A 32-year-old primigravida at 34 weeks gestation comes to the emergency department with right upper quadrant pain that started suddenly yesterday. The patient describes the pain as constant, severe, and stabbing. She has developed some rigors and chills but has had no confusion or mental status changes. The patient's only medication is a daily prenatal vitamin. Temperature is 38.7 C (101.7 F), blood pressure is 136/84 mm Hg, pulse is 105/min, and respirations are 22/min. BMI is 38 kg/m². Fetal heart rate monitoring has a baseline of 170/min with moderate variability. Scleral icterus is present. The uterus is nontender and measures at 34 weeks gestation. There is tenderness to palpation in the right upper quadrant with no rebound or guarding. Deep tendon reflexes are 2+. Bilateral lower extremities have 1+ pedal edema to the midcalf. Laboratory results are as follows: Which of the following is the most likely diagnosis in this patient?

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11ec25c8_d9fe_6f43_bc81_85d9b8f10651_MD0003_00 This patient's fever, right upper quadrant (RUQ) pain, and jaundice (Charcot triad) are most likely due to acute cholangitis. Pregnant women are at increased risk for cholesterol gallstone formation because elevated levels of progesterone and estrogen promote gallbladder stasis and cholesterol supersaturation. These gallstones can become impacted in the common bile duct, resulting in biliary obstruction and subsequent RUQ pain, jaundice, and direct hyperbilirubinemia. As bacteria from the small bowel enter the biliary system, patients develop infection (eg, fever, leukocytosis) and possible sepsis (eg, hypotension, altered mental status). In acute cholangitis, abdominal ultrasound may show a dilated common bile duct or choledocholithiasis but is not always necessary in patients with highly suggestive clinical features and laboratory abnormalities (eg, Charcot triad). Management is with broad-spectrum antibiotics and biliary drainage, typically via endoscopic retrograde cholangiopancreatography (ERCP), which relieves the obstruction by extracting the gallstone and prevents further obstruction with a biliary stent placement. (Choice B) Acute fatty liver of pregnancy can present in the third trimester with RUQ pain, jaundice, and elevated transaminases. However, patients typically have signs of fulminant liver failure, including thrombocytopenia (<100,000/mm³) and profound hypoglycemia, not seen in this patient. (Choice C) HELLP syndrome commonly presents in the third trimester with RUQ pain and elevated transaminases, but diagnosis also requires signs of hemolysis and low platelets. This patient has a normal platelet count and a normal indirect bilirubin (ie, no hemolysis). (Choice D) Intraamniotic infection (or chorioamnionitis) can present with fever, maternal tachycardia, and fetal tachycardia; however, patients typically have diffuse (rather than focal RUQ) pain and uterine tenderness, making the diagnosis unlikely in this patient. (Choice E) Preeclampsia with severe features can present with RUQ pain and elevated transaminases; however, this diagnosis requires maternal hypertension (≥140/90 mm Hg), not seen in this patient. Educational objective: Pregnant women are at increased risk for gallstone formation and subsequent acute cholangitis, which typically presents with fever, right upper quadrant pain, and jaundice (ie, direct hyperbilirubinemia) (Charcot triad). Patients with severe cases may also develop hypotension and altered mental status. References: ERCP in acute cholangitis during third trimester of pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/23425808) Cholangitis: causes, diagnosis, and management. (http://www.ncbi.nlm.nih.gov/pubmed/30846028)

A 32-Year-Old Primigravida at 34 Weeks Gestation Comes to the Emergency