Acute appendicitis (pregnancy)

Case contributed by Hoe Han Guan


Pregnant lady (26 weeks of gestation) with right sided abdominal pain and fever for 3 days.

Patient Data

Age: 25 years
Gender: Female

Blind-ending tubular structure noted at the right lumbar region, where it is being displaced superolaterally by the gravid uterus, in keeping with appendix. The appendix is enlarged (diameter 1.2cm) with periappendiceal fat streakiness. No appendicolith, periappendiceal free fluid or collection. No pneumoperitoneum.

Presence of singleton intrauterine fetus.

Annotated image

Red arrows denote the dilated appendix with periappendiceal fat streakiness and adjacent peritoneal thickening.

Case Discussion

Intraoperative findings: acute inflammed appendicitis.

Radiation dose to fetus should be essential part of consideration to justify CT scan study for pregnant patient, especially CT abdomen/pelvis. As the first line of imaging modality ultrasound unable provides the conclusive findings in this case, this patient proceeded with contrast enhanced CT abdomen and pelvis.

The better next imaging modality after ultrasound scan for case of suspected acute appendicitis should be the radiation-free MRI abdomen (without contrast gadolinium as it is contraindicated during pregnancy), by using some specific sequence such as
1. Single-shot turbo spin echo (SSH-TSE) T2-weighted images (WI) in axial, coronal and sagittal planes for anatomy of the appendix
2. T2 weighted fat saturation to look for edema and fluid collection
3. DWI/ADC sequence to look for any restricted diffusion at the cecal pole.

Abdominal pain in pregnancy protocol (MRI)

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