Right upper quadrant pain during pregnancy can stem from a surprisingly wide range of causes, some routine and some genuinely dangerous. The most common culprit is gallbladder disease, driven by hormonal shifts that slow bile flow and promote stone formation. But the same location of pain can also signal preeclampsia with liver involvement, a displaced appendix, kidney problems, or rarer conditions like acute fatty liver of pregnancy. Because the growing uterus reshuffles organ positions and pregnancy alters blood chemistry, a pain that would suggest one straightforward diagnosis in a non-pregnant person opens up a longer list of possibilities in someone who is expecting.
Gallbladder Disease Is the Most Frequent Culprit
Pregnancy creates near-ideal conditions for gallstones. Rising estrogen and progesterone levels reduce how forcefully the gallbladder contracts, which lets bile sit and stagnate. At the same time, estrogen increases cholesterol secretion into the bile. The result is thicker, more stone-prone bile pooling in a sluggish gallbladder.1PubMed Central. Between guidelines and reality; the complex decision-making of acute cholecystitis in pregnancy A stone that blocks the cystic duct causes biliary colic, a crampy pain in the right upper abdomen that often flares after meals. If the blockage persists and the gallbladder wall becomes inflamed, the pain becomes constant, sometimes radiating to the right shoulder blade, and can be accompanied by fever and nausea. This is acute cholecystitis, and it is the most common reason a pregnant person ends up needing non-obstetric surgery.
When surgery is necessary, laparoscopic cholecystectomy is the preferred approach. A large network meta-analysis involving over 29,000 pregnant women found that laparoscopic removal carried a significantly lower risk of preterm delivery, fetal complications, and maternal complications compared with both open surgery and conservative management alone.2PubMed. Optimal treatment strategies for gallbladder disease in pregnancy: a systematic review with dual network meta-analyses Timing matters: the second trimester is generally considered the safest window. By the third trimester, the enlarged uterus makes the procedure more technically difficult and raises the risk of maternal complications.3PubMed Central. Laparoscopic cholecystectomy during pregnancy: three case reports That said, when a gallbladder emergency arises, delaying treatment carries its own serious risks. The guiding principle across all non-obstetric surgery in pregnancy is that the mother’s health comes first, and a preoperative team that includes an obstetrician and neonatologist is standard practice.4PubMed. Non-obstetric surgery in pregnancy (including bowel surgery and gallbladder surgery)
Preeclampsia and HELLP Syndrome
Right upper quadrant pain in the second half of pregnancy, especially after 20 weeks, should always raise the question of preeclampsia. Preeclampsia is a hypertensive disorder in which blood pressure rises and organ damage begins, and the liver is one of its main targets. When the liver is affected, the capsule surrounding it stretches, producing a deep, steady ache under the right ribs or in the upper middle abdomen. If you also have a headache, visual changes, or sudden swelling, the combination is a red flag that warrants immediate evaluation.
HELLP syndrome is a severe variant of preeclampsia named for its three hallmarks: hemolysis (destruction of red blood cells), elevated liver enzymes, and low platelets. The liver damage in HELLP appears to start with tiny blood clots forming in the liver’s microscopic blood vessels, which obstruct normal flow and cause liver cells to die.5PubMed. The role of hepatic sinusoidal obstruction in the pathogenesis of the hepatic involvement in HELLP syndrome: Exploring the literature This ischemic damage is what produces the pain, the rise in liver enzymes, and in rare cases, bleeding beneath the liver capsule or even liver rupture.
