Acute appendicitis in pregnancy

Authors
Andrei Rebarber, MD
Brian P Jacob, MD
Section Editors
Charles J Lockwood, MD, MHCM
Deborah Levine, MD
Martin Weiser, MD
Deputy Editor
Kristen Eckler, MD, FACOG
All topics are updated as new evidence becomes available and our peer review process is
complete.
Literature review current through: Dec 2015. | This topic last updated: Nov 18, 2015.
INTRODUCTION Acute appendicitis is the most common general surgical problem
encountered during pregnancy [1]. The diagnosis is particularly challenging during pregnancy
because of the relatively high prevalence of abdominal/gastrointestinal discomfort, anatomic
changes related to the enlarged uterus, and the physiologic leukocytosis of pregnancy.
Appendiceal rupture occurs more frequently in pregnant women, especially in the third
trimester, possibly because these challenges and reluctance to operate on pregnant women
delay diagnosis and treatment [2,3].
INCIDENCE Acute appendicitis is suspected in 1/600 to 1/1000 pregnancies and confirmed
in 1/800 to 1/1500 pregnancies [4-7]. In a case control study of 53,000 women undergoing
appendectomy, pregnant women were less likely to have appendicitis than age-matched,
nonpregnant women [8]. The incidence of appendicitis was slightly higher in the second
trimester than in the first and third trimesters or postpartum. In addition, cohort study of over
350,000 pregnancies reported that the rate of acute appendicitis was 35 percent lower during
the antepartum period than the time outside of pregnancy. This study reported the lowest
rates of appendicitis during the third trimester [9]. For women aged 15 to 34 years, there was
no increased risk in postpartum appendicitis compared with the time outside of pregnancy. In
contrast, an 84 percent increased risk of postpartum appendicitis was reported for women
older than 35 years.
CLINICAL FEATURES
Patient presentation In the "classic" presentation, the patient describes the onset of
abdominal pain as the first symptom. The pain is periumbilical initially and then migrates to
the right lower quadrant as the inflammatory process progresses [10-12]. Anorexia, nausea
and vomiting, if present, follow the onset of pain. Fever up to 101.0F (38.3C) and
leukocytosis develop later.

However, many patients have a nonclassical presentation, with symptoms such as heartburn,
bowel irregularity, flatulence, malaise, or diarrhea. If the appendix is retrocecal, patients often
complain of a dull ache in the right lower quadrant rather than localized tenderness. Rectal or
vaginal examination in such patients is more likely to elicit pain than abdominal examination.
A pelvic appendix can cause tenderness below McBurney's point (described below); these
patients often complain of urinary frequency and dysuria or rectal symptoms, such as
tenesmus and diarrhea. The spectrum of clinical and laboratory findings associated with acute
appendicitis is described in detail separately [13]. (See "Acute appendicitis in adults: Clinical
manifestations and differential diagnosis".)
Pregnant women are less likely to have a classic presentation of appendicitis than
nonpregnant women, especially in late pregnancy. The most common symptom of
appendicitis, ie, right lower quadrant pain, occurs close to McBurney's point in the majority of
pregnant women, regardless of the stage of pregnancy [5,14,15]; however, the location of the
appendix migrates a few centimeters cephalad with the enlarging uterus, so in the third
trimester, pain may localize to the mid or even the upper right side of the abdomen [16-18].
McBurney's point tenderness is described as maximal tenderness at 1.5 to 2 inches from the
anterior superior iliac spine (ASIS) on a straight line from the ASIS to the umbilicus [19]. This
tenderness may be less prominent during pregnancy because the gravid uterus lifts and
stretches the anterior abdominal wall away from the inflamed appendix [20-22]. Since direct
contact between the area of inflammation and parietal peritoneum is impeded, there is less
rebound tenderness or guarding. The gravid uterus may also inhibit contact between the
omentum and the inflamed appendix.
The largest review describing the frequency of the clinical signs and symptoms of appendicitis
in pregnancy included 720 cases reported in the literature [23]. The strength of this review is
its size, which is 10-fold larger than other series; however, it has several limitations, including
nonconsecutive selection of cases and case ascertainment prior to widespread use of current
diagnostic imaging procedures. The following summary illustrates the cumulative frequency of
signs and symptoms of appendicitis reported in this review. It does not account for differences
in frequency according to gestational age and consists of a case mix of 75 percent acute
inflammation only and 25 percent perforation.
Symptoms:
Abdominal pain: 96 percent
Right lower quadrant: 75 percent

