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John A. Sinclair and Penny Marzalik

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Suspected Appendicitis in the Pregnant Patient

Correspondence Penny Marzalik, PhD, CNM, IBCLC, RN, Niehoff School of Nursing, Loyola University Chicago, 2160 South First Avenue, Bldg. 105, Room 2856, Maywood, IL 60153. pmarzal@luc.edu Keywords abdominal pain pregnancy appendicitis diagnostic imaging

ABSTRACT
Appendicitis is the most common nonobstetric cause of abdominal pain in pregnancy. Pregnant patients may present with an atypical examination, thereby challenging clinicians. National specialty organizations recommend that nonionizing imaging options be pursued to aid in early diagnosis. Multiple studies suggest that magnetic resonance imaging technology is a safe and accurate alternative to ionizing imaging such as X-ray or computerized tomography imaging. A standard protocol that incorporates magnetic resonance imaging technology in the evaluation of the pregnant patient is proposed.

JOGNN, 38, 723-729; 2009. DOI: 10.1111/j.1552-6909.2009.01074.x

Accepted May 2009

John A. Sinclair MSN, ACNP, ACCNS, CEN, MHR, RN, is a lieutenant in the United States Navy Nurse Corps, Naval Medical Center, Portsmouth, VA. Penny Marzalik, PhD, CNM, IBCLC, RN, is an assistant professor in the Niehoff School of Nursing, Loyola University Chicago, Maywood, IL.

he most common physical complaint of emergency department (ED) patients is abdominal pain (Gallagher, 2004). The art and science of diagnosing and treating abdominal pain presents a challenge to emergency care providers. This complaint becomes an even greater challenge to ED clinicians when the patient with the abdominal complaint is also pregnant. Nurses and physicians in the ED rely on physical exam ndings and standardized tests, including plain radiographs, computerized tomography (CT), and/or laboratory indices to aid in the diagnostic process. However, when treating the pregnant patient for abdominal pain, the clinician must also consider potential complications and contraindications for both the mother and fetus. In treating the pregnant patient, the steps taken to arrive at a diagnosis are very different. Not only are there specic physical alterations that the clinician must consider, but there are also safety concerns related to ionizing radiation exposure for both the mother and fetus. In an effort to quickly determine whether the source of the abdominal pain is of a uterine or nonuterine origin, clinicians need to be knowledgeable regarding diagnostic testing. This knowledge will help the clinician to order the imaging study that will yield the best results for their patients and at the same time will be safe for the fetus.

Overview
Gastrointestinal disorders are not uncommon during pregnancy and can range from gastric reux and hyperemesis to acute appendicitis and cholecystitis. Acute abdomen is seen in 1 out of every 500 pregnancies, and as many as 1 out of 100 pregnant patients will require some form of nonobstetric surgery (Parangi, Levine, Henry, Isakovich, & Pories, 2007). Appendicitis is the most common nonobstetric cause of abdominal pain in pregnancy, with an overall frequency of 1 per 1,500 to 2,000 (.06%) of all pregnancies (Parangi et al.). While the physical symptoms of the pregnant patient with appendicitis are similar to that of the nonpregnant patient, there are some variations in the physical ndings that make the diagnosis more difcult (see Table 1). Pain is often the most severe and earliest sign of acute appendicitis. However, pregnant patients often lack this symptom. Stretching of the abdominal wall in pregnancy can result in a diminished pain receptor response normally accompanying peritoneal irritation, presenting a challenge to even the most seasoned practitioner (Parangi et al., 2007). The anatomical and physiological changes that occur during pregnancy contribute to the diagnostic difculty for the clinician. The anatomic displacement of the intraperitoneal organs by the uterus

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& 2009 AWHONN, the Association of Womens Health, Obstetric and Neonatal Nurses

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Appendicitis is the most common nonobstetric cause of abdominal pain in pregnancy.

2003). Maternal morbidity is low if the appendix is intact at the time of removal. Additionally, little evidence exists to suggest long-term consequences for the woman who has an appendectomy during pregnancy. Recommendations to reduce the risk of rupture include surgical intervention within 20 hours of symptom onset for pregnant patients compared to 36 hours for nonpregnant patients (Bickell, Aufses, Rojas, & Bodian, 2006; Yilmaz, Akgun, Bac, & Celik, 2007). To assist in a timely diagnosis, several imaging studies are available.