Subcapsular liver hematoma is one of those rare but life-threatening complications. It presents with sudden-onset right upper quadrant pain, sometimes severe enough to radiate to the right shoulder, along with nausea and vomiting from the swelling of the liver tissue and its capsule.6PubMed Central. Grade III subcapsular liver hematoma secondary to HELLP syndrome: A case report of conservative management If the hematoma ruptures, the situation becomes a surgical emergency: blood fills the abdomen, and hypovolemic shock can follow rapidly. A systematic review of 391 reported cases emphasized that spontaneous liver rupture in pregnancy is underrecognized and highly lethal, and recommended that it be actively ruled out in any patient with preeclampsia, eclampsia, or HELLP syndrome who develops right upper abdominal pain with hemodynamic instability.7PubMed Central. Hypertensive disorders in pregnancy complicated by liver rupture or hematoma: a systematic review of 391 reported cases Unruptured hematomas can sometimes be managed conservatively with close monitoring, but rupture demands immediate delivery and surgical repair of the liver.8PubMed Central. Hepatic Rupture Associated With HELLP (Hemolysis, Elevated Liver Enzymes, and Low Platelets) Syndrome: A Report of Two Cases and Literature Review
Acute Fatty Liver of Pregnancy
Acute fatty liver of pregnancy (AFLP) is another condition unique to pregnancy that can cause right upper quadrant pain, though it is far rarer than preeclampsia. It typically shows up in the third trimester or very early postpartum period. The underlying problem involves a defect in how the fetus metabolizes fatty acids, which causes toxic fat metabolites to accumulate in the mother’s liver. Symptoms can look deceptively similar to preeclampsia, viral hepatitis, or cholestasis of pregnancy, which makes early diagnosis tricky.9PubMed Central. Acute fatty liver of pregnancy
What often distinguishes AFLP from HELLP is the degree of liver failure. Patients with AFLP tend to develop jaundice, low blood sugar, and clotting problems that go beyond what you typically see in HELLP. The treatment is prompt delivery, after which the liver usually begins to recover. Because AFLP is rare, it is easy to miss in the early stages when nausea, fatigue, and mild abdominal pain might be attributed to normal late-pregnancy discomfort. Any new right-sided pain accompanied by jaundice, dark urine, or confusion in the third trimester should be evaluated urgently.
Appendicitis and the Migrating Appendix
Appendicitis is one of the most common surgical emergencies during pregnancy, and it poses a diagnostic challenge because the appendix does not stay put. As the uterus grows, it gradually pushes the appendix upward from its usual position in the lower right abdomen. By the later months, the appendix can sit as high as the right upper quadrant or right flank.10PubMed. Revisiting MRI for appendix location during pregnancy This displacement is clinically important: the classic teaching is that early in pregnancy, appendicitis still hurts in the lower right abdomen, but in the second and third trimesters, the pain migrates upward and can involve the upper quadrant or the entire right side of the abdomen.11JAMA Surgery. Acute Appendicitis During Pregnancy: Diagnosis and Management
This means that right upper quadrant pain in the second or third trimester could be appendicitis masquerading as gallbladder disease or a liver problem. The consequences of missing the diagnosis are serious: a ruptured appendix during pregnancy raises the risk of preterm labor and fetal loss. When the clinical picture is ambiguous, imaging with ultrasound or MRI can help pin down whether the appendix is inflamed, regardless of where it has migrated to.
Kidney Stones and Hydronephrosis
The right kidney and ureter are another source of upper quadrant pain during pregnancy, and the anatomy works against you here. Progesterone relaxes smooth muscle throughout the body, including the walls of the ureters, which slows urine flow. At the same time, the growing uterus physically compresses the ureters as they cross the pelvic brim. This combination causes a degree of hydronephrosis (swelling of the kidney from backed-up urine) that is considered normal in pregnancy, but it is far more common on the right side because the uterus naturally rotates slightly rightward.12The Open Urology & Nephrology Journal. Management of Acute Symptomatic Hydronephrosis of Pregnancy by Postural Drainage
When a kidney stone forms or gets caught in this already-narrowed system, the pain can be intense, typically in the flank or right upper abdomen, sometimes radiating to the groin. Management starts conservatively: hydration, safe pain relief, and close monitoring. Paracetamol (acetaminophen) is the first-line analgesic because NSAIDs carry risks to the fetus including premature closure of a key heart vessel. Low-dose, short-term opioids like morphine can be used cautiously, but long-term or high-dose use has its own fetal risks. Somewhere between a quarter and more than four out of five women will pass the stone without intervention. When they don’t, emergency decompression with a ureteral stent or nephrostomy tube becomes necessary.13PubMed Central. Management of Kidney Stone Disease in Pregnancy: A Practical and Evidence-Based Approach
One practical tip that has clinical support: lying in a semi-prone position with the affected side facing up and the head slightly elevated can help the gravid uterus fall forward and take pressure off the compressed ureter, sometimes relieving the obstruction enough to allow drainage.12The Open Urology & Nephrology Journal. Management of Acute Symptomatic Hydronephrosis of Pregnancy by Postural Drainage
Intercostal Neuralgia
Not every right upper quadrant pain in pregnancy comes from an organ. Intercostal neuralgia, pain originating from the nerves that run between the ribs, is an underappreciated cause of sharp, unilateral chest or flank pain in pregnant women. The expanding uterus and the mechanical strain it places on the rib cage can irritate these nerves, producing pain that mimics gallbladder trouble or even a pulmonary embolism. A case series from a German university hospital treated 17 pregnant women with severe unilateral chest or flank pain diagnosed as intercostal neuralgia. All patients reported immediate relief from ultrasound-guided nerve blocks, with only two needing a second procedure for recurrence.14PubMed Central. Ultrasound-guided intercostal block for the management of intercostal neuralgia in pregnant women: Case series and review of the literature
The reason this diagnosis matters is that it is essentially benign and treatable, but it often gets caught up in lengthy workups for more dangerous conditions. A pregnant person whose pain is sharp, follows the line of a rib, and worsens with specific movements or breathing may be dealing with a nerve issue rather than an abdominal emergency. Of course, ruling out more serious causes first is still appropriate.
