Indexing Title:  HABalucating 06-07

MAR Title: Appendicitis in Pregnancy

Date of Medical Observation: August 2006

Narration:

During one of our tour of duty at the ER, our team received a referral from the Department of Obstertrics and Gynecology regarding a 20-year old pregnant patient with right lower quadrant pain. 

The referral was for further evaluation and management of abdominal pain.  Their working impression was G1P0 PU 20-weeks AOG, NIL to consider Acute Appendicitis.

As the 1st year of our team, I would usually be the one to take the referral and be the first one to assess the patient and refer it to my senior. 

The patient’s history revealed a sudden onset of epigastric pain, 1 day prior to consult which localized the right lower quadrant area with associated anorexia, vomiting of previously ingested food and undocumented low grade fever.

Patient was crying in severe pain when I was examining her.  My abdominal examination showed direct and rebound tenderness in the right lower and right upper quadrant area but with no muscle guarding.  She also has costovertebral tenderness. 

Her laboratory results showed WBC count of 11.1 with 64% neutrophil count.  Her urinalysis showed 15-20 pus cells per hpf and 0-1 rbc per hpf with moderate epithelial cells.

I referred the patient to my senior with an primary impression of UTI with 60 % certainty and acute appendicitis with 40% certainty as my secondary impression.  My senior resident agreed with my clinical impression. 

He requested a graded compression ultrasound but the radiology resident-on-duty was unable to visualize the appendix.  Nevertheless, she did a transvaginal ultrasound which revealed intrauterine pregnancy with good fetal movement.  The patient’s ovaries and adnexae were normal.

We signed out the patient as UTI 60%, acute appendicitis 40%. We suggested to maintain the patient on NPO, to start IV fluids and IV antibiotics and we will monitor her abdominal status.

On her 1st hospital day, patient’s abdominal pain disappeared with no fever and vomiting.  She was then monitored for one more day for any recurrence of symptomps but there was none.  She was then discharged with a final diagnosis of UTI.

Insights (Stimulus, Discovery, Reinforcement) (Physical, Psychosocial, Ethical)

It was my first time to encounter such patient.  The diagnosis of acute appendicitis pregnant patient should be one of the skills that I should learn in my training as a surgery resident. 

I believe I will encounter more of these kinds of patients in my training. Perhaps, it will really be acute appendicitis and I would get a chance to operate on the patient.

For a starter, some lectures I have a read from the book would help me diagnose acute appendicitis in pregnancy when I again encounter such patient.

1.  Appendicitis is the most common surgical problem in pregnancy.

2.  The most reliable symptom of appendicitis during pregnancy is periumbilical or diffuse abdominal pain that later localizes to the right lower quadrant.

 3.  Although as the gravid uterus grows, it pushes the appendix cephalad and posteriorly, right lower quadrant pain remains the most consistent symptom of appendicitis in any trimester.

4.  Abdominal guarding and rebound tenderness is present in 60% to 70% of patients with appendicitis; however, these findings are less common during the third trimester because of the laxity of the abdominal wall muscles

5.  It can be differentiated from adnexal or uterine pain with the help of the Adler sign: if the point of maximal tenderness shifts medially with repositioning on the left lateral side, the etiology is generally adnexal or uterine.

6.  A urinalysis is necessary to rule out a urinary tract infection, which occurs in 10% to 20% of pregnant women.

7.  USG can be done to visualize an inflamed appendix.