makes the physical assessment more challenging. Since there is a physiological increase in cardiac output and heart rate, an early nding of tachycardia and hypertension may mask a more severe appendiceal infection. Additionally, physiological anemia and leukocytosis during pregnancy make early detection of appendicitis from laboratory ndings improbable. Finally, since fever is seen in only 25% of patients with appendicitis, it is not a reliable physical nding for the pregnant patient or the nonpregnant patient with a possible appendicitis diagnosis (Parangi et al., 2007). In fact, reliance on physical examination and laboratory data alone are predictive of appendicitis only about 50% of the time (Maslovitz, Gutman, Lessing, Kupferminc, & Gamzu, 2003). These dilemmas lead to a higher false-positive appendicitis diagnosis rate of 30% in pregnant women when compared to a 15% rate in nonpregnant women (Mourad, Elliott, Erickson, & Lisboa, 2000). Although obstetric complications may occur with appendectomy, the risk to the mother and fetus increases once the appendix has ruptured. A spontaneous abortion rate of 33% in the rst trimester and a premature delivery rate of 14% in the second trimester were reported in a study of 56 women undergoing appendectomy. No obstetric complications were seen following a third trimester appendectomy (Andersen & Nielsen,1999). A delay in surgical intervention due to waiting on test results or an inconclusive diagnosis increases the risk of rupture. The risk of fetal loss with a perforated appendix is 20% to 35% versus 0% to 1.5% for surgery completed prior to rupture (Malangoni,

Diagnostic Imaging Exams

Choosing the proper diagnostic imaging study for a pregnant patient with abdominal pain can be a daunting task for the clinician. In health care today, the major sources of ionizing radiation come from X-rays (plain radiographs) and CT. X-rays are beams of photons or energy that travel in straight lines when released from their source. As the beams travel through the body some of the energy is absorbed as it interacts with atoms in the tissue. The denser the tissue the more radiation absorbed. Computerized tomography accounts for the highest percentage of ionizing radiation exposure from diagnostic imaging. More than 60 million CT examinations are being performed per year in the United States (Martin & Semelka, 2007). Cunningham et al. (2005) in Williams Obstetrics summarizes the amount of ionizing radiation that the fetus absorbs depending on maternal exposure (see Table 2). The exact amount of radiation that actually reaches and is absorbed by the fetus depends on many factors, including the mothers abdomen size, uterus size, fetal size, and fetal position within the uterus (Harrison & Crystal, 2003). The exact sequelae of short- versus long-term exposure to ionizing radiation are still being debated

Table 1: Clinical Signs and Symptoms of Appendicitis

Nonpregnant Symptom Pain Leukocytosis Elevated band count Fever Not a common nding Tachycardia Normal nding Typical nding Typical nding Pregnant Female May be pain free Normal nding A clinical clue Female Pain usually noted Typical nding Usually noted

Table 2: Estimated Radiation Doses to the Fetus

Radiological Procedure Chest Ray (2 view) Abdominal Ray (1 view) CT head or chest CTabdomen
Note. CT 5 computerized tomography.

Fetal Exposure 0.02-0.07 mrad 100 mrad o 1 rad 3.5 rad

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(Martin & Semelka, 2007). The Committee on Biological Effects of Ionizing Radiation (2005) has reevaluated the incidence and mortality related to leukemia from the survivors of the 1945 atomic bomb strike in Hiroshima and Nagasaki, Japan. The conclusions presented were impressive: individuals in the lowest-dose radiation exposure group of atomic bomb survivors showed a signicant rise in cancer incidence and mortality since the last report. Typical equivalent doses (3-5 rad) of ionizing radiation can be received from a single, routine, adult abdominal CT examination (Martin & Semelka). Furthermore, ionizing radiation effects may not be evident for many decades. Researchers now state that they do not know what long-term impact radiation will have on patient outcomes (Committee on Biological Effects of Ionizing Radiation, 2005), and the cumulative effect of repeated radiation exposure is still not clear. Martin and Semelka (2007) proposed that the time period from rst exposure to a cancer formation may take as long as 10 to 20 years. Because of these concerns, it is preferential to use nonionizing techniques for diagnostic testing in pregnant patients, resorting to plain X-ray and CT only when absolutely necessary (Lazarus, DeBenedectis, Mayo-Smith, & Spencer, 2007).