How Right Upper Quadrant Pain Is Investigated During Pregnancy
Sorting through this many possible causes requires a thoughtful diagnostic approach, and imaging plays a central role. Ultrasound is the first-line tool because it is safe, widely available, and effective at spotting gallstones, hydronephrosis, and liver abnormalities.15PubMed Central. MR imaging of acute abdominal pain in pregnancy When ultrasound doesn’t give a clear answer, MRI is the go-to second step. It provides superior soft-tissue detail and spatial resolution compared with ultrasound and overcomes the limitation of the enlarged uterus blocking the view. Importantly, MRI does not use ionizing radiation. The main precaution is avoiding gadolinium contrast agents because of theoretical risks to the fetus.16PubMed. Acute abdominal and pelvic pain in pregnancy: ESUR recommendations
Blood tests are the other half of the puzzle, and interpreting them during pregnancy requires knowing what “normal” looks like in a pregnant person, which is different from a non-pregnant one. Albumin levels drop due to hemodilution (increased blood volume diluting the protein). Alkaline phosphatase rises, especially in the third trimester, because the placenta produces it. Bilirubin actually falls. And some enzymes that normally suggest liver damage, like AST and total bile acids, stay roughly the same as in non-pregnant women.17PubMed. Liver function tests in normal pregnancy: a prospective study of 103 pregnant women and 103 matched controls This means that a truly elevated AST, ALT, or bile acid level in pregnancy is not a normal variant and should be taken seriously. What looks like a mildly abnormal result in a non-pregnant person may actually reflect more significant disease in a pregnant patient, precisely because pregnancy tends to keep these markers flat or even lower them.18PubMed. The interpretation of liver function tests in pregnancy
Why the Growing Uterus Complicates Everything
A thread that runs through nearly all of these conditions is the physical reality of intra-abdominal crowding. Over the course of pregnancy, the volume inside the abdomen increases dramatically. Until about 24 weeks, the change is gradual, around 5% total. After that, the growth becomes exponential, and by 40 weeks, intra-abdominal volume has risen by roughly 61%. By term, the volume reserve of the abdomen is essentially exhausted.19PubMed Central. Physiology of intra-abdominal volume during pregnancy
This crowding does more than just make you uncomfortable. It pushes the appendix upward, compresses the ureters, raises intra-abdominal pressure on the bile ducts, and changes how pain is perceived and localized. A condition that would produce textbook symptoms in someone who is not pregnant may present atypically once the anatomy has been rearranged. This is one reason clinicians maintain a low threshold for imaging when a pregnant person reports new abdominal pain: physical exam findings alone are less reliable when organs have shifted.
When Pain Persists After Delivery
Right upper quadrant pain does not always resolve the moment a baby is born. Preeclampsia and HELLP syndrome can develop or worsen in the first days after delivery, sometimes catching patients and clinicians off guard. In one reported case, a 31-year-old woman presented after delivery with fever, hypertension, headache, and right upper abdominal pain. HELLP was initially suspected, but the workup ultimately pointed to postpartum preeclampsia with liver dysfunction and edema in multiple organs, including the lungs, without the classic hemolysis and low platelets of HELLP.20PubMed Central. Gallbladder wall thickening in a woman with postpartum preeclampsia: A case report HELLP itself can also first appear postpartum, sometimes alongside acute pancreatitis and cholecystitis, as reported in a case where all three conditions emerged on the first day after delivery and resolved with conservative treatment by the third day.21PubMed. Acute pancreatitis and cholecystitis associated with postpartum HELLP syndrome: a case and review
Fitz-Hugh-Curtis syndrome, a perihepatitis causing sharp right upper quadrant pain from inflammation around the liver capsule, is another uncommon but documented postpartum cause. It is classically associated with pelvic infections like chlamydia or gonorrhea, but it has also been reported as a complication of postpartum endometritis following cesarean delivery.22PubMed Central. Fitz-Hugh-Curtis Syndrome Secondary to Postpartum Endometritis: Case Report and Literature Review The takeaway for the postpartum period is that new right upper quadrant pain in the days and weeks after delivery still warrants prompt attention. The assumption that delivery resolves all pregnancy-related complications is not always correct.