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Difficulty: MediumObstetric Complications

Match each clinical presentation occurring in the third trimester to the most likely obstetric or pregnancy-related diagnosis.

  • A multiparous patient at 35 weeks gestation presents with nausea, severe right upper quadrant pain, profound hypoglycemia, and elevated ammonia levels.Acute fatty liver of pregnancy
  • A primigravida at 36 weeks gestation presents with new-onset blood pressure of 160/110 mm Hg, platelet count of 90,000/mm³, and AST of 150 U/L.HELLP syndrome
  • A patient at 31 weeks gestation complains of severe, unremitting generalized pruritus that is worse at night and primarily affects the palms and soles.Intrahepatic cholestasis of pregnancy
  • A nulliparous patient at 38 weeks gestation has an asymptomatic new-onset blood pressure of 150/95 mm Hg and 320 mg of protein in a 24-hour urine collection.Preeclampsia without severe features

Answer

The presentations successfully distinguish third-trimester hepatobiliary and hypertensive complications based on distinct laboratory and clinical hallmarks.
Each clinical vignette highlights the pathognomonic features of a specific obstetric complication. Hypoglycemia and hyperammonemia define Acute fatty liver of pregnancy; severe hypertension with thrombocytopenia and elevated AST points to HELLP syndrome; palmar and plantar pruritus is classic for Intrahepatic cholestasis of pregnancy; and isolated new-onset hypertension with proteinuria defines Preeclampsia without severe features.

Step-by-Step Solution

1
Analyze the first presentation involving right upper quadrant pain, profound hypoglycemia, and hyperammonemia.
This indicates fulminant hepatic synthetic failure, which matches Acute fatty liver of pregnancy.
Profound hypoglycemia and elevated ammonia are classic markers of liver synthetic dysfunction seen in AFLP, distinguishing it from other hepatic complications of pregnancy.
2
Evaluate the second presentation featuring severe hypertension, thrombocytopenia, and elevated AST.
This triad meets the diagnostic criteria for HELLP syndrome.
The combination of severe hypertension with specific laboratory abnormalities (low platelets and elevated transaminases) confirms HELLP syndrome.
3
Examine the third presentation detailing severe nocturnal pruritus of the palms and soles.
This presentation is the pathognomonic symptom of Intrahepatic cholestasis of pregnancy.
Pruritus without a primary rash that predominantly affects the palms and soles is the classic hallmark of ICP, driven by elevated serum bile acids.
4
Review the fourth presentation showing asymptomatic mild-to-moderate hypertension and 320 mg of proteinuria.
These findings fulfill the criteria for Preeclampsia without severe features.
Blood pressure >= 140/90 mm Hg and >= 300 mg proteinuria/day after 20 weeks gestation without end-organ damage or severe symptoms define this condition.

Key Concept

Differentiating obstetric complications involving the liver and hypertensive disorders of pregnancy.
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Topics

Obstetric Complications

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