Right upper quadrant: 20 percent

Nausea: 85 percent
Vomiting: 70 percent
Anorexia: 65 percent
Dysuria: 8 percent

Signs:
Right lower quadrant tenderness: 85 percent
Rebound tenderness: 80 percent
Abdominal guarding: 50 percent
Rectal tenderness: 45 percent
Right upper quadrant tenderness: 20 percent
Temperature >37.80 Celsius (1000 F): 20 percent
Laboratory Approximately 80 percent of nonpregnant patients with appendicitis have a
preoperative leukocytosis (white cells >10,000cells/microL) and a left shift in the differential
[23-26]. However, mild leukocytosis can be a normal finding in pregnant women: the total
leukocyte count may be as high as 16,900 cell/microL in the third trimester (table 1), rising as
high as 29,000 cells/microL during labor, and a slight left shift may occur [27,28]. (See
"Hematologic changes in pregnancy", section on 'White blood cells'.) In a retrospective review
of 66,993 consecutive deliveries including 67 women with a probable diagnosis of acute
appendicitis, the mean leukocyte counts in women with proven appendicitis and in those with
histologically normal appendices were 16,400 cells/microL and
14,000 cells/microL, respectively [5].
Microscopic hematuria and pyuria may occur when the inflamed appendix is close to the
bladder or ureter, but these findings are generally reported in less than 20 percent of patients
[20,23,29-32].

Mild elevations in serum bilirubin (total bilirubin >1.0 mg/dL) have been described as a marker
for appendiceal perforation (sensitivity 70 percent and specificity 86 percent [33]).
An elevated c-reactive protein level occurs in appendicitis, but is a nonspecific sign of
inflammation.
DIAGNOSIS Acute appendicitis is a histological diagnosis. The clinical diagnosis should be
strongly suspected in pregnant women with classic findings: abdominal pain that migrates to
the right lower quadrant, right lower quadrant tenderness, nausea/vomiting, fever, and
leukocytosis with left shift (see 'Clinical features' above).
With a nonclassical presentation, which often happens in pregnancy, imaging is indicated
[1,4,32]. The primary goal of imaging is to reduce delays in surgical intervention due to
diagnostic uncertainty. A secondary goal is to reduce, but not eliminate, the negative
appendectomy rate. In these cases, ultrasound may reveal the probable cause of the patients
symptoms (eg, ovarian cyst or torsion, degeneration or torsion of a fibroid, nephrolithiasis,
cholecystitis).
The diagnosis of acute appendicitis in a laboring patient requires a high index of suspicion, is
especially difficult, and may not be possible. Labor can be associated with pain that may be
lateralized, fever if chorioamnionitis is present, leukocytosis, and vomiting. Persistence or
progression of these symptoms after delivery should prompt physical examination and
imaging studies to evaluate for appendicitis.
Imaging
Ultrasonography The initial modality of choice for diagnostic imaging of the appendix in
pregnancy is graded compression ultrasonography [34]. The clinical diagnosis of suspected
appendicitis is supported by identification of a noncompressible blind-ended tubular structure
in the right lower quadrant with a maximal diameter greater than 6 mm (image 1A-B) [35,36].
The diagnosis should not be excluded if the appendix appears normal, unless sonographic
findings suggest a likely alternative diagnosis (eg, ovarian torsion, nephrolithiasis).
Test performance appears to be lower in pregnant women than nonpregnant individuals
because the gravid uterus can interfere with visualizing the appendix and performing graded
compression, particularly in the third trimester, leading to inconclusive ultrasound findings
[37-39]. Several studies reported nonvisualization of the appendix in a large percentage of
pregnant women with suspected appendicitis [40-44]. However, in one review of studies of
the value of ultrasound in diagnosing appendicitis in pregnancy, sensitivity ranged from 67 to
100 percent and specificity ranged from 83 to 96 percent, compared to general population in

