A 35-year-old pregnant woman at 36 weeks has BP 158/104 mmHg on two occasions 4 hours apart. She has no proteinuria but new-onset thrombocytopenia (platelets 88,000/µL) and elevated liver enzymes (ALT 180 U/L). What is the MOST likely diagnosis?

• A Gestational hypertension
• B Chronic hypertension with superimposed pregnancy
• C Thrombotic thrombocytopenic purpura in pregnancy
• D Severe pre-eclampsia with HELLP syndrome features ✓

Explanation

Per the ACOG 2020 diagnostic criteria, pre-eclampsia can be diagnosed WITHOUT proteinuria if new-onset hypertension (≥140/90 mmHg) is accompanied by severe features — including thrombocytopenia (<100,000/µL), renal insufficiency, impaired liver function, or neurological symptoms. This patient has hypertension + thrombocytopenia (88,000) + elevated liver enzymes, fulfilling criteria for pre-eclampsia with severe features, specifically evolving HELLP syndrome (Haemolysis, Elevated Liver enzymes, Low Platelets). Gestational hypertension lacks these features. Definitive treatment is delivery, especially at ≥34 weeks.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.