Appendicitis in Pregnancy – Quick Consult
Last Updated / Reviewed: June 2022
Key History
Key Physical Exam
Risk Factors for Appendicitis
Differential Diagnosis
Diagnostic Testing
Clinical Risk and Safety Pearls
Treatment
ACEP Policy 

Key History

  • Anorexia
  • Nausea
  • Vomiting
  • Pain is usually present before nausea and vomiting.
  • Constipation or diarrhea
  • Indigestion
  • Low grade temperature
  • 25% of pregnant women will rupture their appendix before diagnosis.
  • Maintain a high clinical suspicion in patients with “new” abdominal pain.

Pregnant women are less likely to have a classic presentation of appendicitis. This is especially true in late pregnancy. The most common symptom of appendicitis – right lower quadrant pain – occurs close to McBurney’s point in the majority of pregnant women, regardless of the stage of pregnancy. However, the location of the appendix migrates a few centimeters toward the right upper quadrant with the enlarging uterus. Thus, in the third trimester, pain may be localized to the mid or even the upper right quadrant of the abdomen.

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Key Physical Exam

  • Tender abdominal exam especially in the RLQ
  • Tenderness in McBurney’s point (point 1/3 of proximal line extending from the anterior superior iliac crest to umbilicus)
  • Pain may be higher – even RUQ, in later pregnancy as the gravid uterus crowds the abdomen (controversial whether this actually occurs).
  • Rebound suggests perforation.
  • Rebound may be present and suggests perforation.
  • Psoas, Obturator and Rovsing’s sign present less than 1/3 of the time.
  • Psoas sign – pain in RLQ with extension to the right hip
  • Obturator sign – pain in RLQ with internal rotation of hip
  • Rovsing’s sign – pain in RLQ with palpation of LLQ
  • May have tenderness during rectal and pelvic exam
  • Dull ache associated with retro-cecal appendix
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Risk Factors for Appendicitis

Several risk factors are mentioned in the texts, but there is probably only one that impacts decision-making. Appendicitis can occur at any age, but the peak incidence correlates with the time period when appendiceal lymphoid tissue is maximal, between the ages of 11 and 20. Over two-thirds of appendicitis cases develop before age 30. However, it is important to remember that about 10% of the cases of appendicitis occur in patients less than 10 years old, and another 10% in patients over 50 years of age.

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Differential Diagnosis

Gastrointestinal Genitourinary Cardiovascular
  • Appendiceal neoplasm
  • Appendicitis
  • Cecal diverticulitis
  • Cholecystitis
  • Cholelithiasis
  • Constipation
  • Crohn's disease
  • Diverticulitis
  • Gastroenteritis
  • GERD
  • GI Bleed
  • Hepatitis
  • Intestinal obstruction
  • Irritable bowel syndrome
  • Meckel’s diverticulitis
  • Mesenteric adenitis
  • Omental torsion
  • Pancreatitis
  • Peptic ulcer disease
  • Perforated ulcer
  • Peritonitis
  • Small bowel obstruction
  • Typhlitis
  • Nephritis
  • Pyelonephritis
  • Renal colic
  • Ureterolithiasis
  • Urinary tract infection
Gynecological Other
  • Dysmenorrhea
  • Ectopic pregnancy
  • Endometriosis
  • Pelvic inflammatory disease
  • Ruptured cyst
  • Tubal ovarian abscess
  • Twisted ovarian cyst
  • Ovarian torsion
  • Diabetes ketoacidosis
  • Hemolytic uremic syndromes
  • Herpes zoster
  • Henoch schoenlein purpura
  • Pneumonia
  • Sickle Cell Crisis
  • Streptococcal pharyngitis

