Differential Diagnoses for Right Upper Quadrant Pain in Pregnancy
In pregnant patients presenting with RUQ pain, the primary differential diagnoses include acute cholecystitis, cholelithiasis, acute cholangitis, pancreatitis, HELLP syndrome, acute fatty liver of pregnancy, hepatic infarction/rupture, appendicitis (especially in second/third trimester when the appendix migrates superiorly), urolithiasis with right-sided hydronephrosis, and pyelonephritis. 1, 2
Pregnancy-Specific Hepatobiliary Conditions
Biliary Disease
- Acute cholecystitis and cholelithiasis are the most common surgical causes of RUQ pain in pregnancy, occurring mainly during the last trimester and postpartum period, presenting with RUQ pain (75% of cases), fever (21% of cases), and gallbladder wall thickening with stones on ultrasound. 3, 4, 5
- Acute cholangitis should be suspected when RUQ pain is accompanied by jaundice, fever, chills, elevated inflammatory markers, and biliary dilatation or evidence of obstruction (stricture, stone, or mass) on imaging. 6
- Biliary pancreatitis can occur during pregnancy with similar frequency as in non-pregnant patients, typically caused by gallstones rather than alcohol, and may present with epigastric pain radiating to the back, elevated lipase, and nausea/vomiting. 5, 2
Preeclampsia-Associated Liver Disease
- HELLP syndrome (hemolysis, elevated liver enzymes, low platelets) occurs in association with preeclampsia and may include hepatic infarction and rupture, though liver test abnormalities do not correlate with the degree of liver injury, requiring aggressive treatment with delivery. 2
- Acute fatty liver of pregnancy (AFLP) is associated with preeclampsia and represents a life-threatening condition requiring immediate delivery. 2
- Hepatic infarction and rupture can occur as complications of severe preeclampsia/HELLP syndrome and represent surgical emergencies. 2
Other Pregnancy-Related Conditions
- Cholestasis of pregnancy typically presents with pruritus and elevated bile acids, though it can cause RUQ discomfort. 3, 2
- Hyperemesis gravidarum involves liver abnormalities in 50% of cases, though it typically presents earlier in pregnancy with severe nausea and vomiting. 2
Non-Pregnancy-Specific Conditions
Gastrointestinal/Surgical
- Appendicitis is the most common cause of abdominal pain requiring emergent surgery in pregnant patients, and the location of pain may not correlate with appendiceal position due to superior migration of the appendix with advancing gestation, potentially causing RUQ pain in later trimesters. 6, 1
Genitourinary
- Urolithiasis with right-sided hydronephrosis and pyelonephritis can present with RUQ or right flank pain radiating anteriorly, fever, pyuria, and require differentiation from biliary disease. 6, 7
Hepatic Infections
- Hepatitis E and herpes simplex hepatitis are more likely to be severe in pregnant women and can lead to fulminant hepatic failure, though these are less common causes. 2
Vascular
- Budd-Chiari syndrome is more prevalent in pregnant women due to hypercoagulability and should be considered in cases with hepatomegaly, ascites, and RUQ pain. 2
Critical Red Flags Requiring Immediate Escalation
- Fever, tachycardia, signs of sepsis, or hemodynamic instability suggest severe infection, perforation, or hepatic rupture requiring urgent surgical consultation. 1, 7
- Significant leukocytosis with left shift indicates severe inflammation or infection. 1
- Elevated transaminases (>500 U/L), thrombocytopenia, hemolysis, or coagulopathy suggest HELLP syndrome or AFLP requiring immediate obstetric consultation and consideration of delivery. 2
- Vaginal bleeding, syncope, or signs of preeclampsia (hypertension, proteinuria, headache, visual changes) broaden the differential to obstetric emergencies. 7, 2