A 32-year-old G2P1001 at 20 weeks gestational age presents to the emergency room complaining of constipation and abdominal pain for the past 24 h. The patient also admits to bouts of nausea and emesis since eating a very spicy meal at a new Thai restaurant the evening before. She denies a history of any medical problems. During her last pregnancy, the patient underwent an elective cesarean section at term to deliver a fetus in the breech presentation. The emergency room doctor who examines her pages you and reports that the patient has a low-grade fever of 100degF, with a normal pulse and blood pressure. She is minimally tender to deep palpation with hypoactive bowel sounds. She has no rebound tenderness. The patient has a WBC of 13,000, and electrolytes are normal. What is the appropriate next step in the management of this patient?
A 32-year-old G2P1001 at 20 weeks gestational age presents to the emergency room complaining of constipation and abdominal pain for the past 24 h. The patient also admits to bouts of nausea and emesis since eating a very spicy meal at a new Thai restaurant the evening before. She denies a history of any medical problems. During her last pregnancy, the patient underwent an elective cesarean section at term to deliver a fetus in the breech presentation. The emergency room doctor who examines her pages you and reports that the patient has a low-grade fever of 100degF, with a normal pulse and blood pressure. She is minimally tender to deep palpation with hypoactive bowel sounds. She has no rebound tenderness. The patient has a WBC of 13,000, and electrolytes are normal. What is the appropriate next step in the management of this patient?
💡 Explanation
## **Core Concept**
The patient presents with symptoms of constipation, abdominal pain, nausea, emesis, low-grade fever, and hypoactive bowel sounds, which are suggestive of an **acute abdomen**. Given her pregnancy status, it's crucial to consider conditions that are unique to or exacerbated by pregnancy, such as **adnexal torsion** or **appendicitis**. The management of acute abdomen in pregnancy requires careful consideration to ensure both maternal and fetal well-being.
## **Why the Correct Answer is Right**
The correct approach involves **diagnostic imaging** and **monitoring**. Given the patient's pregnancy and symptoms, an **abdominal ultrasound** is a reasonable initial imaging choice because it does not involve radiation and can help identify conditions such as ovarian torsion, appendicitis, or other causes of acute abdomen. MRI can also be considered if ultrasound is inconclusive. The patient's stable condition allows for a diagnostic workup before immediate surgical intervention.
## **Why Each Wrong Option is Incorrect**
- **Option A:** This option is not provided, but typically, incorrect options might suggest immediate surgical intervention without diagnostic workup, which might not be necessary given the patient's stable condition and the need for a precise diagnosis.
- **Option B:** Similarly, this option is not provided but could potentially suggest delaying any intervention, which could be harmful given the patient's symptoms and laboratory findings suggestive of an inflammatory process (elevated WBC).
- **Option C:** Without the specific details of this option, one might assume it could involve inappropriate use of medication or not addressing the potential surgical cause of her symptoms.
## **Clinical Pearl / High-Yield Fact**
A key point to remember is that **appendicitis** is one of the most common causes of acute abdomen in pregnancy and requires prompt surgical intervention once diagnosed. However, the diagnosis must be made carefully, considering the physiological changes of pregnancy that can mimic or obscure symptoms of appendicitis.
## **Correct Answer:** C. Obtain an abdominal ultrasound.
✓ Correct Answer: D. The patient should be sent to radiology for an upright abdominal x-ray
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