Differential Diagnosis
The patient's presentation of severe epigastric pain, hypertension, and proteinuria at 37 weeks gestation suggests a pregnancy-related complication. The following differential diagnoses are considered:
- Single most likely diagnosis
- Preeclampsia with HELLP syndrome: The patient's symptoms of severe epigastric pain, hypertension, and proteinuria are consistent with preeclampsia. The absence of fever, vomiting, or diarrhea and the normal ultrasound of the right upper quadrant make other diagnoses less likely. The patient's BMI and anxiety may contribute to her condition, but preeclampsia with HELLP syndrome is the most likely diagnosis given her symptoms and laboratory results.
- Other Likely diagnoses
- Acute fatty liver of pregnancy: Although the ultrasound of the right upper quadrant is normal, acute fatty liver of pregnancy can cause epigastric pain and hypertension. However, the patient's proteinuria and lack of other symptoms such as polydipsia or polyuria make this diagnosis less likely.
- Gastroesophageal reflux disease (GERD): The patient's epigastric pain and nausea could be attributed to GERD, which is common in pregnancy. However, the severity of her pain and the presence of hypertension and proteinuria suggest a more serious condition.
- Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)
- Placental abruption: Although the patient has no vaginal bleeding or contractions, placental abruption can cause severe abdominal pain and hypertension. This diagnosis must be considered due to the potential for severe maternal and fetal morbidity.
- Ureteral stone: A ureteral stone could cause severe pain and hypertension, but the patient's proteinuria and lack of other symptoms such as flank pain or hematuria make this diagnosis less likely.
- Rare diagnoses
- Hepatic rupture: Although rare, hepatic rupture can cause severe epigastric pain and hypertension in pregnancy. This diagnosis is considered due to the potential for severe maternal morbidity, but it is less likely given the patient's normal ultrasound and lack of other symptoms.
- Pancreatitis: The patient's epigastric pain and nausea could be attributed to pancreatitis, but the absence of other symptoms such as vomiting or elevated pancreatic enzymes makes this diagnosis less likely.