Can clinical scoring systems overcome the limitations of diagnostic methods for acute appendicitis in pregnancy?

Acute appendicitis during pregnancy is the most common indication for non-obstetric emergency surgery. However, physiological changes associated with pregnancy can reduce the sensitivity of its clinical signs and symptoms. This study aimed to compare the diagnostic performance of the Alvarado, Appendicitis Inflammatory Response (AIR), Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA), and Tzanakis scoring systems in pregnant patients, as well as to evaluate surgical outcomes.

A total of 39 pregnant patients who underwent surgery for acute appendicitis between January 2017 and January 2025 were retrospectively analyzed. Demographic characteristics, gestational age, clinical presentation, laboratory parameters (white blood cell count [WBC], C-reactive protein [CRP]), ultrasonography findings, surgical approach (open vs. laparoscopic), histopathological results, and maternal and fetal outcomes were recorded. Alvarado, AIR, RIPASA, and Tzanakis scores were calculated for each patient. Patients were stratified into risk categories based on established cut-off values from the literature, and diagnostic performance was assessed against histopathological findings.

The mean age was 26.0±5.3 years, and the mean gestational age was 19.6±7.9 weeks; 53.8% of patients were in the second trimester. Open appendectomy was performed in 61.5% of cases, while 38.5% underwent laparoscopic appendectomy. High-risk classification rates were 66.7% for Alvarado, 69.2% for AIR, and 79.5% for both RIPASA and Tzanakis scores. Histopathology confirmed acute appendicitis in 66.7% of patients, perforated appendicitis in 15.4%, and a normal appendix in 17.9%. WBC and CRP levels were significantly higher in patients with confirmed appendicitis (p<0.05). The highest sensitivity and specificity were observed with the RIPASA (93.7% and 85.7%, respectively) and Tzanakis (90.6% and 71.4%) scoring systems. Laparoscopic surgery was associated with a shorter hospital stay compared to open surgery (p<0.001), with comparable maternal and fetal safety outcomes.

Clinical scoring systems are effective and reliable tools for diagnosing acute appendicitis in pregnant patients, with the RIPASA score demonstrating the highest diagnostic accuracy. Elevated CRP levels and leukocytosis may further support diagnosis. Laparoscopic appendectomy is a safe option associated with a shorter hospital stay compared with open surgery. These findings support the safe use of both clinical scoring systems and laparoscopic surgery in pregnant patients.