Radiology in the Pregnant Patient with Acute Abdominal Pain

  • Mustafa M. AlikhanEmail author


Abdominal and pelvic pain in the pregnant patient is a very common problem that can cause diagnostic dilemmas for the surgeon due to the normal physiologic changes of pregnancy. Imaging of the acute abdomen has progressively increased in pregnancy secondary to its importance in yielding a cohesive diagnosis. However, there are practical considerations that the surgeon must be aware of in order to mitigate risks to the developing fetus and mother. Many of the basic imaging modalities in the field of radiology utilize ionizing radiation which is known to be harmful to a developing fetus. The American College of Radiology (ACR) thus recommends utilizing imaging techniques that are free of radiation. Those studies that utilize radiation should be reserved for emergent cases only when other options are nondiagnostic or not possible. The surgeon should be cognizant of the ramifications of radiation during pregnancy. Ultrasonography is the first-line imaging modality due to its wide availability, lack of radiation, and ease of use. MRI is considered a second-line modality because it is less readily available but may be requisite since ultrasound may not be able to see deep within the abdomen and pelvis. Additionally, MRI offers superior contrast resolution of soft tissues and can show fluid collections more distinctly. A practical understanding of the way to employ these imaging modalities on different pathologic states is incumbent for the pregnant patient.


Acute abdomen Epigastric pain Abdominal pain Pregnancy MRI pregnancy Ultrasound appendicitis Fetal radiation Fetal exposure Non-obstetric abdominal pain MRI acute appendicitis CT pregnant Pregnant surgery Appendicitis Nephrolithiasis 


