Ambulatory Care Quarterly

Pregnant patient at risk for unnecessary appendectomy

Pregnant women who come to the ED with abdominal pain often are misdiagnosed and undergo unnecessary appendectomies, says a new study.1

Researchers looked at 94,789 women who underwent open or laparoscopic appendectomy, and 3,133 of them were pregnant. The rate of negative appendectomy was significantly higher in pregnant women (23% vs. 18%) than in nonpregnant women.

"I think the most important message for ED nurses is that abdominal pain in the pregnant patient can be difficult to diagnose and may include both surgical and nonsurgical causes," says Marcia McGory, MD, the study's author and research fellow at the Center for Surgical Outcomes and Quality at the University of California — Los Angeles Medical Center

Although negative appendectomy in other patient populations generally does not have any unforeseen consequences, unnecessary surgery should be minimized in the pregnant patient due to risk to the fetus, she explains. The study's results suggest that improved diagnostic accuracy of appendicitis in pregnant women may minimize risk of fetal loss or early delivery, says McGory. "ED nurses can assist with patient advocacy by encouraging pregnant women to pursue additional imaging prior to making the decision to undergo surgery to remove the appendix," she says.

Assessing pregnant patients

At Virginia Commonwealth University Medical Center in Richmond, ED nurses ask patients the following questions at triage for pregnant patients with abdominal pain, says Steve Rasmussen, RN, CEN, clinical coordinator for the ED:

  • How many weeks pregnant are you? "Under 20 weeks, the fetus is considered nonviable and is seen in the ED, although even this is being reconsidered in light of recent premature saves," he says. "Over 20 weeks, and the patient is sent to OB for evaluation."
  • How many pregnancies have you had and how many live births?
  • Have you had prenatal care?
  • Do you have a history of multiple pregnancies or multiple births?
  • Have you had problems with other pregnancies, or how is this pregnancy different?
  • Do you use drugs or alcohol?
  • Have you had a recent urinary tract infection, sexually transmitted disease, or vaginal discharge?
  • Is there a history of HIV, hepatitis, tuberculosis, MRSA, diabetes, congestive heart failure, or preeclampsia?
  • Are you bleeding? If so, how much?
  • Is the bleeding painful? Placental abruption can cause severe hemorrhage and is a significant cause of maternal and fetal mortality, says Rasmussen. "Abdominal pain, uterine tenderness, tetanic uterine contractions, hypertension, and preeclampsia are associated with increased rates of occurrence," he says. Painless bleeding can indicate placenta previa, which means the placenta is implanted abnormally, he adds. "It is most common in the third trimester and may require a cesarean to stop the bleeding and save the mother's life," he says.
  • Did bleeding or pain occur spontaneously or after sex or some type of trauma?
  • Is there a possibility of domestic violence?
  • Is there a psychological history, with or without drug therapy? "Remember when assessing fetal heart tones with an audible Doppler, palpate the mother's pulse and make sure you are not listening to the mother's heart rate," says Rasmussen.

Reference

  1. McGory ML, Zingmond D, Tillou A, et al. Negative appendectomy in pregnant women is associated with a substantial risk of fetal loss. J Am Coll Surg 2007; 205:534-540.