The American Journal of Surgery (2009) 198, 753–758

The Southwestern Surgical Congress

Diagnosis of appendicitis in pregnancy

Michael Freeland, M.D., Erin King, M.D., Karen Safcsak, R.N.,
Rodney Durham, M.D.*

Department of Surgery, Orlando Regional Medical Center, 86 W. Underwood, Orlando, FL 32806, USA

KEYWORDS: Abstract
Pregnancy; BACKGROUND: The diagnosis of appendicitis in pregnant patients is challenging.
Appendicitis; METHODS: The records of pregnant patients with suspected appendicitis were reviewed.
Computed RESULTS: Forty-seven patients with suspected appendicitis were identified. Twenty-four patients
tomography; did not undergo surgery. Twenty-three patients had ultrasound (US), none of which visualized the
Ultrasound appendix. Seventeen patients were followed up clinically and improved. Six patients had a negative
computed tomography (CT) and none required surgery. Twenty-three patients underwent surgery for
presumed appendicitis. Three patients had no imaging. Twelve patients had US only; US was positive
in 5 patients and all had appendicitis. Seven patients who underwent surgery had a nondiagnostic US.
One patient had appendicitis. Seven patients had a positive CT and appendicitis at surgery. One patient
had a positive US and magnetic resonance imaging, and had appendicitis. A total of 43 patients had US,
of which 86% were nondiagnostic. Six US were read as positive and all patients had appendicitis.
Thirteen patients had CT with no false-positive or false-negative results.
CONCLUSIONS: US, when read as positive, requires no further confirmatory test other than surgery.
If US is nondiagnostic, further imaging may avoid a negative appendectomy.
© 2009 Elsevier Inc. All rights reserved.

Appendicitis is the most common general surgical emer-
gency in the pregnant population. However, pregnant pa-
tients with suspected appendicitis present a diagnostic di-
lemma.1–3 Vomiting and anorexia are common in pregnant
patients without appendicitis. Pregnant patients with appen-
dicitis may not present with right lower-quadrant pain be-
cause the appendix is displaced into the upper abdomen as
the pregnancy progresses. Fever is not present in many
patients and white blood cell counts may not be useful
because these patients have a physiologic leukocytosis.
The clinical diagnosis of appendicitis balances the risk of
perforation if the diagnosis is delayed against the risk of a
negative appendectomy. In the past, an aggressive surgical
approach was taken in these patients because it was believed
* Corresponding author. Tel.: ⫹1-813-601-1763; fax: ⫹1-850-475-4619.
E-mail address: chinon66@hotmail.com
Manuscript received March 10, 2009; revised manuscript May 18, 2009
that dangers of perforation to the mother and fetus greatly
exceeded the danger associated with a negative appendec-
tomy. This resulted in negative appendectomy rates of 30%
to 50% in some series.2,3 However, more recently it has
become apparent that proceeding directly to the operating
room for a diagnosis is not without consequences. In one
study, 30% of all pregnant women undergoing appendec-
tomy who sustained a fetal loss or early delivery had a
negative appendectomy.4
Although some institutions have interdisciplinary proto-
cols in place for the work-up of pelvic and lower abdominal
pain in pregnant women, other institutions do not have a
uniform approach to these patients. Surgeons, obstetricians,
and radiologists may have differing opinions about the di-
agnostic accuracy and consequences to the fetus of the
various diagnostic modalities available. The basic diagnos-
tic evaluation usually consists of a history and physical
examination, laboratory testing, and a pelvic or fetal ultra-

0002-9610/$ - see front matter © 2009 Elsevier Inc. All rights reserved.
