A 27-year-old G1P0 at 35 weeks gestation is evaluated in the obstetric triage unit for a 2… — USMLE Step 2 CK

A $27$ -year-old G1P0 at $35$ weeks gestation is evaluated in the obstetric triage unit for a $2$ -day history of progressively worsening right upper quadrant pain, nausea, and profound fatigue. She reports normal fetal movement and denies any vaginal bleeding or leakage of fluid. Her temperature is $37.0^\circ\text{C}$ ( $98.6^\circ\text{F}$ ), blood pressure is $156/102$ mm Hg, and heart rate is $92$ /min. Physical examination reveals tenderness to deep palpation in the right upper quadrant and $2+$ pitting edema of the bilateral lower extremities. Laboratory studies show:

Test	Result
Hemoglobin	$10.2$ g/dL
Platelets	$82,000$ /mm $^3$
Aspartate aminotransferase (AST)	$165$ U/L
Alanine aminotransferase (ALT)	$180$ U/L
Creatinine	$1.1$ mg/dL

A continuous fetal heart rate monitor shows a baseline of $145$ /min, moderate variability, and frequent early decelerations coincident with mild, irregular uterine contractions. Which of the following is the most appropriate next step in management?

Initiation of intravenous magnesium sulfate and induction of laborAnswer
B
Immediate preparation for an emergency cesarean delivery
C
Administration of intramuscular betamethasone and delay of delivery for 48 hours
D
Initiation of intravenous labetalol and expectant inpatient management until 37 weeks
E
Reassurance and discharge home as the findings reflect expected physiologic adaptations

Answer

The most appropriate next step in management is the initiation of intravenous magnesium sulfate and induction of labor.

The correct answer is the initiation of intravenous magnesium sulfate and induction of labor. This patient presents with right upper quadrant pain, hypertension, thrombocytopenia, and elevated transaminases, which is highly consistent with HELLP (Hemolysis, Elevated Liver enzymes, Low Platelets) syndrome. HELLP syndrome is a severe, life-threatening obstetric complication. According to clinical guidelines, the definitive management for HELLP syndrome at or beyond

34

weeks gestation is prompt delivery. Because the fetal heart rate tracing is reassuring (Category I with benign early decelerations) and there are no obstetrical contraindications, a trial of labor via induction is preferred over a primary cesarean delivery. Concurrently, intravenous magnesium sulfate must be administered for maternal seizure prophylaxis.

Step-by-Step Solution

Analyze the clinical presentation and laboratory data.

The patient presents with right upper quadrant pain, hypertension, thrombocytopenia (

82,000

/mm

^3

), and elevated transaminases.

This specific triad of Hemolysis, Elevated Liver enzymes, and Low Platelets confirms the diagnosis of HELLP syndrome, a severe variant of preeclampsia.

Determine the gestational age and evaluate maternal-fetal stability.

The gestational age is

35

weeks. The fetal heart rate tracing is Category I (moderate variability, benign early decelerations).

Management of HELLP syndrome depends heavily on gestational age, as well as the immediate stability of both the mother and the fetus.

Select the appropriate definitive management.

Proceed with prompt delivery and seizure prophylaxis.

For HELLP syndrome at or beyond

34

weeks gestation, definitive treatment is delivery. Induction of labor is preferred over cesarean section because the maternal and fetal statuses are stable. Magnesium sulfate is indicated to prevent eclamptic seizures.

Key Concept

The definitive management of HELLP syndrome at or beyond 34 weeks gestation is prompt delivery, preferably via induction of labor if the fetus is stable, along with magnesium sulfate for seizure prophylaxis.

Estimated Time:1m 30s

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