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Difficulty: MediumObstetric Complications

Match each clinical vignette describing a hypertensive disorder of pregnancy with its most appropriate diagnosis.

  • During a routine initial prenatal visit at 1616 weeks gestation, a healthy nulliparous patient is found to have elevated blood pressures of 148/96148/96 mm Hg and 145/94145/94 mm Hg taken 44 hours apart. Urinalysis and basic metabolic panel are completely normal.Chronic hypertension
  • At a 3535-week routine obstetric checkup, a multiparous patient is asymptomatic but found to have newly elevated blood pressure readings of 152/98152/98 mm Hg and 150/96150/96 mm Hg. A subsequent 2424-hour urine collection yields 150150 mg of protein.Gestational hypertension
  • A nulliparous patient in the late third trimester (3838 weeks) presents to the emergency department complaining of an unremitting headache and flashing lights. Her blood pressure is sustained at 165/112165/112 mm Hg, and a urine dipstick reveals 2+2+ proteinuria.Preeclampsia with severe features
  • While in the triage unit at 3232 weeks gestation, a multiparous patient reports severe epigastric and right upper quadrant discomfort. Her blood pressure is 158/102158/102 mm Hg. Laboratory analysis demonstrates a platelet count of 75,00075,000 / μ\mu L, aspartate aminotransferase of 145145 U/L, and schistocytes on a peripheral blood smear.HELLP syndrome

Answer

The vignettes match as follows: The patient at 16 weeks gestation has Chronic hypertension; the asymptomatic patient at 35 weeks with 150 mg proteinuria has Gestational hypertension; the patient with headache, visual changes, and BP 165/112 mm Hg has Preeclampsia with severe features; and the patient with right upper quadrant pain, low platelets, and elevated liver enzymes has HELLP syndrome.
Each hypertensive disorder of pregnancy has strict diagnostic criteria. Chronic hypertension is diagnosed when hypertension is present before 20 weeks gestation. Gestational hypertension requires new-onset hypertension at or after 20 weeks without significant proteinuria (≥300\geq 300 mg/day) or severe features. Preeclampsia with severe features is diagnosed when there are severe blood pressure elevations (≥160/110\geq 160/110 mm Hg) or signs of end-organ dysfunction, such as cerebral or visual disturbances. HELLP syndrome is a life-threatening variant identified by the triad of hemolysis, elevated liver enzymes, and low platelets, frequently accompanied by right upper quadrant pain due to liver swelling.

Step-by-Step Solution

1
Evaluate the first vignette for timing of onset and severity.
The patient has elevated blood pressure prior to 20 weeks gestation, which confirms the diagnosis of chronic hypertension.
Blood pressure elevations before 20 weeks are considered preexisting or chronic, rather than pregnancy-induced.
2
Evaluate the second vignette for signs of preeclampsia.
The patient has new-onset hypertension after 20 weeks, but her 24-hour urine protein is less than 300 mg, classifying her condition as gestational hypertension.
Without significant proteinuria or severe features (end-organ damage), new hypertension after 20 weeks is simply gestational hypertension.
3
Evaluate the third vignette for severity criteria.
The patient has severe-range blood pressures (≥160/110\geq 160/110 mm Hg) and signs of cerebral/visual dysfunction (headache, scotomata), which defines preeclampsia with severe features.
The presence of severe end-organ damage symptoms elevates the diagnosis to preeclampsia with severe features, regardless of the exact amount of proteinuria.
4
Evaluate the fourth vignette's laboratory abnormalities.
The combination of hemolysis, elevated liver enzymes, and low platelets points directly to HELLP syndrome.
HELLP syndrome is a severe variant of preeclampsia characterized specifically by this laboratory triad, often presenting with epigastric or right upper quadrant pain.

Key Concept

Differentiating hypertensive disorders of pregnancy based on gestational age of onset, presence of proteinuria, and signs of end-organ damage.
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Topics

Obstetric Complications

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