A 32-year-old woman, gravida 2 para 1, at 30 weeks gestation comes to the emergency department due to abdominal pain. Twelve hours ago the patient began to have right-sided abdominal pain that has become progressively worse, and she now has nausea and vomiting. She has irregular contractions but no vaginal bleeding or leakage of fluid. The patient has no chills, dysuria, or urinary frequency. She has chronic hypertension. Her only surgery was a term cesarean delivery for superimposed preeclampsia and breech presentation. Temperature is 38 C (100.4 F), blood pressure is 146/98 mm Hg, and pulse is 102/min. Fetal heart rate tracing shows a baseline of 170/min with moderate variability and no decelerations. Contractions occur every 5-12 minutes. There is moderate tenderness to palpation over the right lateral flank and rebound and guarding on the right side of the abdomen. The uterine fundus is nontender and the cervix is closed. Urinalysis is normal. Which of the following is the best next step in management of this patient?

Question

A 32-year-old woman, gravida 2 para 1, at 30 weeks gestation comes to the emergency department due to abdominal pain.  Twelve hours ago the patient began to have right-sided abdominal pain that has become progressively worse, and she now has nausea and vomiting.  She has irregular contractions but no vaginal bleeding or leakage of fluid.  The patient has no chills, dysuria, or urinary frequency.  She has chronic hypertension.  Her only surgery was a term cesarean delivery for superimposed preeclampsia and breech presentation.  Temperature is 38 C (100.4 F), blood pressure is 146/98 mm Hg, and pulse is 102/min.  Fetal heart rate tracing shows a baseline of 170/min with moderate variability and no decelerations.  Contractions occur every 5-12 minutes.  There is moderate tenderness to palpation over the right lateral flank and rebound and guarding on the right side of the abdomen.  The uterine fundus is nontender and the cervix is closed.  Urinalysis is normal.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d9fd_36c0_bc81_eb8955a87972_MD0003_00 This pregnant patient with fever, nausea and vomiting, and right-sided abdominal pain likely has acute appendicitis. During pregnancy, the appendix undergoes cephalad displacement by the gravid uterus; therefore, with increasing gestational age, patients may have an atypical presentation of pain in the right mid-to-upper quadrant or right flank. Like nonpregnant patients with appendicitis, pregnant patients may have signs of intraabdominal inflammation and peritonitis (eg, rebound, guarding). In addition, pregnant patients may develop obstetric symptoms, including uterine irritability and contractions (due to the proximity of the uterus to the inflamed appendix) and fetal tachycardia (due to maternal fever). Given the atypical presentations of appendicitis in pregnancy, pregnant patients often have a delayed diagnosis and increased risk for complications (eg, appendiceal rupture, fetal demise). Index of suspicion should remain elevated, and confirmatory studies (eg, ultrasound) and surgery (eg, laparoscopic) should not be delayed. (Choice A) Ampicillin and gentamicin are used to treat intraamniotic infection, which can present with fever, abdominal pain, and fetal tachycardia. This patient has no fundal tenderness or rupture of membranes, making this diagnosis unlikely. (Choice B) Concealed placental abruption can be caused by maternal hypertension and typically presents with constant abdominal pain, uterine tenderness, uterine tachysystole, and fetal bradycardia or late decelerations. This patient has irregular contractions and no uterine tenderness, making this diagnosis unlikely. uterine tachysystole (Choice D) At <32 weeks gestation, indomethacin is administered for tocolysis in patients with preterm labor (ie, regular contractions causing cervical dilation). This patient has irregular contractions and a closed cervix. (Choice E) Preeclampsia with severe features can present with maternal hypertension and right upper quadrant pain; magnesium sulfate is required for maternal seizure prophylaxis. Preeclampsia is less likely because this patient has obvious signs of infection (eg, fever, peritoneal signs) and no proteinuria. (Choice F) Ureteral obstruction (eg, nephrolithiasis) may present with colicky flank or abdominal pain. However, this patient has no urinary symptoms (eg, dysuria, urinary frequency) and her urinalysis is normal. Educational objective: Acute appendicitis in pregnancy may have an atypical presentation (eg, right mid-to-upper quadrant or flank pain) due to displacement of the appendix by the uterus. This can result in delayed diagnosis and increased risk for complications (eg, appendiceal rupture, fetal demise). Management is with surgery. References: Appendicitis and cholecystitis in pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/20393411)

A 32-Year-Old Woman, Gravida 2 Para 1, at 30 Weeks