The risk of fetal loss with a perforated appendix is 20% to 35% versus 0% to 1.5% for surgery completed prior to rupture.

tient (Harrison & Crystal, 2003). It is recommended by multiple resources as the best initial diagnostic imaging study for the pregnant patient with abdominal pain. The American College of Obstetricians and Gynecologists (ACOG) recommends the use of US as an initial screening exam in the stable patient (ACOG Committee on Obstetric Practice, 2004). Ultrasound technology uses sound waves to create images and is considered safe since there is no ionizing radiation. It is fast, fairly inexpensive, and readily available in almost all emergency centers in the United States. It is especially useful in the evaluation of compressible organs or uid lled environments, such as imaging large vessels and the gravid uterus in pregnancy (Reardon & Jehle, 2004). The images obtained from an endovaginal approach help rule out the main sources of obstetric and gynecological pain including ectopic pregnancy, ovarian torsion, adnexal masses, ovarian cysts, and pelvic inammatory disease (Harrison & Crystal, 2003; Reardon & Jehle). A transabdominal US helps rule out nonobstetric sources of pain by penetrating deeper into other target organs such as bowel, appendix, gall bladder, and distal pelvis (Harrison & Crystal). Keyzer et al. (2005) noted that the major problem with US is that it is often nondiagnostic (see Table 3) when the sonographer is unable to visualize or measure the appendix. Unfortunately, this occurs often even in the presence of true pathology (Lazarus, Mayo-Smith, Mainiero, & Spencer, 2007).

Plain Radiography
Plain lms offer limited value as a diagnostic test because they do not specifically evaluate the appendix, especially in the pregnant patient, making ruling out of appendicitis highly unlikely. Plain lms also expose the fetus to ionizing radiation (see Table 2).

Ultrasonography
Ultrasonography (US) is an invaluable diagnostic adjunct for the rapid evaluation of the emergent pa-

Table 3: Diagnostic Imaging Options in Pregnancy

Ultrasound Sensitivity (%) Specicity (%) Pros Fast, available, nonionizing, inexpensive Cons Requires high skill, often nondiagnostic Uses ionizing radiation, used if benets outweigh risks Expensive, somewhat slower, limited availability, less utilized Fast, available, accurate Accurate, safe, more highly recommended 86-100 92-96 93.6 76-90 Computerized Tomography 90-95 Magnetic Resonance Imaging 100

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Ultrasound images can be technically degraded by both bone and gas (Parangi et al., 2007). Also, as the gravid uterus grows, it displaces the intestines and appendix upward, making adequate visualization and evaluation increasingly more difcult, especially in the third trimester (Oto et al., 2005). A nondiagnostic US to rule out appendicitis is an inconclusive nding and a common occurrence. Even in the hands of experienced operators, the sensitivity of US is relatively low (see Table 3). However, the specicity is high if the appendix is visualized (Keyzer et al.). Given these US problems, Parangi et al. suggested that other imaging such as magnetic resonance imaging (MRI) is needed for the pregnant patient with abdominal pain and a nondiagnostic US.

place of CT allows for imaging testing to be completed without exposure to the mother and fetus (Parangi et al., 2007). Yet despite the recommendations above, CT continues to be performed preferentially in many circumstances on pregnant patients (Jae, Miller, & Merkle, 2007; Lazarus, Mayo-Smith et al., 2007). Jae et al. conducted a survey of radiology residents across the United States and found that most radiologists prefer CT to MRI for imaging any abdominal complaints in pregnant women, especially in the second and third trimesters. In fact, according to Radiological Society of North America (RSNA) research, pregnant women today receive twice as much radiation as they did 10 years ago as part of their diagnostic workup (Lazarus, DeBenedectis et al., 2007). A retrospective study by Lazarus, Mayo-Smith et al. tracked ionizing radiation utilization in pregnant patients from 1997 to 2006. The overall radiologic utilization rate in pregnant patients increased by 107%. Several women received repeated CT scans for abdominal pain with each pregnancy. The greatest increase was in CT usage with an average overall increase of 25% each year (compared to prior year) over 10 years. Of those, 32% of CT scans were abdominal/pelvic studies, usually to rule out appendicitis. This resulted in a fetal exposure of 3.5 rad per scan, which is within the allowable threshold (5 rad is the acceptable limit) during pregnancy (Lazarus, Mayo-Smith et al.). Unfortunately, the exposure of the fetus and mother to high or repeated doses of ionizing radiation has become acceptable and routine. While the risk of congenital fetal malformation from radiation exposures between 5 and 10 rad is unclear, evidence suggests the risk of malformations is increased at doses above 10 rad. Sequelae from repeated CT scans during the same pregnancy are not well studied and represent unknown and undeterminable risks.

