What is the appropriate evaluation and initial management for a 22‑year‑old woman, 5 weeks postpartum, presenting with severe epigastric pain?

Severe Epigastric Pain in a 22-Year-Old Woman at 5 Weeks Postpartum

This patient requires immediate exclusion of life-threatening conditions—particularly myocardial infarction, perforated peptic ulcer, and acute pancreatitis—before considering typical postpartum causes, as missed cardiac or surgical emergencies carry mortality rates of 10-30%. 1, 2

Immediate Life-Threatening Causes to Rule Out First

Cardiac Evaluation (Priority #1)

• Obtain an ECG within 10 minutes of presentation and measure cardiac troponins serially at 0 and 6 hours—never rely on a single troponin measurement. 1, 2
• Myocardial infarction presents atypically with epigastric pain in 10-20% of cases, particularly in young women, and carries 10-20% mortality if missed. 1, 2
• Atypical presentations include epigastric pain mimicking indigestion, isolated dyspnea, and nausea without chest pain. 1, 2
• The postpartum period increases thrombotic risk, making cardiac causes more likely than in non-pregnant young women. 3

Perforated Peptic Ulcer (Priority #2)

• Look for sudden onset of severe epigastric pain that becomes generalized, accompanied by fever, abdominal rigidity, and absent bowel sounds. 1, 2
• Check vital signs immediately for tachycardia ≥110 bpm, fever ≥38°C, or hypotension, which predict perforation or sepsis with high specificity. 1, 2
• Perform physical examination seeking peritoneal signs: rigidity, rebound tenderness, and absence of bowel sounds. 1, 2
• Mortality reaches 30% if treatment is delayed. 1, 2

Acute Pancreatitis (Priority #3)

• Characteristically presents with epigastric pain radiating to the back, which may feel like waves or contractions. 1
• Measure serum amylase ≥4x normal or lipase ≥2x normal, which has 80-90% sensitivity and specificity. 1
• Overall mortality is <10% but reaches 30-40% in necrotizing pancreatitis. 1

Pregnancy-Specific Postpartum Complications

Thromboembolic Disease

• Ovarian vein thrombosis and deep vein thrombosis are more common in the postpartum period due to hypercoagulability. 3
• Consider if pain is lateralized or associated with fever and leukocytosis. 3

Infectious Complications

• Endometritis, pelvic abscess, or deep abdominal collections can present with epigastric pain if inflammation extends superiorly. 3
• Look for fever, foul-smelling lochia, and uterine tenderness. 3

HELLP Syndrome Sequelae

• Although typically presenting before delivery, hemorrhagic liver infarction can occur postpartum and manifest as severe epigastric pain. 3
• Consider if there was preeclampsia during pregnancy. 3

Diagnostic Algorithm

Initial Assessment

1. Check vital signs for hypotension, tachycardia ≥110 bpm, or fever ≥38°C. 1, 2
2. Perform focused physical examination for peritoneal signs, cardiac abnormalities, and costovertebral angle tenderness. 1, 2
3. Evaluate timing (sudden vs. gradual onset), severity (1-10 scale), radiation pattern (back, chest, shoulders), and associated symptoms (nausea, vomiting, hematemesis, heartburn, dyspnea). 1, 2

Mandatory Laboratory Tests

• ECG within 10 minutes of presentation. 1, 2
• Cardiac troponins at 0 and 6 hours (serial measurements are mandatory). 1, 2
• Complete blood count, C-reactive protein, serum lactate. 1, 2
• Liver and renal function tests. 1, 2
• Serum amylase or lipase. 1, 2
• Electrolytes and glucose. 2

Imaging Strategy

• CT abdomen and pelvis with IV contrast is the gold standard when diagnosis is unclear, identifying pancreatitis, perforation (extraluminal gas in 97%, fluid/fat stranding in 89%, ascites in 89%, focal wall defect in 84%), and vascular emergencies. 4, 1, 2
• Abdominal ultrasound can identify ovarian vein thrombosis, pelvic collections, and biliary pathology in postpartum patients. 3
• Upper endoscopy is definitive for peptic ulcer disease, gastritis, and esophagitis once the patient is stable and surgical emergencies are excluded. 1, 5

Initial Management

Resuscitation and Stabilization

• Maintain the patient nil per os until surgical emergency is excluded. 1, 2
• Establish IV access and provide fluid resuscitation if hemodynamically unstable. 1, 2

Empiric Medical Treatment

• Start high-dose proton pump inhibitor therapy (omeprazole 20-40 mg once daily) for suspected acid-related pathology, with healing rates of 80-90% for duodenal ulcers and 70-80% for gastric ulcers. 1, 2
• Avoid NSAIDs as they can exacerbate peptic ulcer disease and increase bleeding risk. 1, 2

Symptom Management (Breastfeeding Considerations)

• For nausea: ondansetron 8 mg sublingual every 4-6 hours, promethazine 12.5-25 mg orally/rectally every 4-6 hours, or prochlorperazine 5-10 mg every 6-8 hours. 1
• Obtain a baseline ECG before administering ondansetron due to QTc prolongation risk. 1
• Monitor for excessive sedation in breastfed infants if opioids are prescribed, as interindividual variation in metabolism can cause neonatal adverse effects. 6, 7

Critical Pitfalls to Avoid

• Never dismiss cardiac causes in young postpartum women with "atypical" epigastric pain—this is a fatal mistake, as the postpartum period increases thrombotic risk. 1, 2, 3
• Do not delay imaging in patients with peritoneal signs, as perforated ulcer mortality increases significantly with delayed diagnosis. 1, 2
• Do not assume typical postpartum pain or GERD without first excluding life-threatening causes, even in patients with known reflux disease. 1, 2
• Persistent vomiting with epigastric pain excludes functional dyspepsia and requires investigation for structural disease such as peptic ulcer disease or acute coronary syndrome. 1, 2
• Do not delay endoscopy in patients with alarm signs: persistent vomiting, weight loss, anemia, dysphagia, or hematemesis. 1, 5, 2

Postpartum-Specific Considerations

• Consider pregnancy-related complications (ovarian vein thrombosis, endometritis, HELLP sequelae) in addition to standard causes of epigastric pain. 3
• CT can be indicated for evaluation of ovarian vein thrombosis extent and deep abdominal collections in postpartum patients. 3
• MRI can provide specific diagnosis of hemorrhagic liver infarction in the clinical setting of HELLP syndrome. 3