A 36-year-old woman, gravida 1 para 0, at 32 weeks gestation comes to the emergency department due to right upper quadrant pain. For the past week, the patient has had intermittent right upper quadrant pain that radiates to the back and resolves within a few hours. The pain has become progressively worse and is now occurring multiple times a day. She has also had increasing dyspnea and fatigue but has had no fever, cough, or headaches. The patient has no chronic medical conditions and has had no surgeries. Temperature is 36.7 C (98 F), blood pressure is 136/84 mm Hg, and pulse is 88/min. BMI is 40 kg/m². Fetal heart rate tracing shows a baseline of 150/min with moderate variability and no decelerations. Cardiac examination reveals a 2/6 midsystolic murmur. The lungs are clear bilaterally. There is tenderness to deep palpation in the right upper quadrant and epigastrium but no palpable mass. The uterus is nontender. Bilateral lower extremities have 1+ pitting edema to the midcalves. Which of the following is the most likely cause of this patient's symptoms?

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11ec25c8_d9ff_0b84_bc81_4d05c372bf3e_MD0003_00 This patient's intermittent right upper quadrant (RUQ) pain (ie, biliary colic) is most likely due to symptomatic cholelithiasis. Pregnant women (particularly those with concomitant obesity) are at increased risk for symptomatic cholelithiasis because they have elevated estrogen levels, which increases cholesterol excretion into bile, and elevated progesterone levels, which decreases gallbladder motility and emptying. As gallstones form and become too large to pass through the cystic duct, they intermittently obstruct the cystic duct when the gallbladder contracts (eg, with fatty meals). This obstruction causes increased intraluminal pressure, leading to the characteristic intermittent RUQ pain that can radiate to the back. Diagnosis is confirmed with RUQ ultrasound, which may show gallstones or biliary sludge (appearing as echogenic foci within the gallbladder). Management during pregnancy is conservative because most cases resolve with supportive care (eg, pain control). Cholecystectomy is usually delayed until the postpartum period. (Choice B) Obstruction and inflammation of the appendix (ie, acute appendicitis) can present with RUQ pain during the third trimester due to displacement of the appendix by the uterus. Patients with acute appendicitis typically have acute-onset, constant pain (rather than intermittent) and signs of inflammation (eg, fever). (Choice C) Passive liver congestion can cause RUQ pain in patients with decompensated right heart failure. Peripartum cardiomyopathy, which primarily causes left-sided heart failure, can lead to secondary right-sided failure. This patient has no signs of left-sided heart failure (ie, no pulmonary edema), making this diagnosis unlikely. Dyspnea, a midsystolic murmur (due to physiologic changes in flow), and 1+ pitting edema are normal in pregnancy. (Choice D) Premature separation of the placenta (ie, placental abruption) presents with diffuse abdominal pain rather than focal RUQ pain. In addition, patients have uterine tenderness and fetal decelerations, which are not seen in this patient. (Choice E) Hepatic adenomas are benign liver tumors associated with high estrogen levels (eg, pregnancy, combination oral contraceptive use). Ruptured hepatic adenomas can cause RUQ pain; however, patients have acute onset of pain, a possible palpable liver mass, and hemodynamic instability (eg, hypotension, tachycardia) due to intraabdominal bleeding. (Choice F) Preeclampsia can cause RUQ pain due to stretching of the liver capsule; however, this diagnosis is unlikely in patients without hypertension (ie, systolic ≥140 mm Hg or diastolic ≥90 mm Hg). Educational objective: Symptomatic cholelithiasis (biliary colic) is common in pregnancy due to increased gallstone formation. Patients have recurrent right upper quadrant and/or epigastric pain from intermittent obstruction of the cystic duct. References: Cholesterol cholelithiasis in pregnant women: pathogenesis, prevention and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/25332259)

A 36-Year-Old Woman, Gravida 1 Para 0, at 32 Weeks