doi:10.1016/j.amjsurg.2009.05.023
754 The American Journal of Surgery, Vol 198, No 6, December 2009

Table 1 Demographics
Age, y Gestation, wk
Nonsurgical management (n ⫽ 24) 26 ⫾ 4 15.2 ⫾ 7.5
Negative appendectomy (n ⫽ 6) 26 ⫾ 6 14.3 ⫾ 9.7
Appendicitis (n ⫽ 17) 28 ⫾ 6 20.1 ⫾ 8.4
Total (n ⫽ 47) 27 ⫾ 5 16.8 ⫾ 8.4
(range, 4–36)
sound (US). Although graded compression US has been
reported to have an accuracy of 98% in diagnosing appen-
dicitis in pregnant patients, we have found it less reliable in
our practice and have found it helpful to obtain additional
studies such as computed tomography (CT) scans and mag-
netic resonance imaging (MRI).5
The purpose of the current study was to examine diag-
nostic modalities, treatment, and outcomes in pregnant
women suspected of having appendicitis.
Materials and Methods
The records of all pregnant patients with abdominal pain
evaluated by the acute care surgical service at a busy wo-
men’s hospital that averaged approximately 13,000 deliver-
ies per year were examined. Clinical presentation, trimester
of pregnancy, diagnostic modalities used, treatment ren-
dered, final diagnosis, and outcomes for the mother and the
fetus were recorded. The data were collected from October
2003 to September 2008 and included approximately
65,000 live births. Information gathered included the history
and physical examination, all laboratory tests, all imaging
studies, and their timing from the patient’s presentation, the
diagnostic results and management plans, surgical logs (in-
cluding findings at time of surgery and pathology of spec-
imen[s] removed), and the delivery information (consisting
of viability at time of birth, weeks’ gestation at birth, and
physical examination/birth defects). CT scans were per-
formed with intravenous and oral contrast. MRI was per-
formed without gadolinium. Radiologic studies were con-
sidered nondiagnostic if on the final written report the
radiologist was unable to confirm or exclude the diagnosis
of appendicitis. Presenting data between patients with and
without appendicitis were compared using the Student t test
with significance set at a P value of less than .05.
Results
Forty-seven patients with suspected appendicitis were
identified over the 5-year period (Table 1). The clinical
presentations for these patients are presented in Table 2.
Twenty-four patients were managed nonsurgically (Fig.
1). One patient was evaluated based solely on clinical ex-
amination. The remaining 23 patients had one or more US,
none of which visualized the appendix. Of these 23 patients,
17 were followed up clinically with no further diagnostic
imaging and improved. The remaining 6 patients had a CT
of the abdomen and pelvis, all of which showed a normal
appendix. There were no false-negative scans. Of the non-
surgically managed patients receiving a CT scan, 3 patients
were in the third trimester, 2 patients were in the second
trimester, and 1 patient was at 8 weeks’ gestation. Each
patient evaluated by CT and managed nonsurgically deliv-
ered a healthy baby.
Twenty-three patients underwent surgery for appendici-
tis, of whom 17 patients (73.9%) had appendicitis confirmed
by the pathologic specimen and 6 patients (26.09%) had
negative appendectomies. Four patients underwent laparo-
scopic appendectomies. All of these patients were in the first
or second trimester (19 weeks) and each delivered a healthy
baby at term. In the remaining 19 patients who underwent
open procedures there was 1 fetal demise and another
patient with premature labor at 33 weeks. Neither of
these outcomes was related directly to the appendectomy.
The remaining patients with open procedures who had
follow-up evaluation (9 of 17) delivered healthy babies at
term. The diagnostic evaluation before surgery is presented in
Figure 2.
Five patients had an US that was diagnostic of appendi-
citis. One of these patients subsequently had an MRI that
also was positive for appendicitis. All of these patients had
appendicitis at surgery confirmed by the pathology speci-
men.
