Right Upper Abdominal Pain in Third Trimester

Critical Life-Threatening Conditions to Rule Out First

The American College of Radiology recommends immediate assessment for life-threatening internal herniation, HELLP syndrome/preeclampsia, acute cholecystitis, and appendicitis in pregnant women with right upper abdominal pain during the third trimester, using ultrasound as first-line imaging followed by MRI if non-diagnostic 1, 2
Internal herniation occurs in 8% of pregnancies after Roux-en-Y gastric bypass (RYGB), and 32.8% of women with upper abdominal pain after RYGB have internal herniation, with maternal mortality of 9% and fetal mortality of 13.6% in case series 1, 2
The Society of American Gastrointestinal and Endoscopic Surgeons recommends that patients with a history of RYGB and symptoms of internal herniation should undergo immediate surgical consultation, without delay for imaging if clinical suspicion is high 1, 2
HELLP syndrome is a life-threatening condition characterized by hemolysis, elevated liver enzymes, and low platelets, and right upper quadrant pain is a cardinal symptom, representing a coagulopathy that is potentially life-threatening 3

The American College of Radiology recommends ultrasound as the initial imaging study for all pregnant patients with right upper abdominal pain, due to its ability to avoid ionizing radiation and good sensitivity for cholecystitis, hydronephrosis, and ovarian pathology 4, 5, 6
If ultrasound is non-diagnostic, MRI without IV contrast is recommended as the next step, with 97% sensitivity and 95% specificity for appendicitis in pregnancy 4, 6

Appendicitis is the most common cause of abdominal pain requiring emergency surgery in pregnancy, with anatomical displacement of the appendix in third trimester making diagnosis challenging, and US abdomen or MRI abdomen/pelvis without IV contrast are appropriate initial imaging 4, 7, 8, 9
The American Urological Association recommends that patients with suspected urolithiasis or pyelonephritis should undergo ultrasound first, then MRI if non-diagnostic, and intervention should not be delayed if sepsis or hemodynamic instability is present 6

The Society of American Gastrointestinal and Endoscopic Surgeons recommends immediate surgical consultation for suspected internal herniation, appendicitis with peritonitis, or ovarian torsion, and multidisciplinary team involvement for any surgical intervention 1, 2, 4, 5
The American College of Surgeons recommends that surgery is preferred first-line for acute cholecystitis, to avoid drug toxicity and complications, and conservative management with IV hydration and symptom control only for uncomplicated biliary colic or conditions that can safely wait until postpartum 5