What are the recommended steps for a 14-week pregnant woman experiencing epigastric pain?

Epigastric Pain at 14 Weeks Gestation

A 14-week pregnant woman with epigastric pain requires immediate evaluation for pregnancy-specific liver disease (particularly HELLP syndrome and acute fatty liver of pregnancy, though rare at this gestational age), preeclampsia, peptic ulcer disease, and biliary pathology, with urgent obstetrical consultation if accompanied by hypertension, proteinuria, or severe symptoms.

Immediate Red Flag Assessment

Assess for life-threatening conditions first:

• Measure blood pressure immediately - any diastolic BP ≥90 mmHg with epigastric pain warrants same-day hospital assessment 1
• Check urine for proteinuria - new proteinuria (≥+ on dipstick) combined with epigastric pain suggests preeclampsia with severe features requiring immediate admission 1
• Evaluate for HELLP syndrome signs - right upper quadrant/epigastric pain with nausea, vomiting, headache, or malaise requires urgent laboratory evaluation including complete blood count, liver enzymes, and coagulation panel with fibrinogen 1
• Assess for acute fatty liver of pregnancy - though typically third trimester, can present earlier with epigastric pain, nausea, vomiting, and jaundice 1

Pregnancy-Specific Considerations at 14 Weeks

While most pregnancy-related liver diseases occur in third trimester, epigastric pain at 14 weeks requires heightened vigilance:

• Preeclampsia can develop before 20 weeks in high-risk patients (history of preeclampsia, chronic hypertension, renal disease, antiphospholipid syndrome, diabetes) 1
• 65% of HELLP syndrome patients present with epigastric pain, and 20% occur within 48 hours of delivery, though most cases are 27-37 weeks 1
• Arrange immediate admission if: diastolic BP ≥90 mmHg with proteinuria ≥+ and epigastric pain, or diastolic BP ≥110 mmHg with proteinuria, or systolic BP ≥170 mmHg with proteinuria 1

Common Non-Obstetric Causes

After excluding pregnancy-specific emergencies, evaluate for:

• Gastroesophageal reflux disease/gastritis - most common cause of epigastric pain in pregnancy, affecting up to 42% of pregnant women monthly 1
• Peptic ulcer disease - incidence 0.1-0.3%, but perforation carries 30% mortality requiring urgent surgical consultation 1
• Biliary pathology - obtain right upper quadrant ultrasound to evaluate for cholecystitis or choledocholithiasis 1, 2
• Pancreatitis - check serum lipase if pain radiates to back or associated with nausea/vomiting 1

Diagnostic Workup

Order the following tests based on clinical presentation:

• Laboratory studies: complete blood count with platelets, comprehensive metabolic panel including liver enzymes, serum fibrinogen, coagulation panel 1, 3
• Urine dipstick for proteinuria - quantify with 24-hour collection or spot protein/creatinine ratio if ≥+ 1
• Right upper quadrant ultrasound - first-line imaging for biliary and hepatic pathology, safe in pregnancy 1, 2
• CT abdomen with IV contrast if needed - do not defer indicated radiographic studies due to pregnancy concerns 3

Initial Management Algorithm

For GERD/gastritis (most likely at 14 weeks without red flags):

• Lifestyle modifications first: small frequent meals, avoid trigger foods (spicy, fatty, acidic), elevate head of bed, avoid eating 2-3 hours before lying down 1, 4
• First-line pharmacotherapy: antacids without salicylates, or H2-receptor antagonists 1, 5
• Second-line: proton pump inhibitors if symptoms persist 1
• Avoid metoclopramide as monotherapy due to potential fetal risks 4

For suspected peptic ulcer disease:

• Refer for same-day hospital assessment if severe pain, hematemesis, or signs of perforation 1
• Endoscopy if necessary should be performed in second trimester when possible 4
• Empiric PPI therapy is reasonable while awaiting endoscopy if no alarm features 1

For biliary pathology:

• Surgical consultation if ultrasound confirms cholecystitis or choledocholithiasis 1
• Laparoscopic cholecystectomy is safe in second trimester if indicated 1

Obstetrical Consultation Criteria

Immediate obstetrical consultation required for:

• Any blood pressure elevation (diastolic ≥90 mmHg) with epigastric pain 1
• New proteinuria (≥+ on dipstick) with epigastric pain 1
• Epigastric pain with headache, visual disturbances, or right upper quadrant tenderness 1
• Abnormal liver enzymes, thrombocytopenia, or elevated creatinine 1

Critical Pitfalls to Avoid

• Do not dismiss epigastric pain as "normal pregnancy discomfort" - it can herald HELLP syndrome or preeclampsia with severe features requiring delivery 1
• Do not delay imaging studies due to radiation concerns when clinically indicated - maternal stabilization is the priority 3
• Do not perform vaginal examination if vaginal bleeding present until placenta previa excluded by ultrasound 3
• Do not attribute all epigastric pain to GERD - maintain high suspicion for peptic ulcer perforation (30% mortality) and biliary emergencies 1