Seventeen patients had a nondiagnostic US. Six of these
patients underwent surgery without further diagnostic stud-
ies and had negative appendectomies. The mean duration of
pain before surgery for these patients was 6.6 days (range,

Table 2 Clinical presentation

Median temperature Nausea/ RLQ Point Median Duration
(range) Median WBC (range) vomiting pain tenderness of pain, d (range)
Nonsurgical management (n ⫽ 24) 98.3 ⫾ 1.1 (97.3–101.8) 11.4 ⫾ 3.9 (4.2–23.2) 70.80% 54.20% 29.20% 2.3 ⫾ 2.8 (1–14)
Negative appendectomy (n ⫽ 6) 98.8 ⫾ 1.2 (97.4–100.3) 8.9 ⫾ 3.2 (5.3–15.0) 83.30% 50.00% 50.00% 6.7 ⫾ 5.0 (1–14)
Appendicitis (n ⫽ 17) 98.6 ⫾ .8 (97.5–100.6) 14 ⴞ 5.1* (4.9–24.6) 76.50% 82.4%* 58.8%* 1.5 ⫾ 1.2* (1–5)
Bold values are statistically significant at P ⬍ .05.
*P ⬍ .05 comparing patients with appendicitis versus patients without appendicitis (nonsurgical mananagement ⫾ negative appendectomy).
M. Freeland et al. Appendicitis in pregnancy
Nonoperative manangement - 24 patients
Nondiagnostic US - 23 patients
Clinical exam only – 1 patient
Clinical follow up - 17 patients
Figure 1 Pregnant patients with suspected appendicitis who were managed nonoperatively.
2–16 d; standard deviation [SD], 5.1 d). Three of the pa-
tients with negative appendectomies were in the third tri-
mester and 3 of the patients were in the first trimester. In one
of the negative procedures, unbeknownst to the surgeon, the
appendix had been removed previously. One patient (17%)
had a gynecologic cause for her abdominal pain. This pa-
tient, who was in the third trimester, had an intraoperative
consult for a tubo-ovarian abscess with adhesions to the
appendix. Of the patients with negative appendectomies, 2
were lost to follow-up evaluation and 2 had normal infants
including the patient with the tubo-ovarian abscess. One
patient who had an open appendectomy in the first trimester
developed severe pre-eclampsia and had a premature deliv-
ery at 33 weeks’ gestation. This infant had an APGARS
score of 5 and 7 and required a prolonged stay in the
neonatal intensive care unit. Finally, fetal demise occurred
in 1 patient 4 weeks after a negative open appendectomy
performed in the first trimester. Neither the early delivery
nor the fetal demise were related directly to the appendec-
tomy.
Five patients who had a nondiagnostic US were taken to
surgery without further imaging and were found to have
Figure 2 Pregnant patients with suspected appendicitis who underwent an operation.
755
CT scan – 6 patients
CT scan visualized appendix in all and was
read as negative for appendicitis.
appendicitis. In these 5 patients, the mean white blood cell
count was 12.5 (range, 10.9 –17.3; SD, 2.7), and all 5
patients had localized tenderness (Table 2). The average
duration of pain before presentation was 1.8 days (range,
1–5 d; SD, 1.7 d). The mean weeks’ gestation was 21
(range, 8 –36 wk; SD, 9.9 wk). One of these patients who
was at 36 weeks’ gestation had abruptio placenta and vag-
inal hemorrhage. She was found to have a perforated ap-
pendicitis at the time of cesarean section. Neither the ap-
pendicitis nor the abruption was identified by US.
Six patients with a nondiagnostic US subsequently were
evaluated by CT. All 6 of these scans were diagnostic for
appendicitis and the diagnosis was confirmed at surgery. An
additional patient was evaluated by CT only. The CT scan
was positive for appendicitis and the diagnosis was con-
firmed at surgery.
