INTRODUCTION: Gastric adenocarcinoma usually presents in advanced stages and after 40 years of age. Presentation in pregnancy is rare, occurring in less than 0.1% of all pregnancies, and it presses additional challenges as the symptoms are usually overlooked. Reports of gastric adenocarcinoma in pregnancy undergoing different mainstays of therapy have been described. Here, we present a case of poorly differentiated gastric adenocarcinoma diagnosed at 26 weeks gestation, who had to undergo an individualized and multi-disciplinary approach, with a favorable outcome thus far. CASE DESCRIPTION/METHODS: A 24-year-old woman with no significant history, gravida 2, para 1 at 26 weeks gestation presented with hyperemesis, dehydration and anorexia requiring inpatient management. She had lost 19 Kgs during the second trimester. Lab work revealed hypokalemia of 2.8 mEq/L, and transaminitis: AST 206 U/L, ALT 354 U/L. MRI abdomen without contrast showed mild distention of the proximal stomach of unclear significance. Ultrasound of the liver, kidneys and appendix were non-revealing. Symptoms progressed; therefore, she underwent upper endoscopy, which revealed inflamed antral mucosa with nodularity. Biopsy did not show H. pylori, but rather poorly differentiated adenocarcinoma with signet ring features. This was further classified as IHC positive for CDX-2 and E-cadherin, HER-2+ (IHC 2+, FISH amplified). The patient was initially treated with neoadjuvant FOLFOX for 4 cycles given concurrent pregnancy, followed by induction of pregnancy at 36 weeks gestation. She then underwent surgical resection with total gastrectomy, omentectomy and lymphadenectomy. Surgical biopsy showed metastatic disease stage ypT3N1. Currently, 7 months after diagnosis, the patient is tolerating adjuvant chemotherapy with FLOT (5-FU, oxaliplain, docetaxel). Radiation therapy is planned following chemotherapy. The patient’s baby is alive and thriving. DISCUSSION: Gastric adenocarcinoma rarely presents in pregnancy and is often overshadowed by pregnancy-related symptoms as these may overlap. Thus, red flags such as extreme weight loss in pregnancy should raise suspicion for underlying pathology. Diagnosis and treatment pose challenges as these can encompass risks for the fetus, especially early on gestation. Nevertheless, gastric adenocarcinoma often presents as poorly differentiated disease in pregnancy warranting prompt diagnosis, staging and expeditious intervention with chemotherapy and surgical resection.