitivity; Sp, specificity; LR+, positive likelihood ratio; LR–, negative likelihood ratio; CT, computed tomography. Source: Teresawa et al, Ann Intern Med 2004.7 REFERENCES 1. Hansen GC, Toot PJ, Lynch CO. Subtle ultrasound signs of appendicitis in pregnancy. A case report. J Reprod ■ Med 1993; 3:223–224. Imaging test characteristics: 2. Tamir IL, Bongard FS, Klein SR. Acute appendicitis in Is sonography enough? the pregnant patient. Am J Surg 1990; 160:571–576. Thus, it is imperative that any pregnant 3. Hodjati H, Kazerooni, T. Location of the appendix in the gravid patient: a re-evaluation of the established con- patient that comes in to the hospital or cept. Int J Gynecol Obstet 2003; 81:245–247. clinic with abdominal pain be evaluated 4.
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