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Right Lower Quadrant Pain in Early Pregnancy
JAMA Surgery ( IF 16.9 ) Pub Date : 2018-02-01 , DOI: 10.1001/jamasurg.2017.4936
Salomone Di Saverio 1 , Clarissa Ann Elisabeth Gelmi 1 , Antonino Perrone 2
Affiliation  

A woman in her mid-20s who was 8 weeks pregnant presented to the emergency department for abdominal pain localized in the right iliac fossa (RIF), numbness in the right lower limb, and nausea and vomiting. On examination she had tenderness in the RIF with a positive Blumberg sign; blood testing showed leukocyte count 10 450/μL (to convert to ×109/L, multiply by 0.001) without any shift, C-reactive protein 1.29 mg/dL (to convert to nanomoles per liter, multiply by 0.331), and hemoglobin 11.4 g/dL (to convert to grams per liter, multiply by 10). The Alvarado score was 7. A transabdominal ultrasonographic scan showed a tubular structure in the RIF consistent with a mildly inflamed appendix and stratification of the appendiceal wall (7 mm in the proximal and 11 mm in the appendiceal distal tract). A small amount of free fluid was present in the Douglas pouch. A transvaginal ultrasonographic scan confirmed normal intrauterine gestation with a vital embryo. Working diagnosis was uncomplicated appendicitis and initial conservative management was amoxicillin clavulanate because of the potential risks of miscarriage associated with performing an avoidable appendectomy and general anesthesia during early gestation. The patient initially improved and was discharged home 2 days later with an Alvarado score of 4; oral antibiotic therapy was continued. Three days later she returned to the emergency department with recurrent pain; the clinical and ultrasonographic findings were unchanged, without evidence of complicated appendicitis, intra-abdominal fluid collection, or abscess. The Alvarado score was 5. The patient was admitted to the surgical ward and given intravenous antibiotics. In the next 48 hours the symptoms and pain did not resolve, although inflammatory markers were low and the patient was not septic. The surgeon on call requested an urgent magnetic resonance imaging (MRI) investigation (Figure 1).



中文翻译:

妊娠早期右下腹疼痛

一名孕妇在20多岁时怀孕了8周,因腹部疼痛而出现在急诊室,腹部疼痛位于右窝(RIF),右下肢麻木,恶心和呕吐。经检查,她在RIF处有压痛,并伴有阳性的Blumberg征兆。验血显示白细胞计数为10 450 /μL(转换为×10 9/ L,乘以0.001),C反应蛋白为1.29 mg / dL(转换为每升纳摩尔,乘以0.331),血红蛋白为11.4 g / dL(转换为每升克,乘以10) 。Alvarado评分为7。经腹部超声检查显示,RIF中的管状结构与阑尾轻度发炎和阑尾壁分层一致(近端7 mm,阑尾远端11 mm)。道格拉斯邮袋中存在少量的游离液体。经阴道超声检查证实子宫内有重要胚胎正常妊娠。工作诊断为单纯性阑尾炎,而最初的保守治疗为阿莫西林克拉维酸,因为在妊娠早期进行可避免的阑尾切除术和全身麻醉可能引起流产。患者最初情况好转,两天后出院回家,Alvarado评分为4。继续口服抗生素治疗。三天后,她因反复疼痛回到急诊室。临床和超声检查结果无变化,无复杂性阑尾炎,腹腔积液或脓肿的证据。Alvarado得分是5。患者被送往外科病房并接受了静脉内抗生素治疗。在接下来的48小时内,症状和疼痛均未缓解,尽管炎症标记物很低并且患者没有脓毒症。待命的外科医生要求进行紧急磁共振成像(MRI)检查(图1)。

更新日期:2018-02-21
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