Welcome to USMLE practice question #149! Today’s topic is OBGYN.
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A 28-year-old woman, gravida 2 para 1, presents to the clinic at 32 weeks of gestation with complaints of persistent headaches and blurred vision over the past two days. She denies abdominal pain or contractions. Her prenatal course has been otherwise unremarkable. On physical examination, her blood pressure is 162/104 mmHg, and there is 3+ proteinuria on urinalysis. Laboratory studies reveal the following:
Hemoglobin: 11.5 g/dL
Platelets: 190,000/μL
Creatinine: 0.8 mg/dL
Alanine aminotransferase (ALT): 22 U/L
Aspartate aminotransferase (AST): 24 U/L
Which of the following is the most likely diagnosis?
A) Chronic hypertension
B) Gestational hypertension
C) Preeclampsia
D) HELLP syndrome
E) Eclampsia
Detailed Breakdown of Answers + Correct Answer Below ⏬
GENERAL ANALYSIS
This 28-year-old pregnant woman at 32 weeks of gestation presents with new-onset hypertension (BP 162/104 mmHg) proteinuria.
ANSWER CHOICES:
CHOICE A: Chronic hypertension
Explanation: Chronic hypertension is defined as hypertension that predates pregnancy or develops before 20 weeks of gestation. It is not associated with proteinuria unless there is superimposed preeclampsia. Additionally, this patient developed hypertension after 20 weeks of gestation, and the presence of significant proteinuria strongly supports a diagnosis different from chronic hypertension.
CHOICE B: Gestational hypertension
Explanation: Gestational hypertension is defined as new-onset hypertension after 20 weeks of gestation without proteinuria or end-organ dysfunction. This patient has significant proteinuria (3+ on urinalysis) and symptoms of end-organ involvement (headaches, blurred vision).
CHOICE C: Preeclampsia
Explanation: Preeclampsia is defined as new-onset hypertension (≥140/90 mmHg) after 20 weeks of gestation with one or more of the following:
Proteinuria (≥300 mg/24 hours or ≥1+ on dipstick).
Evidence of end-organ dysfunction (e.g., severe headache, visual disturbances, elevated liver enzymes, thrombocytopenia, or renal dysfunction).
CHOICE D: HELLP syndrome
Explanation: HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets) is a severe form of preeclampsia characterized by microangiopathic hemolytic anemia, elevated liver enzymes, and thrombocytopenia. Symptoms may include right upper quadrant pain, nausea/vomiting, and malaise. This patient does not have elevated liver enzymes or thrombocytopenia; therefore, HELLP syndrome is unlikely.
CHOICE E: Eclampsia
Explanation: Eclampsia is defined as preeclampsia complicated by new-onset seizures that cannot be attributed to another cause. It represents a severe progression of preeclampsia. This patient has no history of seizures, ruling out eclampsia.
FINAL VERDICT…
CORRECT ANSWER: C) Preeclampsia
This 28-year-old pregnant woman at 32 weeks of gestation presents with hypertension (BP 162/104 mmHg), 3+ proteinuria, and symptoms of persistent headaches and blurred vision, which are consistent with preeclampsia. Preeclampsia is a pregnancy-specific disorder characterized by new-onset hypertension and proteinuria or end-organ dysfunction after 20 weeks of gestation.
KEY CONCEPTS (Bonus)
Diagnostic Criteria for Preeclampsia:
New-onset hypertension (≥140/90 mmHg) after 20 weeks of gestation.
Proteinuria (≥300 mg/24 hours or ≥1+ on dipstick).
OR evidence of end-organ dysfunction:
Thrombocytopenia (<100,000/μL).
Renal insufficiency (creatinine >1.1 mg/dL).
Elevated liver enzymes.
Pulmonary edema.
Neurological symptoms (e.g., headache, blurred vision).
Severe Features of Preeclampsia:
Severe hypertension (≥160/110 mmHg).
Symptoms of end-organ damage (e.g., persistent headache, visual changes).
Laboratory abnormalities (e.g., thrombocytopenia, elevated creatinine or liver enzymes).
Management of Preeclampsia:
Without severe features: Close monitoring until delivery at ≥37 weeks.
With severe features: Stabilize the mother and deliver at ≥34 weeks.
Antihypertensive therapy (e.g., labetalol, hydralazine) for severe hypertension.
Magnesium sulfate for seizure prophylaxis in severe cases.
Differential Diagnosis for Hypertension in Pregnancy: