A 35-year-old woman, gravida 2 para 1, at 31 weeks gestation comes to the office with severe heartburn and right upper quadrant pain. She has experienced several episodes of nausea and vomiting this morning. The patient has had gastroesophageal reflux disease throughout the pregnancy, but the symptoms have rapidly become much worse. During her visit last week, she was fatigued, and her blood pressure was 130/80 mm Hg. Current blood pressure is 160/90 mm Hg and pulse is 86/min. BMI is 42 kg/m². Physical examination shows extreme tenderness to palpation in the midline and right upper quadrant of the abdomen but absence of peritoneal signs. Fetal heart tones are 130/min using Doppler ultrasound. Laboratory results are as follows:
Urine dipstick shows 2+ protein. Which of the following is the most likely cause of this patient's upper abdominal pain?

Question

A 35-year-old woman, gravida 2 para 1, at 31 weeks gestation comes to the office with severe heartburn and right upper quadrant pain. She has experienced several episodes of nausea and vomiting this morning. The patient has had gastroesophageal reflux disease throughout the pregnancy, but the symptoms have rapidly become much worse. During her visit last week, she was fatigued, and her blood pressure was 130/80 mm Hg. Current blood pressure is 160/90 mm Hg and pulse is 86/min. BMI is 42 kg/m². Physical examination shows extreme tenderness to palpation in the midline and right upper quadrant of the abdomen but absence of peritoneal signs. Fetal heart tones are 130/min using Doppler ultrasound. Laboratory results are as follows:

Urine dipstick shows 2+ protein. Which of the following is the most likely cause of this patient's upper abdominal pain?

Quizplus · Accepted Answer

11ec25c8_da3b_ecdf_bc81_eda1f2dd61ff_MD0003_00 This pregnant patient with hypertension and right upper quadrant pain likely has preeclampsia with severe features (ie, new hypertension at ≥20 weeks gestation with signs of end-organ damage) and/or HELLP (Hemolysis, Elevated Liver enzymes, Low Platelets) syndrome. These disorders likely represent a spectrum of disease causing maternal endothelial dysfunction (eg, hypertension, vasospasm). HELLP syndrome also causes platelet overactivation (ie, thrombocytopenia) and microangiopathic hemolytic anemia (ie, anemia with elevated indirect bilirubin) due to the deposition of platelet-fibrin microthrombi within capillaries. The liver is commonly affected in HELLP syndrome. Microthrombi deposition in the hepatic portal system results in decreased hepatic perfusion, liver ischemia, and hepatocellular injury (eg, nausea/vomiting, right upper quadrant pain, elevated transaminases). The gradual distension of the hepatic [Glisson] capsule causes the classic presentation of worsening right upper quadrant pain without associated peritoneal signs. Severe cases may progress to liver necrosis and hemorrhage, resulting in a subcapsular hematoma (ie, blood pooling beneath the hepatic capsule). blood pooling (Choice A) Obstruction of the cystic duct (ie, cholelithiasis) may cause right upper quadrant pain and elevated liver transaminases; however, patients typically have elevated direct (ie, conjugated) bilirubin levels. There is no association with thrombocytopenia or hypertension. (Choice C) Acute fatty liver of pregnancy (AFLP) and HELLP syndrome share many features, including hypertension, right upper quadrant pain, and elevated transaminases. In contrast to HELLP syndrome, which causes indirect hepatocellular injury due to decreased liver perfusion, AFLP causes fulminant liver failure due to complete fatty infiltration of hepatocytes. Therefore, patients with AFLP typically have jaundice, encephalopathy, coagulopathy, and profound hypoglycemia. (Choice D) Lipase and leukocyte count are normal in this patient, making the diagnosis of pancreatitis less likely. In addition, pain associated with pancreatitis is typically midline and radiates to the back. (Choice E) Patients with peptic ulcer perforation can have right upper quadrant pain; however, they typically have peritoneal signs (eg, abdominal rigidity, rebound/guarding) due to intraperitoneal spillage of caustic gastric acid. (Choice F) Hepatic adenomas are benign liver tumors associated with elevated estrogen (eg, pregnancy, oral contraceptive use). Rupture leads to brisk intraabdominal bleeding, a possible palpable liver mass, and hemodynamic instability (eg, hypotension, tachycardia). Educational objective: HELLP (Hemolysis, Elevated Liver enzymes, and Low Platelets) syndrome can present during pregnancy with worsening right upper quadrant pain due to gradual distension of the hepatic (Glisson) capsule. Patients may have associated hypertension and proteinuria. References: HELLP syndrome: a diagnostic conundrum with severe complications. (http://www.ncbi.nlm.nih.gov/pubmed/27535735) Differentiation of acute fatty liver of pregnancy from syndrome of hemolysis, elevated liver enzymes and low platelet counts. (http://www.ncbi.nlm.nih.gov/pubmed/24428400)

A 35-Year-Old Woman, Gravida 2 Para 1, at 31 Weeks