What is the appropriate management for a pregnant female presenting with epigastric pain?

Management of Epigastric Pain in Pregnancy

Epigastric pain in pregnancy requires immediate systematic evaluation to rule out life-threatening obstetric emergencies (HELLP syndrome, acute fatty liver of pregnancy, placental abruption) and surgical emergencies (internal herniation in post-bariatric surgery patients, appendicitis, acute cholecystitis) before considering benign gastrointestinal causes. 1, 2, 3

Critical Initial Assessment

Immediate Life-Threatening Conditions to Exclude First

Pregnancy-Specific Emergencies:

• HELLP syndrome (hemolysis, elevated liver enzymes, low platelets) presents with right upper quadrant or epigastric pain, nausea, vomiting, and malaise 1, 4
• Check blood pressure immediately—severe hypertension (systolic >160 mmHg or diastolic >110 mmHg) requires urgent treatment 1
• Acute fatty liver of pregnancy manifests with epigastric pain, malaise, headache, nausea, vomiting, and jaundice 1, 4
• Perform abdominal ultrasound if severe preeclampsia or HELLP syndrome is suspected with symptoms of hepatic hematoma (abdominal, epigastric, or right shoulder pain) 1

Surgical Emergencies:

• Internal herniation in patients with prior bariatric surgery (especially Roux-en-Y gastric bypass) carries 9% maternal mortality and 13.6% fetal mortality 2, 3
• This occurs in 8% of pregnancies after RYGB, with 32.8% of women with upper abdominal pain having internal herniation 2
• Immediate surgical consultation is required without delay for imaging if clinical suspicion is high 2
• Appendicitis is the most common non-obstetric surgical emergency in pregnancy, presenting atypically due to anatomical displacement by the gravid uterus 2, 3

Essential History Elements

Timing and Characteristics:

• Sudden versus gradual onset of pain 4
• Pain severity on 1-10 scale 4
• Current gestational age 4

Associated Symptoms:

• Nausea, vomiting, hematemesis 4
• Heartburn or acid regurgitation (suggests GERD/esophagitis) 4
• Headaches, visual changes, swelling (preeclampsia screening) 4
• Right upper quadrant pain with malaise (HELLP indicators) 4

Critical Surgical History:

• Any history of bariatric surgery before pregnancy—ask specifically about colicky/cramping pain, nausea, vomiting (internal herniation signs) 4, 2
• Previous abdominal or pelvic surgery (increases mechanical ileus risk) 5

Physical Examination:

• Vital signs including blood pressure and heart rate 4
• Abdominal examination for tenderness, guarding, rebound, or masses 4
• Assess for peripheral edema and jaundice 4
• Evaluate for peritoneal signs (rigidity, rebound tenderness) 3
• Check for vaginal bleeding 3

Diagnostic Imaging Algorithm

First-Line Imaging:

• Ultrasound is the initial imaging study for all pregnant patients with epigastric pain 2, 3
• Avoids ionizing radiation and has good sensitivity for cholecystitis, hydronephrosis, and ovarian pathology 2
• Perform obstetric ultrasound to assess fetal viability, placental location, and amniotic fluid 3

Second-Line Imaging:

• MRI without IV contrast if ultrasound is non-diagnostic 2, 3
• MRI has 97% sensitivity and 95% specificity for appendicitis in pregnancy 2, 3
• Gadolinium should be avoided during pregnancy 1

Third-Line Imaging:

• CT with IV contrast reserved only for life-threatening situations when diagnosis cannot be made by ultrasound or MRI 3
• Benefits outweigh radiation risks when maternal or fetal life is threatened 3

Management Based on Diagnosis

HELLP Syndrome Management

Blood Pressure Control:

• Non-severe hypertension (140-159/90-109 mmHg): initiate oral labetalol, nifedipine, or methyldopa 1
• Severe hypertension (>160/>110 mmHg): urgent treatment with oral labetalol, nifedipine, or methyldopa; IV labetalol or hydralazine may be required 1

Additional Interventions:

• Magnesium sulfate for seizure prophylaxis in severe hypertension 1
• Corticosteroids (dexamethasone or betamethasone) for fetal lung maturity if delivery before 35 weeks 1
• Deliver promptly once maternal coagulopathy and severe hypertension corrected 1
• Early referral to transplant center if signs of hepatic failure 1

Acute Fatty Liver of Pregnancy

Intensive Care Criteria:

• Encephalopathy, elevated serum lactate (>2.8 mg/dL), MELD score >30, or Swansea criteria >7 1
• Expedite delivery once coagulopathy and metabolic derangements treated 1
• Consider plasma exchange post-delivery for severe hepatic impairment 1
• N-acetylcysteine can be considered in ICU setting 1
• Early transplant center referral if severe hepatic impairment 1

Gallstone Disease

Surgical Approach:

• Laparoscopic cholecystectomy is safe during pregnancy and superior to conservative management 1
• Ideally performed in second trimester, but safe in any trimester 1
• Same-admission cholecystectomy for acute biliary pancreatitis reduces readmission by 85% 1
• Conservative management (IV hydration, symptom control) leads to 60% recurrence rate and high hospitalization rates 1
• Late third trimester: may postpone until delivery if no risk to maternal/fetal health 1

ERCP Considerations:

• Fetal teratogenic threshold is 50 mGy; detrimental outcomes usually >100 mGy 1
• Position patient in left pelvic tilt or left lateral position in second/third trimesters to avoid aortic/IVC compression 1
• Use modern fluoroscopy with collimation, pulsed fluoroscopy, and low radiation protocols 1

Benign Gastrointestinal Causes

When Life-Threatening Causes Excluded:

• GERD, esophagitis, gastritis, peptic ulcer disease are common in pregnancy 1
• 7% of Americans have daily heartburn; 42% experience it monthly 1
• CT abdomen/pelvis may show distal esophageal wall thickening (≥5 mm) with moderate association to reflux esophagitis 1
• Endoscopy remains standard for definitive diagnosis but may be deferred if symptoms respond to conservative management 1

Critical Pitfalls to Avoid

Never Attribute Severe Pain to "Normal Pregnancy":

• Severe abdominal pain should never be dismissed without excluding serious pathology 3
• Pregnancy masks signs and symptoms of intestinal obstruction—high index of suspicion required 6, 5

Do Not Delay Imaging or Surgical Consultation:

• Maternal and fetal outcomes worsen with delayed treatment 3
• Radiation concerns should not prevent necessary imaging when maternal/fetal life threatened 3
• Clinical judgment supersedes negative imaging when excluding placental abruption (ultrasound only 40-50% sensitive) 3

Post-Bariatric Surgery Patients:

• Internal herniation requires immediate surgical consultation without imaging delay if high clinical suspicion 2
• Mechanical ileus should be considered even after onset of labor pains in patients with prior abdominal/pelvic surgery 5

IBD Patients:

• Screen for active disease with fecal calprotectin (cutoff 200 mg/mg has 67-74% positive predictive value) 1
• Unsedated flexible sigmoidoscopy preferred over colonoscopy if endoscopy critical to decision-making 1
• Intestinal ultrasound distinguishes active from quiescent disease with 84% sensitivity and 98% specificity 1