whom sensitivity and specificity were 86 and 96 percent, respectively [45]. We believe that
the wide variation in the reported diagnostic performance of graded compression
ultrasonography for appendicitis during pregnancy is due to multiple factors such as
gestational age, maternal body mass index (BMI), and importantly, the training and
experience of the sonologist or radiologist. (See "Diagnostic imaging procedures during
pregnancy" and "Acute appendicitis in adults: Clinical manifestations and differential
diagnosis".)
Magnetic resonance imaging For pregnant women whose ultrasound examination is
inconclusive for appendicitis, magnetic resonance imaging (MRI) is the preferred next test as it
avoids the ionizing radiation of computed tomography and appears to be cost-effective
(image 2) [34,46,47]. When MRI is performed in pregnant women, gadolinium is not routinely
administered because of theoretical fetal safety concerns, but may be used if essential [48].
(See "Diagnostic imaging procedures during pregnancy", section on 'Magnetic resonance
imaging'.)
MRI has a high sensitivity and specificity for diagnosing appendicitis during pregnancy. In the
largest study of over 700 pregnant women with abdominal or pelvic pain suspected of having
acute appendicitis, 61 women had surgically confirmed disease out of 66 women with
suggestive MRI findings (ie, appendiceal dilation, appendicolith, free fluid, and fat stranding)
[49]. Based on this detection rate, the study reported the following pooled data for MRI
assessment of appendicitis in pregnant women:
Positive predictive value 92.4 percent (95% CI 83.2-97.5)
Negative predictive value 99.7 percent (95% CI 98.9-99.9)
Sensitivity 96.8 percent (95% CI 89-99.6)
Specificity 99.2 percent (95% CI 98.2-99.8)
Accuracy 99.0 percent (95% CI 98.0-99.6)
Of the five women with false-positive MRI studies, pathologic evaluation identified one
ovarian torsion, one appendicolith with mild lymphoid hyperplasia, one fibrous obliteration of
the appendiceal lumen without changes of acute appendicitis, and two normal appendices.
Compared with ultrasound, additional benefits of MRI include potential identification of periappendiceal findings when the appendix is not visualized and recognition of other causes of
abdominal pain. In the above study, of 207 women whose appendix was not visible on MRI,

three were surgically diagnosed with appendicitis; two women had positive secondary MRI
findings (ie, right lower quadrant fluid and pericecal stranding) for appendicitis and one
woman had a negative MRI [49]. Of 643 pregnant women whose MRI studies were negative
for appendicitis, 72 women had alternate MRI findings that could have accounted for their
acute pain.
If there is a prolonged wait time for MRI evaluation, the risk of potential appendiceal rupture
is balanced against the potential benefits of the study, such as identifying a different cause of
pain or avoiding surgery. If MRI if not readily available, then computed tomography (CT) scan
can be performed if the diagnosis is unclear. If either imaging modality is not available quickly
or if the patient declines CT because of the radiation exposure, surgery should not be delayed
in pregnant women with findings suggestive of appendicitis despite inconclusive ultrasound
results.
Computed tomography CT is generally widely available. The main findings of appendicitis
on CT are right lower quadrant inflammation, an enlarged nonfilling tubular
structure, and/or an appendicolith (image 3). The initial experience with helical computed
tomography for the diagnosis of appendicitis in pregnancy appears promising, but data are
limited to small case series [50]. Modifications to the CT protocol can limit estimated fetal
radiation exposure to less than 3 mGy, well below doses known to potentially cause adverse
fetal effects (30 mGy for risk of carcinogenesis, 50 mGy for deterministic effects [51,52]), and
do not limit diagnostic performance [50,53]. Standard abdominal CT scanning with an oral
contrast preparation and intravenous contrast or a specialized appendiceal CT scanning
protocol can also be used, but are associated with higher fetal radiation exposure (20 to 40
mGy [52,54]). The relative advantages and disadvantages of the two protocols and what
constitutes a positive study are described separately. (See "Acute appendicitis in adults:
Clinical manifestations and differential diagnosis", section on 'Imaging studies'.)
We perform CT when clinical findings and ultrasound examination are inconclusive and MRI is
not available, given the proven diagnostic value of CT in nonpregnant individuals: overall
sensitivity 94 percent (95% CI 91-95), specificity 95 percent (95% CI 93-96), positive likelihood
ratio 13.3 (95% CI 9.9-17.9), and negative likelihood ratio 0.09 (95% CI 0.07-0.12) [55].
Data from studies in pregnant women are more limited. A meta-analysis of three
retrospective studies in pregnant women reported the sensitivity and specificity of CT in cases
of normal/uncertain ultrasonography were: sensitivity 85.7 percent (95% CI 63.7-96) and
specificity 97.4 percent (95% CI 86.2-99.9) [56]. These studies included 2 to 49 patients with
appendicitis. In one of the studies, the negative laparotomy rates among patients who
underwent (1) clinical examination alone, (2) clinical evaluation and ultrasound examination,
and (3) clinical evaluation and ultrasound examination followed by CT were 54

