A 37-year-old primigravid woman at 34 weeks gestation comes to labor and delivery from the office due to a blood pressure of 152/96 mm Hg. The patient has a spontaneous dichorionic diamniotic twin gestation, but her prenatal course has otherwise been uneventful, with normal blood pressure measurements throughout the pregnancy. She has no known medical conditions and has exercised throughout her pregnancy. The patient reports no contractions, vaginal bleeding, or leakage of fluid. She has no headaches or visual changes. Repeat blood pressure is 150/102 mm Hg. Deep tendon reflexes are 3+. Nonstress test is reactive for both fetuses. Laboratory results are as follows:

Which of the following is the most likely diagnosis in this patient?

Question

A 37-year-old primigravid woman at 34 weeks gestation comes to labor and delivery from the office due to a blood pressure of 152/96 mm Hg.  The patient has a spontaneous dichorionic diamniotic twin gestation, but her prenatal course has otherwise been uneventful, with normal blood pressure measurements throughout the pregnancy.  She has no known medical conditions and has exercised throughout her pregnancy.  The patient reports no contractions, vaginal bleeding, or leakage of fluid.  She has no headaches or visual changes.  Repeat blood pressure is 150/102 mm Hg.  Deep tendon reflexes are 3+.  Nonstress test is reactive for both fetuses.  Laboratory results are as follows:
 
Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_da6b_fde5_bc81_e52ca8fda247_MD0003_00 This patient has preeclampsia, defined as new-onset hypertension (ie, systolic ≥140 mm Hg or diastolic ≥90 mm Hg) at ≥20 weeks gestation plus proteinuria (eg, urine protein/creatinine ratio ≥0.3) and/or signs of end-organ damage (eg, renal dysfunction). Risk factors include nulliparity, preexisting diabetes mellitus, chronic kidney disease, multiple gestation, advanced maternal age, and prior preeclampsia. Preeclampsia is subclassified as either with or without severe features; this distinction is critical because patients with severe features have significantly greater morbidity (eg, eclampsia, abruptio placentae, fetal demise) and require different management (Choice E). Preeclampsia with severe features is diagnosed when ≥1 of the following is present: Severe-range hypertension (ie, systolic ≥160 mm Hg or diastolic ≥110 mm Hg). Most patients with severe features meet this criterion, but some have milder blood pressure elevations (such as this patient). Headache (severe and/or persistent), visual changes (eg, scotomata, blurred vision), or pulmonary edema. Severe lab abnormalities such as elevated serum creatinine (ie, >1.1 mg/dL or >2x normal), elevated transaminases (ie, >2x upper limit of normal), or platelet count <100,000/mm³. Therefore, this patient with creatinine of 1.8 mg/dL and elevated transaminases has preeclampsia with severe features. (Choice A) Although acute fatty liver of pregnancy can present with elevated transaminases and thrombocytopenia, patients are typically acutely ill with fulminant hepatic failure (eg, vomiting, abdominal pain, jaundice). It is not typically associated with proteinuria. (Choice B) Gestational hypertension is new-onset hypertension at ≥20 weeks gestation without proteinuria or end-organ damage. (Choice C) Intrahepatic cholestasis of pregnancy (ICP) may increase transaminases, but it does not cause hypertension or renal dysfunction. Patients typically have generalized pruritus. Educational objective: Preeclampsia is new-onset hypertension at ≥20 weeks gestation plus proteinuria or signs of end-organ damage (eg, renal dysfunction). Patients with serum creatinine >1.1 mg/dL or transaminases >2x normal have preeclampsia with severe features, which significantly increases morbidity (eg, abruptio placentae, fetal demise). References: Hypertensive disorders of pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/26926408)

A 37-Year-Old Primigravid Woman at 34 Weeks Gestation Comes to Labor