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Diagnostic Testing

Text / literature information and recommendations include:
  1. Labs:
    • WBC - May be elevated or may be normal; however, leukocytosis can be a normal finding in pregnant women. The white count may range from 6,000-16,000 in the first and second trimesters and may rise as high as 20,000-30,000 during labor.
    • Serum C reactive protein (CRP)
    • Urinalysis may show hematuria or pyuria-found in up to 1/3 of patients with appendicitis.
  2. Imaging - Obtain early surgical consultation before imaging in straightforward cases of suspected appendicitis in adults. Imaging is not universally necessary but may be of benefit in certain populations.
    • Graded compression ultrasound. Ultrasound should be the initial imaging modality of choice in pregnant females. Typical findings in appendicitis are a thickened, noncompressible appendix > 6 mm in diameter. A meta-analysis by Doria et al. lists the overall sensitivity of ultrasound as 88% and 83% and its specificity as 94% and 93% for children and adults, respectively.
    • MRI. MRI may be considered as another reliable imaging technology in the evaluation of acute appendicitis, particularly in pregnant women.
    • Noncontrast CT. Unenhanced, noncontrast head CT should be considered an acceptable imaging modality in the workup of acute appendicitis, but it would not be the first choice in pregnant women. There is controversy over the use of IV and oral contrast. Many centers continue to use one or both.
    • KUB. Plain radiography is generally not helpful. Findings are typically nonspecific. An appendicolith may be visualized in up to 50% of children with appendicitis.
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Clinical Risk and Safety Pearls

  • In pregnancy, RLQ pain is the most common symptom of appendicitis. Recent studies refute the past held belief that the location of the appendix migrates upward changing the presentation. The studies show the vast majority of pregnant women have RLQ tenderness within a few centimeters of McBurney’s point, regardless of the stage of pregnancy.
  • Maternal risk following appendectomy is low unless the appendix has perforated. Fetal risk however is significant in the first and second trimesters.
  • Pain is usually before nausea and vomiting, unlike gastroenteritis where nausea and vomiting usually occur first.
  • Pelvic exam is an important part of the evaluation for appendicitis.
  • Use serial evaluations over several hours to improve diagnostic accuracy in patients with unclear causes of abdominal pain.
  • Collect a complete data set before reaching a differential diagnosis; consider a systemic data collection tool, such as a prompted chart.
  • UA may show hematuria or pyuria – found in up to 1/3 of patients with appendicitis.
  • Taking a history of symptoms immediately prior to onset of pain is helpful in determining diagnosis.
  • Early in the presentation the abdominal exam may be unremarkable.

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Treatment

Common text / literature recommendations include:
  • Surgery - Surgery remains the most common approach to treatment.
  • IV hydration
  • Pain medication
  • A single dose of cefoxitin (2 g IV) or cefotetan (2 g IV) or the cefazolin (2 g if < 120 kg, or 3 g if ≥ 120 kg IV) plus metronidazole (500 mg IV). If patient is allergic to penicillins and cephalosporins, clindamycin plus one of the following: ciprofloxacin, levofloxacin, gentamicin, or aztreonam.

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ACEP Policy

The most recent guidelines from the American College of Emergency Physicians were published in 2010. This was a clinical policy with a focus on 3 or 4 critical issues related to abdominal pain and appendicitis. Subsequent evidence has rendered most of the issues moot, so they will not be reproduced here. There are no subsequent updates or publications on the subject.