Of the 47 patients suspected of having appendicitis, 43
had an US (Table 3). Five of the 43 US were positive for
appendicitis and this was confirmed at surgery. None of the
remaining 38 US were interpreted as excluding the diagno-
sis of appendicitis. This resulted in 38 of 43 (88%) US being
read officially as nondiagnostic. Of the patients with non-
756
Table 3 Radiologic evaluation of pregnant patients with
suspected appendicitis
Total Positive Nondiagnostic Negative
US 43 5 (11.6%) 38 (88.4%) 0 to the disease process has been advocated to avoid progres-
CT 13 7 0 6 sion to appendiceal perforation, which has been associated
MRI 1 1 0 0
There were 38 nondiagnostic US: appendicitis, 9 patients (23.7%)
had appendicitis; 29 patients (76.3%) did not have appendicitis.
diagnostic US, 9 had appendicitis and 29 patients did not
have appendicitis.
Thirteen of the 47 patients had a CT (Table 3). There
were no false-positive or false-negative results. The mean
weeks’ gestation for patients undergoing a CT scan was
23.1 (range, 8 –36 wk; SD, 7.8 wk), with 12 of the 13
patients in the second or third trimester. As noted, 1
patient was at 8 weeks’ gestation. Follow-up pregnancy
data were available on all but 3 patients who received a
CT. Nine patients delivered healthy babies including the
patient scanned at 8 weeks. One patient delivered an
infant by cesarean section at 33 weeks’ gestation second-
ary to severe pre-eclampsia. This infant required inten-
sive care. Finally, 1 patient who had appendicitis diag-
nosed by US, and confirmed by MRI, delivered a healthy
infant at term.
Comments
In our study, as in other studies, the clinical diagnosis of
appendicitis was problematic. Atypical presentations of ap-
pendicitis are common in pregnant patients.1 All 47 patients
evaluated for appendicitis presented with abdominal pain.
Although the mean white blood cell count in patients with
appendicitis was increased statistically compared with those
patients without appendicitis, the range of values was large,
causing the value to be clinically nonuseful in the individual
patient. Likewise, the presence or absence of fever was not
a clinically useful discriminator in the diagnosis of appen-
dicitis. These findings also have been reported in other
studies of appendicitis in both pregnant and nonpregnant
patients.3,6
Diagnostic accuracy rates in pregnant patients undergo-
ing appendectomy have been reported to be as low as
50%.2,3,7–9 Higher accuracy rates of 77% and 75% were
reported by McGory et al4 and by Andersen and Nielsen,10
respectively. Of interest is that only 15% to 20% of patients
undergoing negative appendectomies had another patho-
logic diagnosis (eg, ovarian cyst, ovarian torsion, mesen-
teric adenitis, fibroids, and salpingitis) identified as the
cause of their abdominal pain. Although our numbers were
small, 17 of 23 patients (74%) undergoing appendectomy in
our series had appendicitis. Of the 6 patients undergoing a
The American Journal of Surgery, Vol 198, No 6, December 2009
negative appendectomy only the patient with the tubo-ovar-
ian abscess had another pathologic diagnosis (17%).
Because of the unreliability of the clinical diagnosis of
appendicitis in pregnancy, an aggressive surgical approach
with a high rate of fetal demise.2,3 However, more recently
it has been reported that negative appendectomies also may
be associated with a significant rate of fetal demise. In a
review of the California Inpatient File, McGory et al4 re-
ported on 3,133 pregnant patients who underwent appen-
dectomies. Rates of fetal loss and early delivery in patients
with complicated appendicitis were 6% and 11%, respec-
tively. In comparison, the rates for fetal loss and early
delivery in patients undergoing a negative appendectomy
were 4% and 10%, respectively. By using multivariate lo-
gistic analysis, both complicated appendicitis and a negative
appendectomy were major predictors of fetal demise.
McGory et al4 were of the opinion that “the greatest oppor-
tunity to improve fetal outcomes is by improving diagnostic
accuracy and reducing the rate of negative appendectomy in
pregnant women.”
The study by McGory et al4 was limited because only
fetal demise and early delivery occurring during the hospi-
talization in which the appendectomy was performed was
reported. In our study of the 6 patients with negative ap-
pendectomies, 1 had fetal demise during a different hospi-
talization 4 weeks postoperatively. One patient who under-
went her appendectomy in the first trimester had an early
delivery at 33 weeks. The relationship of the early delivery
and the fetal demise to the appendectomy, if any, was not
defined.
