This document discusses the symptoms, signs, investigations, and management of common causes of epigastric pain in pregnancy. Key points include: 1. A detailed history is important to determine the onset, character, location, and exacerbating/relieving factors of the pain. Physical exam can be more difficult due to the gravid uterus. 2. Common etiologies include gastroesophageal reflux, biliary colic, cholecystitis, hernias, and pregnancy-related conditions. 3. Investigations include blood tests, ultrasound, and limited use of radiation-based imaging. Management focuses on lifestyle changes, medications, and surgery if needed while minimizing risk to the fetus.

1. Epigastric Pain In Pregnancy
Prof. M.C.BANSAL
MBBS. MS. FICOG. MICOG .
Ex Principal & Controller .,
Jhalawar Medical College and Hospital.
&
MGMC & H. Sitapura,. Jaipur.

2. Symptoms And Signs
• History Taking
• A detailed history of presenting symptoms is extremely important .
The complaints should be co related and interpreted with reference
to period of gestation , Etiology & changes through out pregnancy.
Following questions may be enquired to reach an appropriate
diagnosis :
1. Is the onset of pain gradual or sudden ?
2. Is it dull, aching and constant or is it sharp and
stabbing ?
3. Is it associated with meals ?
4. Is it localizing or radiating / shifting / piercing to back ?
5. is there any associated nausea / vomiting ?
6. Is there any exacerbating / relieving factor ?

3. Physical Examination
• Clinical features may be less obvious and more difficult
to elicit in pregnancy as compared to non pregnant
woman .
• Peritoneal signs are absent in pregnancy as a result of
stretching of abdomen and peritoneal cavity, as
inflamed organ is not in direct contact of parietal
peritoneum hence guarding is reduced.
• Try to distinguish between extra uterine and intra
uterine tenderness. Examination of patient in lateral
decubitus position may be useful . This maneuver
displaces the pregnant uterus to one side .

4. Conditions with increased Frequency in
Pregnancy
• 1.Gastro-oesophagial reflux /oesophagitis .
• Biliary Colic.
• Acute Chole-cystitis.
• Diaphragmatic Hernia.

6. Conditions Due To Pregnancy.
• Rupture of the rectus abdominis muscle.
• Acute Fatty Liver of Pregnancy.
• HELLP ( Haemolysis ,Elevated liver enzymes
and Low Platelet counts. )
• Spontaneous rupture of Liver due to HELLP .
• Prodromal symptom of impending Eclampsia .

7. Conditions Incidental to Pregnancy.
• Non ulcer Dyspepsia.
• Gastric / duodenal ulcer –Oral Iron therapy.
( usually become silent during pregnancy but
incidence of aggravated symptoms or even
perforation increase during post partum
period.)
• Acute and chronic Pancreatitis.

8. Investigations
• Routine CBP, Urine analysis and Serological investigations for
sugar , creatinin , electrolytes ,Urea ,Liver Enzymes, Bleeding /
clotting Profile.
• USG --- Liver, Gall Bladder , Kidneys , Pancreas can be
evaluated easily .
• Ionizing radiation that produces exposure < 0.05Gy =50 rad
have not been found associated with foetal
anomalies., however prenatal X ray exposure has been co
related with increased possibility of childhood cancers.
• Ionizing radiations should be used when absolutely indicated
and other imaging options have been considered and
rejected.
• MRI and MRI contrast media are contra indicated in early
gestational period .

9. Gastro-esophageal Reflux Disease.
• It is almost universal to some degree in
pregnancy.
• It is due to an increased intra abdominal pressure
from a gravid uterus , dysfunction of lower
oesophageal sphincter , delayed gastric empting
due to smooth muscle relaxant effect of
progesterone.
• There is also delayed clearance of the reflux
leading to increased acid exposure
time, esophageal mucosa is not acid resistant –
leading to esophagitis.

10. Clinical Features of GORD.
• Heart burn , retrosternal pain related to meals , posture
and exercise.
• Water wash ( excess salivation especially during an episode
of pain ).
• Regurgitation of acid and bile can cause rarely nocturnal
sore throat or indeed asthma.
Treatment  Elevation of head end of bed by 30 degree
, small frequent meals, keep seated in erect posture after
meals, avoid any thing that obviously exacerbate the
symptoms.
Alginates are effective for relief of symptoms. There is no
conclusive evidence regarding safety of H2 blocker and
proton pump inhibitors in pregnancy.

11. Biliary Colic and Acute cholecystitis
• Asymptomatic gall bladder disease occurs in 3-4 % of pregnant women .
• Acute cholecystitis occurs in 1:1130 -12890 pregnancy.
Clinical Features:
1. Pain is usually moderately severe and constant in both acute chloecystitis
and biliary colic. In these cases It is commonly felt in the right upper
quadrant and can be epigastric radiating to the back and right shoulder.
2. Vomiting occurs in 50% of cases , fever is present in cholecystitis.
3 . USG is diagnostic and safe .
4 .Leucocytosis and raised Alkaline phosphatase levels may be present in
healthy pregnancy hence inconclusive .
5 .Transient increase in Amylase can occur in 30 % those with biliary colic but
markedly raised suggests Pancreatitis.

12. Biliary Colic And Acute Cholecystitis
• Treatment
1. Conservative treatment with intravenous
fluids , analgesics , broad spectrum antibiotics
are started.
2. Surgery should be undertaken preferably
in mid 2nd trimester or post partum period
, laparoscopy is safe in this period of gestation.

13. Acute Pancreatitis
• This occurs most often secondary to gall
stones and associated with a fetal loss of 10-
20 %.
• In these cases , endoscopic retrograde
cholangiopancreaticogram and
sphincterectomy can be performed safely in
pregnancy . Uterus should be lead shielded.

14. Gastric Ulcer /Duodenal Ulcer
• Pre existing gastric ,duodenal ulcer become silent
during pregnancy and de novo ulceration is rare.
• It presents with epigastric pain after / before
meals and often associated with anorexia and
weight loss.
• It is commonly caused by Helicobacter pylori and
unprotracted use of NSAIDs ,diagnosed
endoscopically.
• Treatment for H. pylori can be given during
pregnancy.

15. Thank you