percent (7/13), 36 percent (20/55), and 8 percent (1/13), respectively [38]. The ultrasound
studies were interpreted as either diagnostic of appendicitis or as normal/inconclusive, thus
the authors did not determine whether CT was useful after a normal versus an inconclusive
ultrasound study. (See "Diagnostic imaging procedures during pregnancy", section on 'Effects
of ionizing radiation on the fetus' and "Acute appendicitis in adults: Clinical manifestations
and differential diagnosis", section on 'Imaging studies'.)
DIFFERENTIAL DIAGNOSIS The differential diagnosis of suspected acute appendicitis
includes disorders typically considered in nonpregnant individuals (see "Acute appendicitis in
adults: Clinical manifestations and differential diagnosis", section on 'Differential diagnosis').
In addition, pregnancy-related causes of lower abdominal pain, fever,
leukocytosis, nausea/vomiting, and changes in bowel function, need to be considered:
The possibility of ectopic pregnancy should be excluded in any woman with a positive
pregnancy test and right lower quadrant pain. (See "Ectopic pregnancy: Clinical manifestations
and diagnosis".)
Indigestion, bowel irregularity, nausea/vomiting, and malaise are common symptoms of
both appendicitis and normal early pregnancy. In appendicitis, nausea and vomiting, if they
occur, follow the onset of pain, whereas nausea and vomiting of pregnancy are not associated
with pain. (See "Clinical manifestations and diagnosis of early pregnancy".)
Round ligament syndrome is a common cause of mild right lower quadrant pain in early
pregnancy, but is not associated with other symptoms and is not progressive. (See "Clinical
manifestations and diagnosis of early pregnancy".)
Pyelonephritis is more common in pregnant women than in nonpregnant women. Pregnant
women with right-sided pain, fever, leukocytosis, and pyuria may be treated for
pyelonephritis without further investigation, in which case the actual diagnosis of appendicitis
may be delayed.
In the second half of pregnancy, preeclampsia and HELLP syndrome can be associated
with nausea/vomiting and abdominal pain, but in contrast to appendicitis, the pain is usually
in the right upper quadrant or epigastrium, hypertension is usually present, and fever and
leukocytosis are atypical. (See "Preeclampsia: Clinical features and diagnosis" and "HELLP
syndrome".)
Abruptio placenta and uterine rupture are associated with lower abdominal pain, which may
be midline or lateral. Unlike appendicitis, both diagnoses are often associated with vaginal

