What questions should be asked to a pregnant patient presenting with epigastric pain?

Key Questions for Pregnant Patients with Epigastric Pain

When evaluating a pregnant patient with epigastric pain, a structured approach focusing on potentially life-threatening conditions is essential, as early detection and prompt intervention can significantly reduce maternal and fetal morbidity and mortality.

Initial Assessment Questions

• Timing and onset of pain:

  • When did the pain start? Was it sudden or gradual? 1
  • Is the pain constant or intermittent? 1
  • Does the pain coincide with meals or occur on an empty stomach? 1

• Pain characteristics:

  • Can you describe the location precisely? Is it truly epigastric or radiating? 1
  • How would you rate the severity on a scale of 1-10? 1
  • Is the pain burning, cramping, colicky, or sharp? 1
  • Does the pain radiate to the back (concerning for pancreatitis or aortic issues)? 1

• Associated symptoms:

  • Do you have nausea, vomiting, or hematemesis? 1
  • Any heartburn or regurgitation of acid/food? 1
  • Do you have fever or chills? 1
  • Any changes in bowel habits (diarrhea, constipation)? 1
  • Any dysphagia or early satiety? 1, 2

Pregnancy-Specific Questions

• Pregnancy history:

  • What is your current gestational age? 1
  • Have you had any complications during this pregnancy? 1
  • Any history of bariatric surgery before pregnancy? 1

• Preeclampsia screening:

  • Have you experienced headaches, visual changes, or swelling? 1
  • Have you noticed any changes in your urinary output? 1
  • Any right upper quadrant pain in addition to epigastric pain? 1

Critical Questions for Life-Threatening Conditions

• HELLP syndrome indicators:

  • Ask about right upper quadrant or epigastric pain, nausea, vomiting, and malaise 1
  • Inquire about headaches, which are present in approximately 30% of HELLP cases 1
  • Question about visual disturbances that may indicate severe preeclampsia 1

• Acute fatty liver of pregnancy:

  • Ask about malaise, headache, nausea, vomiting, and jaundice 1
  • Inquire about confusion or altered mental status 1

• Internal herniation (especially post-bariatric surgery):

  • Ask about colicky or cramping abdominal pain 1
  • Inquire about nausea and vomiting, which occur in approximately 50% of internal herniation cases 1
  • Question about previous bariatric surgery, especially RYGB 1

Surgical Emergency Questions

• Intestinal obstruction:

  • Ask about previous abdominal or pelvic surgeries 3
  • Inquire about constipation, obstipation, or inability to pass gas 3
  • Question about abdominal distension 1

• Epigastric hernia:

  • Ask about bulging in the epigastric region that worsens with straining 4
  • Inquire about previous hernia repairs 4

• Gastric band complications:

  • For patients with adjustable gastric bands, ask about symptoms of band slippage (increased reflux, dysphagia, or regurgitation) 1

Gastrointestinal Disorder Questions

• Peptic ulcer disease/gastritis:

  • Ask about relationship of pain to meals (relief or worsening) 1
  • Inquire about NSAID use during pregnancy 1
  • Question about H. pylori risk factors 1

• Gastroesophageal reflux:

  • Ask about burning sensation rising toward the neck 1
  • Inquire about worsening symptoms when lying down 1
  • Question about regurgitation of sour or bitter fluid 1

Rare but Serious Conditions

• Vascular issues:

  • Ask about sudden, severe pain that may indicate mesenteric or portal vein thrombosis 5
  • Inquire about personal or family history of thrombophilia 5

• Malignancy:

  • Though rare, ask about persistent symptoms, weight loss, early satiety, or family history of gastric cancer 2

• Placenta percreta:

  • In second or third trimester, ask about dysuria or urinary symptoms accompanying abdominal pain 6
  • Inquire about previous cesarean deliveries 6

Key Physical Examination Elements

• Vital signs with special attention to blood pressure and heart rate 1
• Abdominal examination for tenderness, guarding, rebound, or masses 1
• Assessment for peripheral edema 1
• Evaluation for jaundice 1

Remember that epigastric pain in pregnancy can signal serious conditions requiring urgent intervention, including preeclampsia, HELLP syndrome, acute fatty liver of pregnancy, and internal herniation, especially in patients with prior bariatric surgery.