  1. 1.
    Andersen B, Nielsen TF. Appendicitis in pregnancy: diagnosis, management and complications. Acta Obstet Gynecol Scand. 1999;78(9):758–62.CrossRefGoogle Scholar
  2. 2.
    Israel GM, Malguria N, McCarthy S, et al. MRI vs. ultrasound for suspected appendicitis during pregnancy. J Magn Reson Imaging. 2008;28(2):428–33.CrossRefGoogle Scholar
  3. 3.
    Mourad J, Elliott JP, Erickson L, et al. Appendicitis in pregnancy: new information that contradicts long-held clinical beliefs. Am J Obstet Gynecol. 2000;182(5):1027–9.CrossRefGoogle Scholar
  4. 4.
    Oto A, Srinivasan PN, Ernst RD, et al. Revisiting MRI for appendix location during pregnancy. AJR Am J Roentgenol. 2006;186(3):883–7.CrossRefGoogle Scholar
  5. 5.
    Woodfield CA, Lazarus E, Chen KC, et al. Abdominal pain in pregnancy: diagnoses and imaging unique to pregnancy–review. AJR Am J Roentgenol. 2010;194(6 Suppl):WS14–30.CrossRefGoogle Scholar
  6. 6.
    Long SS, Long C, Lai H, et al. Imaging strategies for right lower quadrant pain in pregnancy. AJR Am J Roentgenol. 2011;196(1):4–12.CrossRefGoogle Scholar
  7. 7.
    Tamir IL, Bongard FS, Klein SR. Acute appendicitis in the pregnant patient. Am J Surg. 1990;160(6):571–5. discussion 575–6CrossRefGoogle Scholar
  8. 8.
    Pedrosa I, Levine D, Eyvazzadeh AD, et al. MR imaging evaluation of acute appendicitis in pregnancy. Radiology. 2006;238(3):891–9.CrossRefGoogle Scholar
  9. 9.
    Bickell NA, Aufses AH Jr, Rojas M, Bodian C. How time affects the risk of rupture in appendicitis. J Am Coll Surg. 2006;202(3):401.CrossRefGoogle Scholar
  10. 10.
    Oto A, Srinivasan PN, Ernst RD, Koroglu M, Cesani F, Nishino T, Chaljub G. Revisiting MRI for appendix location during pregnancy. AJR Am J Roentgenol. 2006;186(3):883.CrossRefGoogle Scholar
  11. 11.
    Gjelsteen AC, Ching BH, Meyermann MW, et al. CT, MRI, PET, PET/CT and ultrasound in the evaluation of obstetric and gynecologic patients. Surg Clin North Am. 2008;88:361–90.CrossRefGoogle Scholar
  12. 12.
    Ornella de Bari TY, Wang ML, et al. Cholesterol cholelithiasis in pregnant women: pathogenesis, prevention and treatment. Ann Hepatol. 2014;13(6):728–45.CrossRefGoogle Scholar
  13. 13.
    Jana GH, Kane S. Pregnancy and inflammatory bowel disease. Gastroenterol Hepatol (NY). 2015;11(2):96–102.Google Scholar
  14. 14.
    Calderwood AH, Kane SV. IBD and pregnancy. MedGenMed. 2004;6(4):14.PubMedPubMedCentralGoogle Scholar
  15. 15.
    Stern MD, Kopylov U, Ben-Horin S, Apter S, Amitai MM. Magnetic resonance enterography in pregnant women with Crohn’s disease: case series and literature review. BMC Gastroenterol. 2014;14:146.CrossRefGoogle Scholar
  16. 16.
    Naganuma M, Hisamatsu T, Kanai T, Ogata H. Magnetic resonance enterography of Crohn’s disease. Expert Rev Gastroenterol Hepatol. 2015;9(1):37–45.CrossRefGoogle Scholar
  17. 17.
    Juneja SK, Gupta S, Satpal SV, et al. Acute panreatitis in pregnany: a treatment paradigm based upon our hospital experience. Int J Appl Basic Med Res. 2013;3(2):122–5.CrossRefGoogle Scholar
  18. 18.
    Mali P. Pancreatitis in pregnancy: etiology, diagnosis, treatment, and outcomes. Hepatobiliary Pancreat Dis Int. 2016;15(4):434–8.CrossRefGoogle Scholar
  19. 19.
    Ducarme G, Maire F, Chatel P, et al. Acute pancreatitis during pregnancy: a review. J Perinatol. 2014;34(2):87–94.CrossRefGoogle Scholar
  20. 20.
    Jain V, Chari R, Maslovitz S, et al. Guidelines for the management of a pregnant trauma patient. J Obstet Gynaecol Can. 2015;37(6):553–71.CrossRefGoogle Scholar
  21. 21.
    Brown HL. Trauma in pregnancy. Obstet Gynecol. 2009;114(1):147–60.CrossRefGoogle Scholar
  22. 22.
    Raptis CA, Mellnick VM, Raptis DA, et al. Imaging of trauma in the pregnant patient. Radiographics. 2014;34:748–63.CrossRefGoogle Scholar
  23. 23.
    Nguyen CP, Goodman LH. Fetal risk in diagnostic radiology. Semin Ultrasound CT MRI. 2012;33:4–10.CrossRefGoogle Scholar
  24. 24.
    Ralls PW, Balfe DM, Bree RL, et al. Evaluation of acute right lower quadrant pain. In: ACR appropriateness criteria. Reston: American College of Radiology; 1999. p. 1–8.Google Scholar
  25. 25.
    Smith MP, Katz DS, et al. ACR appropriateness criteria right lower quadrant pain – suspected appendicitis. Ultrasound Q. 2015;31(2):85–91.CrossRefGoogle Scholar
  26. 26.
    Rosenfield AT, Newhouse JH, Bluth EI, et al. Acute onset flank pain, suspicion of stone disease. In: ACR appropriateness criteria. Reston: American College of Radiology; 1998. p. 1–3.Google Scholar
  27. 27.
    Shur J, Bottomley C, Walton K, Patel JH. Imaging of acute abdominal pain in the third trimester of pregnancy. BMJ. 2018;361:k2511.CrossRefGoogle Scholar
  28. 28.
    Cogley JR, Ghobrial PM, et al. pulmonary embolism evaluation in the pregnant patient: a review of current imaging approaches. Semin Ultrasound CT MRI. 2011;33:11–7.CrossRefGoogle Scholar
  29. 29.
    Vu L, Ambrose D, et al. Evaluation of MRI for the diagnosis of appendicitis during pregnancy when ultrasound is inconclusive. J Surg Res. 2009;156:145–9.CrossRefGoogle Scholar
  30. 30.
    Khandelwal A, Fasih N, Kielar A. Imaging of acute abdomen in pregnancy. Radiol Clin N Am. 2013;51:1005–22.CrossRefGoogle Scholar
  31. 31.
    Flexer SM, Tabib N, Peter MB. Suspected appendicitis in pregnancy. Surgeon. 2014;12:82–6.CrossRefGoogle Scholar
  32. 32.
    Scheiner E, Abramowicz JS. A symposium on obstetric ultrasound: is all the C4 the fetus? Clin Obstet Gynecol. 2012 March;55(1):188–98.CrossRefGoogle Scholar
  33. 33.
    Smith-Bindman R, Miglioretti DL, Larson EB. Rising use of diagnostic medical imaging in a large integrated health system. Health Aff (Millwood). 2008;27(6):1491–502.CrossRefGoogle Scholar
  34. 34.
    Lazarus, E. Mayo-Smith W., et al. Utilization of radiological examinations in pregnant women: a ten year review – 1997–2006. RSNA annual meeting, Chicago; 2007: p. SSJ05–SSJ02.Google Scholar
  35. 35.
    Abramowicz JS. Benefits and risks of ultrasound in pregnancy. Semin Perinatol. 2013 Oct;37(5):295–300.CrossRefGoogle Scholar
  36. 36.
    Hurwitz LM, Yoshizumi T, et al. Radiation dose to the fetus from body MDCT during early gestation. AJR Am J Roentgenol. 2006;186:871–6.CrossRefGoogle Scholar
  37. 37.
    ACR–SPR practice parameter for imaging pregnant or potentially pregnant adolescents and women with ionizing radiation. Accessed online at:
  38. 38.
    ACR appropriateness criteria® radiation dose assessment introduction subcommittee on appropriateness criteria radiation exposure: Dianna D. Cody, PhD; David W. Jordan, PhD; Murray Becker, MD, PhD; Samuel Brady, PhD, MS; Karin E. Dill, MD; Richard A. Geise, PhD; Mary Ann Keenan, DMP; Tasneem Lalani, MD; Max P. Rosen, MD, MPH; Keith J. Strauss, MS (revised 2018). Accessed online at:

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Department of RadiologyTripler Army Medical CenterHonoluluUSA

Personalised recommendations