bleeding, fetal heart rate abnormalities, and uterine tenderness. (See "Placental abruption:
Clinical features and diagnosis" and "Uterine dehiscence and rupture after previous cesarean
delivery".)
In postpartum patients, ovarian vein thrombophlebitis (OVT) should be considered. These
patients usually present within one week after delivery and appear clinically ill; symptoms may
include fever and abdominal pain and tenderness localized to the right if the right ovarian vein
is affected. Nausea, ileus, and other gastrointestinal symptoms may occur but are usually
mild, which may be helpful in distinguishing right-sided OVT from appendicitis. (See "Septic
pelvic thrombophlebitis", section on 'Ovarian vein thrombophlebitis'.)
MANAGEMENT AND SHORT-TERM OUTCOME
Appendectomy The treatment of acute appendicitis is appendectomy, which is curative.
Perioperative antibiotic treatment should provide Gram-negative and Gram-positive coverage
(eg, a second-generation cephalosporin) and coverage for anaerobes (eg, clindamycin or
metronidazole). Management with antibiotic therapy alone is not recommended because it is
associated with both short-term and long-term failure, with minimal data in pregnant patients
[57]. (See "Management of acute appendicitis in adults", section on 'Role of nonoperative
management'.)
Prompt diagnosis and surgical intervention are indicated, as delaying surgical intervention for
more than 24 hours after symptom onset increases the risk of perforation [2,40], which occurs
in 14 to 43 percent of such patients. Maternal morbidity following appendectomy is
comparable to that in nonpregnant women and low [58], except in patients in whom the
appendix has perforated. Importantly, the risk of fetal loss is increased when the appendix
perforates (fetal loss 36 versus 1.5 percent without perforation [59]) or when there is
generalized peritonitis or a peritoneal abscess (fetal loss 6 versus 2 percent; early delivery 11
versus 4 percent [60]).
Given the difficulties in the clinical diagnosis of appendicitis and the significant risk of fetal
mortality if the appendix perforates, a higher negative laparotomy rate (20 to 35 percent)
compared to nonpregnant women is generally considered acceptable. Aggressive use of
radiologic imaging, especially magnetic resonance (MR) and computed tomography (CT)
scanning, has the potential to reduce the incidence of negative appendectomy. There is some
evidence that the higher rate of negative laparotomy in pregnant women is linked, at least in
part, to a reluctance to perform preoperative CT in these patients [38,61]. (See 'Imaging'
above.)

A normal-appearing appendix should be removed because histological examination may

reveal acute inflammation, excision avoids the potential for future evaluation and intervention
for suspected appendicitis, and appendectomy is associated with a very low risk of
complications.
Cesarean delivery is rarely indicated at the time of appendectomy. For patients who remain
undelivered, the risk of dehiscence of the appendectomy incision during labor and vaginal
delivery should not be increased when the fascia has been appropriately reapproximated [6].
Perforated appendix The management of appendiceal perforation depends on the nature
of the perforation: free versus walled-off.
Free perforation A free perforation can cause intraperitoneal dissemination of pus and
fecal material. These patients are typically quite ill and may be septic; they are at increased
risk of preterm labor and delivery and fetal loss [59,60]. Urgent laparotomy is necessary for
appendectomy with irrigation and drainage of the peritoneal cavity.
Walled-off perforation Nonpregnant patients who present with a long duration of
symptoms (more than five days) and have findings of a contained perforation can be treated
initially with antibiotics, intravenous fluids, bowel rest, and close monitoring. These patients
will often have a palpable mass on physical examination and imaging may reveal a phlegmon
or abscess. Many of these patients will respond to nonoperative management since the
appendiceal process has already been "walled-off." Moreover, immediate surgery in patients
with a long duration of symptoms and phlegmon formation is associated with increased
morbidity due to dense adhesions and inflammation. Under these circumstances,
appendectomy often requires extensive dissection and may lead to injury of adjacent
structures. Complications such as a postoperative abscess or enterocutaneous fistula may
ensue, necessitating an ileocolectomy or cecostomy. Because of these potential
complications, a nonoperative approach is a reasonable option if the patient is not illappearing. (See "Management of acute appendicitis in adults", section on 'Nonoperative
approach'.)
Although there is good evidence to support this approach to walled-off perforation in
nonpregnant individuals, there is only sparse evidence in pregnant women. In a single report
including only two patients, antibiotic therapy (ampicillin, gentamicin, and clindamycin),
intravenous fluids, and bowel rest were associated with improvement in symptoms over two
to three days [57]. In one patient, interval appendectomy was performed two months postvaginal delivery. In the other patient, appendectomy was performed at cesarean delivery
because of breech presentation with preterm labor; this patient had an appendiceal
phlegmon that had been treated conservatively seven weeks earlier, but with recurrence of

