An 18-year-old primigravida at 27 weeks gestation comes to the emergency department due to severe right upper quadrant pain. The pain started 2 hours ago, and the patient has also had nausea, vomiting, and irregular uterine contractions. Temperature is 36.7 C (98.1 F), blood pressure is 172/118 mm Hg, and pulse is 110/min. BMI is 34 kg/m2. On abdominal examination, tenderness to palpation is present over the right upper quadrant. Aspartate aminotransferase (SGOT) is 220 U/L and alanine aminotransferase (SGPT) is 240 U/L. Abdominal imaging reveals a hepatic subcapsular hematoma. This patient is most at risk for which of the following complications?
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 severe end-organ damage) and/or HELLP (Hemolysis, Elevated Liver enzymes, Low Platelet count) syndrome. Both conditions share common features and likely represent a spectrum of disease; they are characterized by widespread endothelial dysfunction that leads to dysregulated vascular tone (eg, hypertension), increased vessel permeability (eg, proteinuria), and end-organ vasospasm. Patients with HELLP syndrome also have platelet overactivation with widespread deposition of platelet-fibrin microthrombi within capillaries.
Both vasospasm and microthrombi deposition result in decreased hepatic blood flow, liver ischemia, and hepatocellular injury (eg, nausea, vomiting, right upper quadrant pain, elevated transaminases). Severe cases may progress to liver necrosis and hemorrhage, causing a subcapsular hematoma (ie, blood pooling beneath the hepatic [Glisson] capsule with capsular distension).
Because preeclampsia and HELLP syndrome cause widespread endothelial dysfunction and vasospasm, multiple organ systems are affected, and patients are at increased risk for other complications. These include seizures (due to cerebral vasospasm, thrombosis, and/or edema); renal insufficiency (due to intrarenal vasospasm); thrombocytopenia; and disseminated intravascular coagulation (due to overactivation of the coagulation cascade) (Choice F).
(Choice A) Although this patient is at risk for renal insufficiency, she is not at increased risk for acute interstitial nephritis, which is typically drug induced (eg, nonsteroidal anti-inflammatory drugs).
(Choice B) Bleeding esophageal varices typically occur in patients with liver cirrhosis due to venous portal hypertension. In contrast, HELLP syndrome and preeclampsia cause arterial hypertension.
(Choice C) The risk for intraamniotic infection is increased with prolonged rupture of membranes or genitourinary infection (eg, group B Streptococcus, Chlamydia trachomatis).
(Choice D) Risk factors for pancreatitis include biliary disease, chronic alcohol use, and hypertriglyceridemia.
Educational objective:
Pregnant women with severe preeclampsia can develop HELLP (Hemolysis, Elevated Liver enzymes, Low Platelet count) syndrome. Nausea/vomiting and right upper quadrant pain occur due to liver ischemia and/or hemorrhage (eg, subcapsular hematoma). These patients are also at risk for seizure, renal insufficiency, and disseminated intravascular coagulation due to widespread endothelial dysfunction.