|January 2006 · Vol. 18, No. 1
CASES THAT TEST YOUR SKILLS
Abdominal pain in a pregnant woman
Tenderness and pain in right upper and lower quadrants began last night. What imaging studies are appropriate?
Graded compression technique: Using the pressure of the ultrasound probe, start above the tender area and work toward the tender area while scanning for the appendix
Rupture of the appendix occurs 2 to 3 times more often in pregnancy because of delayed diagnosis
The graded compression ultrasound technique was as accurate as focused unenhanced single-detector helical CT
University of Texas, Health Sciences Center at San Antonio
Q What’s your diagnosis?
A 24-year-old woman at 22 weeks’ gestation came to OB triage with abdominal pain, nausea, and vomiting. She said that sharp pain began the night before, starting at the umbilicus and radiating toward her right side. She rated her pain level at 7. She felt no contractions and had no vaginal bleeding, fluid leaking, or dysuria. She had GERD at times and chills the day before, but no fever. Similar pain 1 month before had resolved spontaneously, and no cause was determined. She had no notable personal or family medical history. On examination, she was afebrile, normotensive, and in no apparent distress. Heart and lungs were normal. Her abdomen was soft and gravid with a fundal height of 22 cm. Bowel sounds were present in all 4 quadrants. Fetal heart tones were normal, and there was no indication of contractions. Her abdomen was diffusely tender, with significant tenderness to deep palpation in the right upper quadrant at first. There was no rebound or guarding. The psoas sign was negative. The obturator sign was positive, with increased pain, level 4, in the right lower quadrant. There were no abdominal masses. Digital rectal examination found no masses, and a guaiac stool test was negative. A few hours later, the tenderness seemed to move toward the right lower quadrant (FIGURES 1 AND 2).