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  1. Abbasi N, Patenaude V, Abenhaim HA. Management and outcomes of acute appendicitis in pregnancy-population-based study of over 7000 cases. BJOG. 2014; 121:1509.
  2. Basaran A, Basaran M. Diagnosis of acute appendicitis during pregnancy: A systematic review. Obstet Gynecol Surv. 2009;64(7):481-488.
  3. Butala P, Greenstein AJ, Sur MD, Mehta N, Sadot E, Divino CM. Surgical management of acute right lower-quadrant pain in pregnancy: A prospective cohort study. J Am Coll Surg. 2010;211(4):490-494.
  4. Dai L, Shuai J. Laparoscopic versus open appendectomy in adults and children: A meta-analysis of randomized controlled trials. United European Gastroenterol J. 2017;5(4):542-553.
  5. Di Saverio S, Birindelli A, Kelly MD, et al. WSES Jerusalem guidelines for diagnosis and treatment of acute appendicitis. World J Emerg Surg. 2016;11:34.
  6. Doria AS, Moineddin R, Kellenberger CJ, et al. US or CT for diagnosis of appendicitis in children and adults? A meta-analysis. Radiology. 2006;241(1):83-94.
  7. Expert Panel on Gastrointestinal Imaging; Garcia EM, Camacho MA, Karolyi DR, et al. ACR Appropriateness Criteria®: Right Lower Quadrant Pain-Suspected Appendicitis. J Am Coll Radiol. 2018;15(11S):S373-S387.
  8. Gorter RR, Eker HH, Gorder-Starn MA, et al. Diagnosis and management of acute appendicitis. EAES consensus development conference 2015. Surg Endosc. 2016;30(11):4668-4690.
  9. Harnoss JC, Zelienka I, Probst P, et al. Antibiotics versus surgical therapy for uncomplicated appendicitis: Systematic review and meta-analysis of controlled trials (PROSPERO 2015). Ann Surg. 2017;265(5):889-900.
  10. Hlibczuk V, Dattaro J, Jin Z, et al. Diagnostic accuracy of noncontrast computed tomography for appendicitis in adults: a systematic review. Ann Emerg Med. 55: 51, 2010.
  11. House JB, Bourne CL, Seymour HM, Brewer KL. Location of the appendix in the gravid patient. J Emerg Med. 2014; 46:741.
  12. Howell J, Eddy O, Lukens T, et al. Clinical policy: critical issues in the evaluation and management of emergency department patients with suspected appendicitis. Ann Emerg Med. 55: 71, 2010. [PMID: 20116016]
  13. McGory, ML, Zingmond, DS, Tillou, A, et al. Negative appendectomy in pregnant women is associated with a substantial risk of fetal loss. J Am Coll Surg 2007; 205:534.
  14. Oto, A, Ernst, RD, Shah, R, Koroglu, M, et al. Right-lower-quadrant pain and suspected appendicitis in pregnant women: evaluation with MR imaging-Initial experience. Radiology 2005; 234:445.
  15. Pates JA, Avendanio TC, Zaretsky MV, et al. The appendix in pregnancy: confirming historical observations with a contemporary modality. Obstet Gynecol. 2009; 114:805.
  16. Salminen P, Paajanen H, Rautio T, et al. Antibiotic therapy vs appendectomy for treatment of uncomplicated acute appendicitis: the APPAC randomized clinical trial. JAMA. 2015;313(23):2340-2348.
  17. Sartelli M, Baiocchi GL, Di Saverio S. Prospective Observational Study on acute Appendicitis Worldwide (POSAW). World J Emerg Surg. 2018;13:19.
  18. Sartelli M, Viale P, Catena F, et al. 2013 WSES guidelines for management of intra-abdominal infections. World J Emerg Surg. 2013;8(1):3.
  19. Talan DA, Saltzman DJ, Mower WR, et al. Antibiotics-first versus surgery for appendicitis: a US pilot randomized controlled trial allowing outpatient antibiotic management. Ann Emerg Med. Published online ahead of print Dec. 11, 2016. [PMID: 19733421]
  20. Zingone F, Sultan AA, Humes DJ, West J. Risk of acute appendicitis in and around pregnancy: a population-based cohort study from England. Ann Surg. 2015; 261:332.

This is intended solely as reference material and is not a recommendation for any specific patient. The practitioner must rely upon his or her own professional judgment and medical decision-making to determine whether it is relevant in a particular case. Materials are derived from medical and nursing texts, medical literature and national guidelines and should not be considered complete or authoritative. Users must rely on specific patient presentation, experience and judgment when utilizing any of the information contained herein relative to an actual patient.
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