What are the causes of sharp epigastric pain during pregnancy?

From the Guidelines

Sharp epigastric pain during pregnancy is a concerning symptom that requires immediate medical attention, with preeclampsia being a leading cause, and prompt diagnosis and treatment are essential for maternal and fetal wellbeing. The causes of sharp epigastric pain in pregnancy can be varied, including:

• Preeclampsia, which typically occurs after 20 weeks gestation and presents with epigastric pain, high blood pressure, and protein in the urine, requiring immediate medical attention 1
• HELLP syndrome, a severe variant of preeclampsia, causes epigastric pain with liver dysfunction and low platelets 1
• Acute fatty liver of pregnancy, a rare but serious condition in the third trimester causing epigastric pain and liver failure 1
• Gastroesophageal reflux disease (GERD), which can be managed with lifestyle changes like avoiding trigger foods and using antacids or H2 blockers such as ranitirin 150mg twice daily or famotidine 20mg twice daily 1
• Gallbladder disease, particularly gallstones, is more common during pregnancy due to hormonal changes affecting bile composition 1
• Pancreatitis can occur from gallstones or high triglycerides 1
• Gastritis or peptic ulcer disease may worsen during pregnancy 1 It is essential to note that any pregnant woman with severe, persistent epigastric pain should seek immediate medical attention, especially if accompanied by nausea, vomiting, fever, or changes in blood pressure, as prompt diagnosis and treatment are essential for maternal and fetal wellbeing 1.

The management of these conditions should be guided by the most recent and highest quality evidence, with a focus on reducing morbidity, mortality, and improving quality of life for both the mother and the fetus. According to the most recent guidelines, women with preeclampsia should be managed with a multidisciplinary team, and those with HELLP syndrome should receive prompt delivery once maternal coagulopathy and severe hypertension have been corrected 1.

In terms of specific treatments, lifestyle changes and medications such as antacids or H2 blockers should be considered for managing GERD, while women with preeclampsia or HELLP syndrome may require more aggressive management, including hospitalization and close monitoring. The use of aspirin prophylaxis, calcium supplementation, and magnesium sulphate may also be considered in certain cases 1.

Overall, the key to managing sharp epigastric pain in pregnancy is prompt recognition and treatment of the underlying cause, with a focus on reducing morbidity, mortality, and improving quality of life for both the mother and the fetus.

From the Research

Causes of Sharp Epigastric Pain in Pregnancy

• Sharp epigastric pain in pregnancy can be caused by various factors, including gastroesophageal reflux disease (GERD) 2, 3, 4, 5.
• GERD is a common condition in pregnancy, affecting up to 80% of women, especially during the third trimester 3.
• The high incidence of GERD in pregnancy can be attributed to altered structure and function of the normal physiological barriers to reflux of gastric contents into the oesophagus 2.
• Other causes of abdominal pain in pregnancy include complications of the pregnancy, such as abortion, ectopic pregnancy, and abruptio placentae, as well as gynaecological and nongynaecological conditions, such as torsion of an ovarian cyst and acute appendicitis 6.

Gastroesophageal Reflux Disease (GERD) as a Cause of Sharp Epigastric Pain

• GERD can cause sharp epigastric pain, heartburn, and regurgitation in pregnant women 2, 3, 5.
• The symptoms of GERD can be managed with lifestyle modifications, antacids, and medications such as histamine-2 receptor antagonists and proton pump inhibitors 2, 3, 5.
• Alginate-based formulations, which create a foamy raft that prevents reflux of gastric contents into the oesophagus, are a safe and effective treatment option for GERD in pregnancy 3.

Diagnosis and Management of Sharp Epigastric Pain in Pregnancy

• A careful history, physical examination, and simple ultrasonographic investigations can help diagnose the cause of sharp epigastric pain in pregnancy 6.
• The management of sharp epigastric pain in pregnancy depends on the underlying cause and may involve lifestyle modifications, medications, and surgical interventions 2, 3, 5, 6.
• It is essential to have a high index of suspicion and awareness of the ways in which medical and surgical conditions may present in pregnancy to ensure early diagnosis and prompt management 6.