What is the initial workup for a pregnant patient with chest tightness, epigastric discomfort, mild shortness of breath, and right upper quadrant pain, and is a d-dimer recommended?

Initial Workup for a Pregnant Patient with Chest Tightness, Epigastric Discomfort, and RUQ Pain

For a pregnant patient presenting with central sternal chest tightness, epigastric discomfort, mild shortness of breath, and right upper quadrant pain, a comprehensive pre-eclampsia workup should be performed immediately, and D-dimer testing is not recommended as it has limited diagnostic value in pregnancy due to physiologically elevated levels.

Pre-eclampsia Assessment

History and Focused Physical Examination

• Assess for emergency symptoms: headache, visual disturbances, chest pain, dyspnea, neurological symptoms, abdominal pain, nausea, anorexia 1
• Document duration of hypertension and previous BP control
• Check for signs of complications: brisk reflexes, papilledema, hepatic tenderness 1
• Evaluate for pulmonary edema suggesting heart failure 1

Vital Signs

• Blood pressure measurements (at least two separate occasions, 15 minutes apart)
  • Pre-eclampsia: BP ≥140/90 mmHg
  • Severe pre-eclampsia: SBP ≥160 mmHg or DBP ≥110 mmHg 1, 2
• Heart rate (normal increase of 10-20 bpm in pregnancy) 1
• Respiratory rate (should be unaltered in pregnancy; RR >20 suggests pathology) 1
• Fetal heart rate (FHR 135 noted in this case is within normal range)

Laboratory Tests

1. Complete Blood Count

   • Hemoglobin, platelet count (thrombocytopenia is part of HELLP syndrome) 1
   • Fibrinogen levels

2. Liver Function Tests

   • AST, ALT, LDH (elevated in HELLP syndrome) 1, 3
   • Haptoglobin (decreased in hemolysis)

3. Renal Function

   • Serum creatinine, eGFR, electrolytes 1
   • Urine: Albumin-to-creatinine ratio (ACR) for proteinuria assessment 1, 2
   • Urine microscopy: red cells, leukocytes, casts

4. Specific Biomarkers

   • sFlt-1/PlGF ratio (≤38 can help exclude pre-eclampsia) 1
   • High-sensitivity cardiac troponin (if acute chest pain is prominent) 1
   • NT-proBNP (if heart failure is suspected) 1

Imaging Studies

• Echocardiography (if heart failure, aortic dissection, or ischemia is suspected) 1
• Liver ultrasound (if RUQ pain is prominent, to assess for hepatic infarction) 3
• Fetal assessment:
  • Electronic fetal heart monitoring
  • Ultrasound for fetal growth
  • Amniotic fluid assessment 1

D-dimer Testing in Pregnancy

Why D-dimer Is Not Recommended

• D-dimer levels increase physiologically throughout pregnancy 1, 4
• By the third trimester, nearly 25% of pregnant women have D-dimer levels above the threshold used for VTE "rule-out" 1
• This significantly reduces the specificity and utility of D-dimer testing in pregnancy 1, 4

When D-dimer May Be Considered

• If pulmonary embolism (PE) is strongly suspected after pre-eclampsia has been ruled out 1
• In early pregnancy (before 20 weeks), approximately 50% of women may still have normal D-dimer levels 1
• A negative D-dimer in early pregnancy with low clinical probability may help avoid unnecessary radiation exposure 1

Diagnostic Algorithm

1. First Priority: Rule Out Pre-eclampsia

   • Complete laboratory workup as outlined above
   • If pre-eclampsia with severe features is confirmed (BP ≥160/110 mmHg with end-organ damage), initiate immediate management 1, 2

2. If Pre-eclampsia Is Excluded:

   • Consider pulmonary embolism in differential diagnosis
   • Assess clinical probability of PE using validated scoring systems 1
   • For low-risk patients in early pregnancy, D-dimer may be considered 1
   • For intermediate to high-risk patients or those in late pregnancy, proceed directly to imaging 1

3. Imaging for Suspected PE (if needed):

   • Compression ultrasound of lower limbs (positive result warrants treatment without further imaging) 1
   • If ultrasound negative but PE still suspected:
     • Perfusion lung scan (if chest X-ray normal and no cardiopulmonary disease) 1
     • CTPA if perfusion scan inconclusive or unavailable 1

Important Considerations

• Epigastric and RUQ pain in pregnancy should raise immediate concern for pre-eclampsia with liver involvement or HELLP syndrome 3
• Chest tightness may represent cardiac manifestations of pre-eclampsia, pulmonary edema, or PE 1
• Normal physiological changes in pregnancy can mask pathology - respiratory rate should remain normal despite increased heart rate 1
• The combination of symptoms described strongly suggests pre-eclampsia until proven otherwise, particularly with RUQ pain 1, 2

Remember that pre-eclampsia is a leading cause of maternal mortality, and prompt diagnosis and management are essential to prevent serious complications including hepatic infarction, eclampsia, and maternal death 2, 3.