Differential Diagnosis
The patient's presentation of abdominal pain, nausea, vomiting, and right upper quadrant tenderness at 35 weeks' gestation, along with a history of type 1 diabetes mellitus and laboratory findings including a blood smear showing schistocytes, suggests several potential diagnoses. These can be categorized as follows:
Single Most Likely Diagnosis
- HELLP Syndrome: Characterized by Hemolysis, Elevated Liver enzymes, and Low Platelet count, HELLP syndrome is a variant of preeclampsia. The presence of schistocytes (indicative of hemolysis), elevated liver enzymes, and the patient's symptoms align with this diagnosis. The condition is a medical emergency and can lead to severe complications for both the mother and the fetus if not promptly managed.
Other Likely Diagnoses
- Preeclampsia: Given the patient's elevated blood pressure (142/90 mmHg) and gestational age, preeclampsia is a consideration. While the presence of schistocytes and liver tenderness points more towards HELLP syndrome, preeclampsia without severe features is still a possibility.
- Acute Fatty Liver of Pregnancy (AFLP): This condition can present with abdominal pain, nausea, vomiting, and elevated liver enzymes. However, the presence of schistocytes and the specific constellation of symptoms and lab findings make HELLP syndrome more likely.
- Gallbladder Disease: The right upper quadrant tenderness could suggest gallbladder disease, such as cholecystitis or cholelithiasis. However, the systemic findings (e.g., schistocytes, elevated liver enzymes) are less typical for these conditions.
Do Not Miss Diagnoses
- Placental Abruption: Although the fetal heart rate is reactive without decelerations, placental abruption can present with abdominal pain and vomiting. It's crucial to consider this diagnosis due to its potential for severe maternal and fetal morbidity.
- Uterine Rupture: Though less likely given the absence of a previous uterine scar, uterine rupture is a catastrophic event that must be considered in the differential diagnosis of any pregnant woman presenting with acute abdominal pain.
Rare Diagnoses
- Thrombotic Thrombocytopenic Purpura (TTP): This condition can present with thrombocytopenia, hemolytic anemia (schistocytes), renal dysfunction, and neurological symptoms. While it's a rare condition, its consideration is important due to its severity and the need for specific treatment.
- Hemolytic Uremic Syndrome (HUS): Similar to TTP, HUS is characterized by hemolytic anemia, thrombocytopenia, and renal failure. It's less common in pregnancy but should be considered in the differential diagnosis of a patient with these laboratory findings.