Compression ultrasonography has been reported to have
a sensitivity of 86% and a specificity of 81% for the detec-
tion of appendicitis in children and adults.11 However, the
technique is highly operator-dependent and may result in a
significant number of nondiagnostic studies. In our series,
88% of US in pregnant patients were interpreted as nondi-
agnostic. Because no scans were read definitively as nega-
tive we were unable to calculate a negative predictive value
for US. US was not useful for excluding the diagnosis of
appendicitis in our study. On the other hand, US was highly
specific for appendicitis because all patients with a positive
US had appendicitis.
CT scan has been reported to have a sensitivity of 77%
to 100% and a specificity of 83% to 100% for the diagnosis
of appendicitis in nonpregnant patients.12 Most studies re-
port a CT scan to have a better test performance than US for
diagnosing appendicitis.13 CT scan may be particularly use-
ful in excluding appendicitis in pregnant patients with ab-
dominal pain and equivocal or negative ultrasonography.
Lazarus et al14 found that CT scan had a negative predictive
value of 99% in pregnant patients with abdominal pain. In
our study, none of the 6 patients with a negative CT scan
had appendicitis, whereas all 7 patients with positive scans
had appendicitis.
M. Freeland et al. Appendicitis in pregnancy
Figure 3 Algorithm for the evaluation of pregnant patients with suspected appendicitis.
There is an obvious reluctance to perform CT scanning
in pregnant patients because of the risks of exposing the
fetus to ionizing radiation. The exact threshold at which no
teratogenic effects occur to the fetus is estimated to be
between .05 and .15 Gy, or 5 to 15 rad. The estimated dose
of ionizing radiation associated with a CT of a pregnant
patient for appendicitis is between .024 Gy (2.4 rad) in the
first trimester and .046 Gy (4.6 rad) in the third trimes-
ter.14 –16 This is well below the threshold for teratogenic
effects. In addition, ionizing radiation may increase the risk
of childhood cancers. However, because the baseline risk of
fatal childhood malignancies is low, the risk of a fatal
childhood cancer goes from 1 in 2,000 to 2 in 2,000 after
exposure to 5 rad.15 Of the 13 patients in our series who had
CT scans, 12 were scanned in the second or third trimester
and 1 was scanned at 8 weeks. Three of the patients were
lost to follow-up evaluation. The rest of the patients includ-
ing the patient scanned at 8 weeks delivered healthy babies.
We did not have follow-up data or a sufficient sample size
to comment on the risks of childhood cancer.
The sensitivity and specificity of MRI for the detection
of appendicitis in pregnancy has been reported as 100% and
93.6%, respectively, in 1 small series.17 Most studies show
no ill effects of MRI even in the first trimester. MRI appears
to be preferable to other forms of imaging during pregnancy
as stated in the American College of Radiology’s 2007
guidelines.18 However, the use of gadolinium is not recom-
mended when performing these studies. We had only 1
patient who underwent MRI. This study was positive for
appendicitis and the diagnosis was confirmed at surgery.
Although some studies state that laparoscopy is the pre-
ferred method of appendectomy in the first and second
trimesters, these studies have been relatively small.19,20 One
review of a large administrational database did find that the
fetal loss rate after laparoscopic appendectomy was 7%
757
compared with a fetal loss rate of 3% after open appendec-
tomy (P ⬍ .05).4 We performed 4 laparoscopic appendec-
tomies. These were performed in the first trimester in 3
patients and at 19 weeks’ gestation in 1 patient, with no fetal
demise.
Our study had significant limitations in that it was a
small retrospective study from a single institution. The
appendix was visualized on all CT scans. There were no
false-positive or false-negative scans. There was a high rate
of nondiagnostic US. These US were not reviewed for
accuracy. However, all US were read by an attending radi-
ologist and the high nondiagnostic rate reflects the reluc-
tance to exclude the diagnosis of appendicitis base on US in
clinical practice.