Computerized Tomography
Computerized tomography has transformed diagnostic imaging. The role of CT has also transformed emergency medicine, with a CT scanner being adjacent to most EDs today in the United States. Light-speed scans take spiral images or slices of tissue every 10 mm or less in under 5 minutes in many cases. These images are excellent for application in the emergency setting, allowing for early detection of emergent medical conditions (see Table 3). Computerized tomography has become the primary imaging modality of choice for many disorders of the retroperitoneum, abdomen, pelvis, lungs, and mediastinum (Gallagher, 2004) and has a high sensitivity and specicity (see Table 3). This modality is probably the best initial study for detection of acute appendicitis (FitzGerald & Pancioli, 2004). It does, however, come with its own set of problems for the pregnant patient: CT exposes the patient to high doses of ionizing radiation (seeTable 2). Additionally, the contrast required as a medium for good visualization is typically iodinated, which is not desired for pregnant patients, patients with iodine allergy, or those with renal failure (Pedrosa, Zeikus, Levine, & Rofsky, 2007). For this reason, the use of iodinated radioactive contrast medium is contraindicated in pregnancy by the ACOG Committee on Obstetric Practice (2004). Guidelines of the ACOG also clearly state: During pregnancy, other imaging procedures not associated with ionizing radiation (i.e. US, MRI) should be considered instead of x rays . . . and that CT be utilized only when benets outweigh risks (ACOG Committee on Obstetric Practice, 2004, p. 650). Since radiation exposure should be avoided whenever possible, the use of MRI in

Magnetic Resonance Imaging

Many researchers (Incesu et al., 1997; Martin & Semelka, 2007; Oto et al., 2005; Pedrosa et al., 2007; Wolfe & Oto, 2007) have clearly demonstrated the efcacy of MRI technology in evaluation of the pregnant patient with abdominal pain. Like CT, MRI has a high sensitivity and specicity (see Table 3). Magnetic resonance imaging is completely nonionizing. Instead of using radiation, MRI uses magnets to create magnetic energy elds that are exposed to radio frequencies that are then used to create images. It has been established as a great diagnostic tool, able to give sharper and clearer pictures of solid organs, bones, brain,

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ligaments, and tissue than CT can offer (Parangi et al., 2007). In the past, MRI was not considered a viable option for ED patients due to the lengthy imaging time required: as long as 30 to 60 minutes in some cases. Also, patients with abdominal pain had to remain still or hold their breath for several seconds in a small tube that was very loud in order to obtain useful images. However, MRI technology is continuously evolving, and new technology has revolutionized MRI studies, enabling turbo or fast scans to be conducted (Harrison & Crystal, 2003; Nagayama et al., 2002; Pedrosa et al., 2006). Several studies have found that MRI after oral contrast took approximately 25 to 30 minutes (Oto et al., 2005; Pedrosa et al.), while Nagayama et al. found scans could be completed in approximately 15 minutes. Unfortunately, MRI is not available at all health care institutions and is very costly relative to other imaging studies. Many hospitals and clinics have limited availability of MRI to outpatients, including ED patients. Many MRI centers are completely detached and part of free-standing diagnostic imaging centers, only open Monday through Friday and closed in the evening (Singh et al., 2007). Some radiologists and clinicians believe that an increase in MRI usage will cause a disproportional increase in overall cost of hospitalization, often times paid solely by the institution (Beineld & Gazelle, 2005). The cost of MRI is on average about twice that of CT, and both MRI and CT utilization have been on the rise over the last 10 years. Yet the increased use of imaging technology, including MRI, has lead to decreased overall patient costs (Beineld & Gazelle). Diagnostic imaging costs are actually predictive of patient total length of stay, a key issue of hospital administrators and insurance companies alike. An increase of $385.00 in total imaging costs per patient is associated with a reduction of 1 day in total length of stay. Each additional $100.00 in imaging costs decreased length of stay by 0.26 day. These results suggest that limiting or reducing imaging utilization of MRI or CT would actually increase overall costs, and therefore this constraint on the use of technology is ill-advised (Beineld & Gazelle). Geographic areas with higher Health Maintenance Organization (HMO) insurance activity have markedly lower use of MRI technology. Service areas with more HMOs providing coverage had about 40% fewer MRI scanners per 100,000 people than

Standardization of diagnostic imaging protocols or algorithms is essential.

service areas with fewer HMO providers (Baker & Atlas, 2004). It appears that HMOs are indirectly contributing to the reduced usage of MRI technology, and HMO approval of diagnostic imaging is a concern that can impact provider decision making.

