What is the management approach for a pregnant woman at 37 weeks of gestation with hepatomegaly?

Management of Hepatomegaly in Pregnancy at 37 Weeks

At 37 weeks gestation with hepatomegaly, delivery should be expedited after maternal stabilization, as this finding suggests pregnancy-specific liver disease (most likely preeclampsia/HELLP syndrome or acute fatty liver of pregnancy) that requires immediate delivery to prevent maternal mortality and morbidity. 1, 2

Immediate Diagnostic Workup

The presence of hepatomegaly at 37 weeks mandates urgent evaluation to identify the underlying cause:

• Obtain stat laboratory tests including complete blood count with platelet count, comprehensive metabolic panel with liver transaminases (AST/ALT), bilirubin, creatinine, LDH, coagulation studies (PT/INR, fibrinogen), and serum lactate 1, 3
• Check blood pressure immediately and repeatedly, as hepatomegaly with hypertension (≥140/90 mmHg) strongly suggests preeclampsia-related liver disease 1, 2
• Assess for clinical signs of HELLP syndrome: right upper quadrant or epigastric pain, nausea/vomiting, headache, visual changes 1, 3
• Perform abdominal ultrasound to evaluate for hepatic complications including subcapsular hematoma, hepatic hemorrhage, or infarction—particularly if there is abdominal pain or platelet count <20×10⁹/L 1

Differential Diagnosis Priority

At 37 weeks, hepatomegaly most commonly indicates:

1. HELLP syndrome (hemolysis, elevated liver enzymes, low platelets)—the most common preeclampsia-associated liver disease causing hepatomegaly 1, 3, 4
2. Acute fatty liver of pregnancy (AFLP)—a catastrophic condition with microvesicular fatty infiltration causing acute liver failure 1, 3
3. Severe preeclampsia with hepatic involvement—hepatic capsular distension causing right upper quadrant pain and hepatomegaly 1, 3

Less likely but must exclude: intrahepatic cholestasis of pregnancy (typically no hepatomegaly), viral hepatitis, or pre-existing chronic liver disease 3, 5

Criteria for Immediate Delivery

Delivery is mandatory at 37 weeks for any woman with preeclampsia regardless of severity 1, 2, 6. The presence of hepatomegaly suggests organ involvement requiring even more urgent intervention.

Proceed to immediate delivery after stabilization if any of the following are present:

• HELLP syndrome confirmed (thrombocytopenia, hemolysis, elevated liver enzymes) 1, 2
• Progressive deterioration in liver function tests or platelet count 1, 2
• Severe hypertension (≥160/110 mmHg) despite treatment with ≥3 antihypertensive classes 1, 2
• Neurological symptoms: severe intractable headache, visual scotomata, or eclamptic seizures 1, 2
• Coagulopathy (elevated INR, low fibrinogen) suggesting AFLP or severe HELLP 1, 3
• Elevated serum lactate >2.8 mg/dL or encephalopathy suggesting AFLP 1
• Maternal pulse oximetry <90% or pulmonary edema 1, 2
• Non-reassuring fetal status on cardiotocography 1, 2

Pre-Delivery Stabilization

Before proceeding to delivery, stabilize the mother:

• Control severe hypertension urgently (if BP ≥160/110 mmHg) with oral labetalol, nifedipine, or methyldopa; IV labetalol or hydralazine may be required 1, 6
• Administer magnesium sulfate for seizure prophylaxis if severe hypertension or neurological symptoms present (loading dose 4-5g IV over 5 minutes, then 1-2g/hour maintenance) 1, 2, 6
• Correct coagulopathy with fresh frozen plasma, cryoprecipitate, or platelets as needed before delivery 1
• Ensure cross-matched blood products available and establish large-bore IV access for potential hemorrhage 1
• Do NOT delay delivery to fully normalize laboratory values if AFLP or severe HELLP is present—maternal outcomes worsen with delay 1

Mode and Timing of Delivery

• Vaginal delivery is preferred unless standard obstetric indications for cesarean section exist 1, 6
• In AFLP with fetal demise, consider expedited vaginal induction rather than cesarean section 1
• Regional anesthesia (spinal/epidural) may be contraindicated if severe thrombocytopenia (<70-80×10⁹/L) or coagulopathy present; general anesthesia may be required 1

Critical Pitfalls to Avoid

• Do not use serum uric acid or proteinuria levels as criteria for delivery timing—these are unreliable indicators 1, 2
• Do not attempt to classify as "mild" versus "severe" preeclampsia—all cases can rapidly deteriorate into emergencies 1, 2
• Do not delay delivery for expectant management at 37 weeks with hepatomegaly—the risks far outweigh any fetal benefit 1, 2
• Do not give corticosteroids to improve maternal outcomes in HELLP syndrome (only for fetal lung maturity if <35 weeks, which does not apply here) 1
• Blood pressure alone does not stratify risk—serious organ dysfunction including hepatic involvement can occur at relatively mild BP elevations 1, 2, 7

Post-Delivery Monitoring

• Continue intensive monitoring for 72 hours postpartum, as HELLP syndrome and preeclampsia can worsen or develop de novo after delivery 1, 6
• Monitor BP every 4 hours for first 48 hours and continue antihypertensives as needed 6
• Repeat laboratory tests to ensure resolution of hemolysis, thrombocytopenia, and liver dysfunction 1
• If signs of hepatic failure persist (encephalopathy, severe coagulopathy, lactate >2.8 mg/dL), consider early referral to transplant center 1