Assessment of Acute Appendicitis in Pregnant Women: A Systematic Review of Current Evidence

The most frequent nonobstetric surgical emergency during pregnancy is acute appendicitis (AA); however, diagnosing it is still difficult because of anatomical and physiological changes. While magnetic resonance imaging (MRI) has emerged as a possible substitute, traditional methods such as clinical ratings and ultrasound have drawbacks. The latest research on the diagnostic accuracy of clinical scores, laboratory indices, and MRI for AA in pregnant women is compiled in this systematic review. Preferred Reporting Items for Systematic Reviews and Meta-Analyses standards were followed in conducting a systematic review. PubMed, Embase, Cochrane, Scopus, and Web of Science databases were searched from January 2020 to December 2025 for studies evaluating diagnostic tools in pregnant women with suspected appendicitis. Using the Quality Assessment of Diagnostic Accuracy Studies-2 tool, two reviewers independently searched for studies, retrieved data, and evaluated risk of bias. Due to methodological variability, a narrative synthesis was conducted. Fifteen studies were included. MRI demonstrated consistently high specificity and negative predictive value, significantly reducing negative appendectomy rates when used after an inconclusive ultrasound. Clinical scoring systems (e.g., Alvarado, Raja Isteri Pengiran Anak Saleha appendicitis, and Appendicitis Inflammatory Response) showed poor positive predictive value and limited reliability for confirming appendicitis, though they retained utility for initial triage. Compared with conventional indicators such as white blood cell count, novel composite laboratory indices, including the Systemic Immune-Inflammation Index (SII) and Pregnancy Index, showed promising diagnostic accuracy and high specificity. MRI is the cornerstone of noninvasive diagnosis for suspected appendicitis in pregnancy, offering high accuracy and safety. Clinical scores and basic laboratory markers are insufficient for definitive diagnosis but may aid in initial assessment. A sequential diagnostic algorithm utilizing ultrasound first, followed by MRI if inconclusive, is supported by current evidence to optimize maternal and fetal outcomes. Future research should focus on validating pregnancy-specific diagnostic indices and protocols in prospective multicenter studies.