Magnetic Resonance Imaging in Clinical Practice

The establishment of evidence-based goal directed protocols is the optimum method of managing patients (Micek et al., 2006; Rivers et al., 2001). Dr. Ivan Pedrosa, a radiologist at an East Coast medical center, has established a hospital-wide MRI protocol. At this center, all patients (pregnant and nonpregnant) with a differential diagnosis of appendicitis are offered an MRI (Pedrosa et al., 2007). For nonpregnant patients, intravenous gadopentetate dimeglumine is used as a contrast material. Pregnant patients receive an oral preparation consisting of 300 ml of ferumoxsil and 300 ml of barium sulfate starting 1 to 1.5 hours before the examination (Pedrosa et al.). This solution provides negative contrast within the bowel lumen without causing substantial susceptibility effects that can obscure the anatomy. Pregnant patients then undergo a single-shot fast image. This is considered the cornerstone of imaging for diagnosing appendicitis in the pregnant population (Pedrosa et al.). Pedrosa stated An MRI is ordered for every pregnant patient with clinical suspicion of appendicitis and has resulted in the need to perform only three to four CTs out of 180 patients studied when clinical symptoms persisted despite a negative MRI. Of approximately 180 consecutive (pregnant) patients scanned (at this institution), the negative laparotomy rate (number of patients that do not have appendicitis after assessment by direct surgical visualization) is 5%. This has been achieved without causing an increase in the perforation rate, which is approximately 21%. By using the fast scan MRI, results similar to traditional CT scanning in males have been achieved with MRI in pregnant women. Since pregnant women with abdominal pain are much more challenging to study, these results are very positive (I. Pedrosa, personal communication, February 4, 2007). The ability to visualize and determine the cecal tilt angle is very useful in determining the location of

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the appendix in the gravid patient, making the ruling in of appendicitis more reliable. Lee, Rofsky, and Pedrosa (2008) demonstrated the efcacy of MRI imaging at visualizing the appendix. In their study, of the 146 pregnant patients suspected of having appendicitis that underwent MRI imaging, 142 had MRI images in which both the appendix and cecum were identiable in the sagittal plane (Lee et al.). Based on current evidence on previous and ongoing work in MRI technology, the Obstetric, Gynecologic, and Emergency Departments at the east coast medical center where the primary author is employed has implemented this diagnostic protocol for evaluating pregnant patients with abdominal pain.

through the presentation of research (Incesu et al., 1997; Martin & Semelka, 2007; Oto et al., 2005; Pedrosa et al., 2007; Wolfe & Oto, 2007) concerning the use of MRI in the evaluation of the pregnant patient with abdominal pain. Standardization of diagnostic imaging protocols or algorithms is essential. Until national imaging standards during pregnancy are established, institutions can initiate their own evidence-based policies. Institutional policy and protocol must be reviewed and rewritten to reect current evidencebased imaging recommendations. Current ndings suggest increased MRI utilization will lead to decreased overall costs and safer imaging options and outcomes for pregnant women and their infants. Nursing leadership can help bring about a more open discussion with health care providers responsible for updating policies and ordering the appropriate diagnostic tests.

Conclusion
Pregnant patients present a diagnostic dilemma to all ED clinicians. While ED providers need to be considerate of radiation damage to both the mother and the fetus, untreated appendicitis can be a lethal diagnosis for the mother and/or fetus. Ionizing options should be used only when risks outweigh benets when ruling in a diagnosis of appendicitis in the pregnant patient. ACOG Committee on Obstetric Practice (2004), the RSNA (Patel, Reede, Katz, Subramaniam, & Amorosa, 2007), and the American College of Radiology (2007) agree that nonionizing options should be pursued rst in the evaluation of the pregnant patient with abdominal pain. Magnetic resonance imaging should and can be considered as part of that diagnostic process (Incesu et al., 1997; Lee et al., 2008; Martin & Semelka, 2007; Oto et al., 2005; Pedrosa et al., 2006, 2007; Wolfe & Oto, 2007). However, clinical practice does not yet reect these recommendations on a large scale (Jae et al., 2007; Lazarus, DeBenedectis et al., 2007). While research has been conducted to evaluate provider imaging preferences, research concerning provider understanding on the utility and benet of various nonionizing imaging options including MRI is still lacking. Diagnostic imaging during pregnancy is an issue that most nurses will encounter during their careers, and solid understanding of various imaging options during pregnancy is important. Nurses must become educated concerning research ndings and national specialty organization recommendations in order to be able to answer patients questions and concerns. Additionally, nurses can and must contribute to the ongoing discussion on use of nonionizing options for their pregnant patients. Research clearly supports the use of these options, and nurses can enhance provider knowledge

Acknowledgment
The authors thank the U.S. Navy Nurse Corps for educational opportunity and support.

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