What is the most likely diagnosis for a 37-year-old woman, gravida 1 para 0, at 34 weeks gestation, presenting with severe epigastric pain, nausea, vomiting, thrombocytopenia (low platelet count), leukocytosis (elevated white blood cell count), hyperbilirubinemia (elevated total bilirubin), and elevated liver enzymes, including aspartate aminotransferase (AST) and alanine aminotransferase (ALT)?

Differential Diagnosis

• Single most likely diagnosis
  • Acute fatty liver of pregnancy (AFLP): This condition is characterized by nausea, vomiting, and abdominal pain, particularly in the third trimester. The patient's laboratory results, including elevated liver enzymes (AST and ALT), low platelet count, and hypoglycemia, are consistent with AFLP. The patient's lack of routine prenatal care and presentation at 34 weeks gestation also increase the likelihood of this diagnosis.
• Other Likely diagnoses
  • Preeclampsia with HELLP syndrome: Although the patient's blood pressure is not significantly elevated, the presence of thrombocytopenia, elevated liver enzymes, and abdominal pain could suggest HELLP syndrome. However, the absence of hypertension and proteinuria makes this diagnosis less likely.
  • Cholestasis of pregnancy: This condition is characterized by pruritus and elevated liver enzymes, but the patient's presentation with severe abdominal pain and vomiting is not typical.
  • Pancreatitis: The patient's amylase level is slightly elevated, but the lipase level is within normal limits, making pancreatitis less likely.
• Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)
  • Placental abruption: Although the patient's uterus is nontender, placental abruption can present with abdominal pain and vomiting. The fetal heart rate monitoring showing a baseline of 170/min with minimal variability increases the concern for placental abruption.
  • Uterine rupture: This is a rare but life-threatening condition that can present with severe abdominal pain and vomiting. The patient's lack of routine prenatal care and unknown obstetric history increase the risk.
• Rare diagnoses
  • Hepatitis: Although the patient's liver enzymes are elevated, the clinical presentation and laboratory results are not typical for hepatitis.
  • Gastric ulcer disease: The patient's abdominal pain and vomiting could suggest gastric ulcer disease, but the laboratory results and clinical presentation are not consistent with this diagnosis.