The diagnosis of acute appendicitis during pregnancy remains a difficult one. Both anatomic and physiologic changes that occur during pregnancy often mask the classic signs and symptoms. Although the single most reliable symptom of appendicitis in pregnant patients is right lower quadrant pain (83), this may be highly variable. Throughout pregnancy, the appendix migrates upward in the right lower and upper quadrants. This migration may shift the point of maximal tenderness superiorly and laterally, which in the case of a retrocecal appendix may cause back or flank pain leading to a misdiagnosis of urinary tract infection, nephrolithiasis, or pyelonephritis (72,84). In the majority of patients fever is not present and leukocytosis, which is normal during pregnancy, may confuse the clinical picture (34,72).

Appendicitis is the most common acute general surgical condition during pregnancy, with an incidence of appendectomy during pregnancy of one in 1500 to one in 3000 (1,2,85). When uncomplicated, appendicitis results in a 1.5% fetal loss rate. Perforation, which occurs in 10% of cases, increases the fetal loss rate to 35% and may lead to preterm labor and premature delivery in as many as 40% of patients (1,69).

Because of the difficulty in clinically diagnosing acute appendicitis, the negative appendectomy rate is much higher in the pregnant than nonpregnant patient, with mis-diagnosis rates as high as 22% to 55% (15,86). The higher incidence of negative appendectomy in the gravid patient is likely due both to the anatomic and physiologic changes that occur during pregnancy as well as attempts to prevent perforation, since perforation results in high maternal and fetal morbidity and mortality. Up to one-quarter of pregnant women with appendicitis develop appendiceal perforation, and appen-diceal rupture has been reported to occur twice as often in the third trimester (69%) as in the first and second trimesters (87-89). A 66% incidence of perforation has been reported in patients when surgery was delayed by more than 24 hours and a 0% incidence when patients were taken to surgery within 24 hours of presentation (90).

Many authors rely heavily on clinical judgment for the diagnosis of acute appendicitis in the gravid patient. However, some studies suggest that the use of helical computed tomography that exposes the fetus to 300 mrad and ultrasonography are highly accurate for diagnosing acute appendicitis during pregnancy and may help reduce the negative appendectomy rate (91,92). In a case series of 42 women with suspected appendicitis during pregnancy, graded compression ultrasonography was 100% sensitive, 96% specific, and 98% accurate in diagnosing acute appendicitis (92).

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