In a hemodynamically stable 30‑year‑old woman at 10 weeks gestation presenting with hematemesis, is a contrast‑enhanced computed tomography angiography of the abdomen and pelvis indicated?

CTA Abdomen/Pelvis in Hemodynamically Stable Pregnant Patient with Hematemesis

In a hemodynamically stable 30-year-old woman at 10 weeks gestation presenting with hematemesis, CTA abdomen/pelvis is NOT indicated as initial imaging—upper endoscopy is the diagnostic test of choice for hematemesis, and radiographic studies including CT should not be withheld when indicated for maternal evaluation, but the clinical presentation points to an upper gastrointestinal source requiring endoscopic rather than angiographic evaluation. 1, 2

Clinical Context and Imaging Rationale

Why CTA Abd/Pelvis is Not the Primary Study

• Hematemesis localizes bleeding to the upper GI tract (esophagus, stomach, duodenum), making panendoscopy the initial diagnostic and potentially therapeutic intervention rather than cross-sectional imaging. 1

• CTA abdomen/pelvis is specifically indicated for:

  • Active intra-abdominal hemorrhage when the source is unknown 3
  • Persistent hemorrhage after empiric embolization 3
  • Detection of active extravasation with 97% accuracy using multiphasic technique (noncontrast, arterial, portal venous phases) 3
  • Postpartum hemorrhage evaluation in hemodynamically stable patients when conventional treatment fails 3

• The clinical scenario describes hematemesis (vomiting blood), which is a classic presentation of upper GI bleeding—not intra-abdominal or pelvic hemorrhage. 1

Pregnancy-Specific Imaging Considerations

Radiation Safety in Pregnancy

• Radiographic studies indicated for maternal evaluation, including abdominal CT, should NOT be deferred or delayed due to concerns regarding fetal radiation exposure. 2

• The principle is clear: maternal stabilization and diagnosis take priority, and necessary imaging should proceed when clinically indicated. 2, 4

• At 10 weeks gestation, fetal radiation exposure from CT is a consideration, but maternal benefit outweighs theoretical fetal risk when imaging is truly needed for diagnosis. 2

Appropriate Diagnostic Pathway

Initial Management of Hematemesis in Pregnancy

• Hemodynamic stabilization comes first: Two large-bore (14-16 gauge) IV lines, oxygen supplementation to maintain saturation >95%, and fluid resuscitation as needed. 2, 4

• Panendoscopy is the initial diagnostic test for hematemesis and allows simultaneous therapeutic intervention (e.g., variceal banding, ulcer cauterization, injection therapy). 1

• The patient must be hemodynamically stabilized before proceeding with diagnostic evaluation. 1

When CTA Would Be Appropriate

CTA abdomen/pelvis would be indicated in this pregnant patient if:

• She presented with hematochezia or melena with hemodynamic instability suggesting lower GI or intra-abdominal source 3
• There was clinical suspicion of intra-abdominal hemorrhage (e.g., abdominal trauma, ruptured ectopic pregnancy, ruptured hemorrhagic ovarian cyst) 3, 5
• Active extravasation needed localization for interventional radiology embolization 3
• She had persistent bleeding after initial endoscopic intervention and an abdominal source was suspected 3

Critical Pitfalls to Avoid

• Do not order CTA for hematemesis when the bleeding source is clearly upper GI—this delays definitive diagnosis and exposes the patient to unnecessary radiation and contrast. 1

• Do not withhold necessary imaging in pregnancy out of excessive caution about fetal radiation exposure when maternal diagnosis requires it. 2

• Do not confuse postpartum hemorrhage guidelines (which extensively discuss CTA for pelvic/uterine bleeding) with antepartum upper GI bleeding—these are entirely different clinical scenarios. 3

• In hemodynamically unstable patients with suspected intra-abdominal hemorrhage, the decision to image versus proceed directly to surgery depends on the clinical context and institutional capabilities. 3