Introduction: Acute appendicitis (AA) is one of the most common differential diagnoses in a pregnant lady presented with right iliac fossa (RIF) pain. Traditional concept of early exploration has been questioned, as far as recent evidences showed much higher morbidity rates than expected. Mandatory pre-operative imaging (ultrasound or Computer Tomography scan) has been advocated and proven able to significantly reduce its related avoidable morbidity.

Case Presentation: Three cases are presented: Case 1 was a 41-year-old lady who had acute appendicitis which was successfully managed conservatively. Case 2 was a 29-year-old lady at 25 weeks of gestation, presented with 2 weeks history of RIF pain. Open appendectomy was offered for her, as far as obstetric review and ultrasound were inconclusive. Even though, she had a negative appendectomy, and her postoperative period was complicated by recurrent premature uterine contractions. The third case was an unfortunate lady at 30 weeks of gestation. Laparotomy was done for her, as her RIF pain persisted, which was diagnosed by significant fluids at both iliac fossae with other unremarkable obstetric review. Her postoperative period was complicated by paralytic ileus and intra-uterine death.

Conclusions: Our review demonstrated that a pregnant lady suspected of AA poses a great clinical challenge to surgeons, as far as scoring systems are almost unreliable. Positive imaging prior to surgery is warranted, in order to avoid a nontherapeutic surgery which is always associated with high morbidity rates.