Surgical management of acute right lower-quadrant pain in pregnancy: a prospective cohort study

The etiology of right lower-quadrant pain in pregnant patients is a challenge in diagnosis. We discuss the surgical issues among pregnant patients with right lower-quadrant pain and demonstrate the method to diagnosis.

This was a prospective cohort study with enrollment during 2 years. Pregnant patients presenting with acute right lower-quadrant abdominal pain and requiring surgical consult were included. Demographics, gestational age, symptoms, workup, operative results, and pathology were recorded.

One-hundred patients were enrolled, 38 had nonspecific abdominal pain, 15 of whom were admitted. There were no differences in temperature, leukocyte count, and neutrophil shift among the admitted and nonadmitted patients. Forty-one patients underwent surgery and had a substantially higher gestational age, leukocyte count, and neutrophil shift than those who did not. Ultrasound was performed considerably more often on first-trimester patients (81.6%) compared with second- (58.1%) and third-trimester (57.9%) patients, and CT scan was used considerably less in the first trimester compared with the second and third trimesters, and considerably less than ultrasound for the first trimester. Sensitivity of ultrasound for appendicitis was inversely correlated to fetal gestational age, and CT scan retained high sensitivity and specificity throughout pregnancy.

This is one of the first prospective studies assessing diagnoses and workup of pregnant patients with right lower-quadrant pain. We recommend abdominal ultrasound be the first imaging modality for patients for whom surgical consultation is necessary, thereby determining if the pathology is obstetric. If inconclusive, a CT scan is necessary to guide treatment.