acute appendiceal inflammation. In both cases, treatment with antenatal glucocorticoids to

induce fetal lung maturation and tocolytics was avoided due to concerns of suppressing
clinical manifestations of worsening infection and delaying delivery if intraamniotic infection
was also present. On the other hand, a letter to the editor described two deaths related to
appendicitis in pregnant women who appeared to recover after treatment with antibiotics
and were discharged from the hospital [62]. Until more information on nonoperative
management of ruptured, but contained, appendicitis during pregnancy is available, we
suggest that these patients be carefully monitored in the hospital for maternal sepsis and
preterm labor.
While there is some support for interventional drainage of appendiceal abscesses in children,
there is no information regarding such management in pregnant patients.
SURGICAL APPROACH When the diagnosis is relatively certain, both open and a
laparoscopic appendectomy are considered. No randomized trials have been performed to
suggest that one technique is better than another, and the choice of technique should be
based on the surgeons experience level. The intraoperative management of pregnant women
undergoing non-obstetric surgery and monitoring of the fetus are reviewed separately. (See
"Management of the pregnant patient undergoing nonobstetric surgery".)
Open appendectomy When performing an open appendectomy in a pregnant woman, a
transverse incision is made at McBurney's point or, more commonly, over the point of
maximal tenderness [14,15]. When the diagnosis is less certain, we suggest a lower midline
vertical incision since it permits adequate exposure of the abdomen for diagnosis and
treatment of surgical conditions that mimic appendicitis. A vertical incision can also be used
for a cesarean delivery, if subsequently required for the usual obstetric indications. It is
prudent to minimize traction on the uterus and uterine manipulation, although an association
between these maneuvers and preterm birth is unproven.
Laparoscopic appendectomy Case reports, case series and small cohort studies on the use
of laparoscopic appendectomy in pregnancy suggest that laparoscopy can be performed
successfully during all trimesters and with few complications [4,63-74]. The decision to
proceed with a laparoscopic approach should take into consideration the skill and experience
of the surgeon, as well as clinical factors such as the size of the gravid uterus. Suggestions for
modification of laparoscopic technique during pregnancy include slight left lateral positioning
of the patient during the second half of pregnancy, avoiding the use of any cervical
instruments, use of open entry techniques or placement of trocars under direct visualization,
and limiting intraabdominal pressure to less than 12 mmHg [75]. The Society of American
Gastrointestinal and Endoscopic Surgeons (SAGES) guidelines recommend insufflation

pressures of 10 to 15 mm Hg and that the port position should be adapted for fundal height
[76]. (See "Laparoscopic surgery in pregnancy".)
However, concern has been raised that laparoscopic appendectomy may be associated with
higher rates of preterm delivery and fetal loss [77-79]. In a 2012 meta-analysis of 11 studies
that included 3415 women, the risk of fetal loss was greater for laparoscopic versus open
appendectomy in pregnant women [78]. In the largest of the included studies, the rates of
fetal loss in the laparoscopic and open groups were 7 percent and 3 percent, respectively.
Limitations of the studies in this meta-analysis include retrospective design and lack of
adjustment for confounders such as patient age, duration or pregnancy, complications of
appendicitis, surgeon skill, and clinical setting. A subsequent 2014 systematic review that
included many of the above studies stated that while low-grade evidence suggested that
laparoscopic appendectomy during pregnancy may be associated with higher rates of fetal
loss, the evidence was not strong enough to determine the preferred modality of
appendectomy during pregnancy [79].
In our practice, we find the use of laparoscopy safe, especially when patients are
appropriately monitored and no overt signs of preterm labor exist. Laparoscopy affords
optimal visualization and recovery when performed by experienced surgeons. We use slightly
lower intraabdominal pressures of 10 to 12 mmHg (which provides excellent visualization), an
open entry technique, and directly visualized trocar insertion.
LONG-TERM OUTCOME The long-term prognosis for women who undergo appendectomy
during pregnancy seems to be good, but data are limited to small observational series. Such
women do not appear to be at increased risk of infertility or other complications [80]. There is
scant information on long-term outcome in offspring. In a small series of appendectomy at all
stages of pregnancy, children had normal development at 13 to 17 months of age [81].
SUMMARY AND RECOMMENDATIONS
Acute appendicitis is the most common general surgical problem encountered during
pregnancy. (See 'Introduction' above.)
The clinical manifestations of appendicitis in pregnancy are similar to those in nonpregnant
individuals; however, the following points should be noted:
Right lower quadrant pain is the most common symptom and occurs within a few
centimeters of McBurney's point in most pregnant women, regardless of the stage of
pregnancy. In late pregnancy, pain may be the right mid or upper quadrant. Rebound