In conclusion, US, when read as positive, requires no
further confirmatory test other than surgery. If US is non-
diagnostic, further imaging (CT/MRI) may avoid a negative
appendectomy, which has been associated in prior studies
with a significant incidence of fetal demise. Based on this
study, our approach to the pregnant patient with suspected
appendicitis is presented in Figure 3. Patients with clear
clinical indications for surgery proceed directly to the op-
erating room. If imaging is indicated, US is the first study
performed. If it is positive for appendicitis, no other
imaging is necessary. However, there is a high incidence
of nondiagnostic examinations and other imaging studies
should be performed in these patients. For the patient in
the first trimester, MRI imaging without gadolinium
should be considered. In the second and third trimesters,
either MRI or CT scan should be used to confirm or
exclude the diagnosis. The use of this algorithm exposes
the fetus to minimal risks and should decrease the inci-
dence of negative appendectomies while avoiding the
risks of appendiceal rupture.
758
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Discussion
Dr Thomas Helling (Johnstown, PA): Appendicitis oc-
curs infrequently in pregnancy—approximately 1 in 1,000
The American Journal of Surgery, Vol 198, No 6, December 2009
pregnancies from information in this study and in our ex-
perience that we presented before the Southwestern Surgical
Congress 20 years ago in 1989. The authors have presented
a case series report that illustrates some of the difficulties in
establishing a diagnosis of appendicitis in these atypical
patients—meaning pregnant women. While this may be
level 3 evidence, it is not insignificant. The numbers of
subjects are relatively small, but certain valid inferences
from the clinical data can be made. I have 2 questions. First,
in using a clinical examination as a decision-making tool,
have you or did you incorporate the Alvarado score in
deciding for or against the diagnosis of appendicitis? The
Alvarado score has gained some popularity among Emer-
gency Medicine physicians, particularly at either end of the
10-point spectrum of scoring. Second, with the clinical
evaluation as you described it producing so many false-
positive diagnoses, would you routinely—and I stress rou-
tinely— obtain an ultrasound (US), and, if that is nondiag-
nostic, would you routinely—again stressing routinely—
obtain an abdominal pelvic CT scan to establish a
diagnosis?
Dr Freeland: We did not use the Alvarado score. Would
we routinely use US, I think yes. Even though it has a low
rate of visualization of the appendix: in our series, if you do
see appendicitis using US then it saves the patient further
imaging. In terms of that US—if that is nondiagnostic and
the patient is in the first trimester we will proceed with an
MRI; if the patient is in the second or third trimester we
would get either a CT or an MRI.
Dr Bob Sticca (Grand Forks, ND): I just wonder, US is
almost useless because you almost always get a nondiag-
nostic result. The radiologic literature a few years ago had
some information about just doing very limited CTs through
the cecum and the upper part of the pelvis. I would suspect
there is a lot less radiation with that approach. Have you
considered using CT scan in this fashion?
Dr Freeland: No, we don’t. With pregnancy, the varia-
tion of the anatomy would make localizing the appendix in
this way very difficult. We feel it is acceptable to go ahead
and scan the entire abdomen and pelvis in those patients.
Dr Dan Margulies (Los Angeles, CA): I understand the
paper was really about the diagnostic modality, but you did
describe the outcome to these patients. Can you describe a
little bit more about the 23 patients that underwent appen-
dectomy as to whether they were laparoscopic or open?
Dr Freeland: We did 4 laparoscopic procedures. All of
those patients did well postoperatively and had normal de-
liveries at term. The patients that we documented as having
either premature delivery or fetal demise, all had open
procedures.
Dr John Galt (Helena, MT): Did you use oral contrast
with these CTs or did you do them without contrast?
Dr Freeland: They did receive oral contrast.