tenderness and guarding are less prominent in pregnant women, especially in the third
trimester. (See 'Patient presentation' above.)
Mild leukocytosis can be a normal finding in pregnant women: the total leukocyte count may
be as high as 16,900 cell/microL in the third trimester and 29,000 cells/microL during labor, so
leukocytosis may or may not be a sign of appendicitis. (See 'Laboratory' above.)
The clinical diagnosis should be strongly suspected in pregnant women with classic findings:
abdominal pain that migrates to the right lower quadrant, right lower quadrant
tenderness, nausea/vomiting, fever, and leukocytosis with left shift. (See 'Diagnosis' above.)
With a nonclassical presentation, which often happens in late pregnancy, imaging is indicated.
The primary goal of imaging is to reduce delays in surgical intervention due to diagnostic
uncertainty. A secondary goal is to reduce, but not eliminate, the negative appendectomy
rate.
Imaging:
We suggest graded compression ultrasonography in pregnant patients suspected of having
appendicitis. Appendicitis is diagnosed if a noncompressible blind ended tubular structure is
visualized in the right lower quadrant with a maximal diameter greater than 6 mm. (See
'Ultrasonography' above.)
If clinical findings and ultrasound are inconclusive, or in centers where experience with
sonographic examination of the appendix is limited, we suggest magnetic resonance imaging
(MRI), where available, because it avoids fetal exposure to ionizing radiation and performs
well in diagnosis of lower abdominal/pelvic disorders. (See 'Magnetic resonance imaging'
above.)
We suggest computed tomography (CT) when MRI is not available, given its proven value in
nonpregnant individuals. (See 'Computed tomography' above.)
The decision to proceed to laparotomy should be based upon the clinical findings, diagnostic
imaging results, and clinical judgment. Delaying intervention for more than 24 hours increases
the risk of perforation. (See 'Management and short-term outcome' above.)
When the diagnosis is relatively certain, we suggest performing appendectomy through a
transverse incision over the point of maximal tenderness (Grade 2C). When the diagnosis is
less certain, we suggest a lower midline vertical incision (Grade 2C). (See 'Surgical approach'
above.)

ACKNOWLEDGMENT The editorial staff at UpToDate would like to acknowledge William

Barth, Jr, MD, and Joel Goldberg, MD, FACS, who contributed to an earlier version of this topic
review.
Use of UpToDate is subject to the Subscription and License Agreement.
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Disclosures
Disclosures: Andrei Rebarber, MD Nothing to disclose. Brian P Jacob, MD Nothing to
disclose. Charles J Lockwood, MD, MHCMConsultant/Advisory Boards: Celula [Aneuploidy
screening (Prenatal and cancer DNA screening tests in development)]. Deborah Levine,
MDNothing to disclose. Martin Weiser, MD Nothing to disclose. Kristen Eckler, MD,
FACOG Nothing to disclose.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When
found, these are addressed by vetting through a multi-level review process, and through
requirements for references to be provided to support the content. Appropriately referenced
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