Clues Pointing TO This Diagnosis

28-year-old, first pregnancy at 32 weeks — new hypertension after 20 weeks gestation is the defining window for preeclampsia, and nulliparity is a moderate risk factor
Blood pressure 150/95 mm Hg — meets the ≥140/90 threshold for hypertension in pregnancy on which the diagnosis is built
Proteinuria on urinalysis — proteinuria plus new-onset hypertension after 20 weeks fulfills the classic diagnostic dyad for preeclampsia
Severe, persistent headache ("worst ever") — new-onset headache unresponsive to medication is a severe feature and a warning sign of impending eclampsia
Blurry vision/visual disturbance — visual symptoms are a recognized severe feature reflecting cerebral involvement
Right upper quadrant/epigastric pain — severe persistent RUQ or epigastric pain signals hepatic involvement and is a severe feature
Falling platelet count (thrombocytopenia) — platelets <100,000 is a severe feature and a component of HELLP
Rising liver transaminases — liver enzymes >2× normal indicate impaired liver function, a severe feature
Marked edema (facial/pedal swelling) — although not diagnostic alone, rapid-onset edema commonly accompanies preeclampsia
Constellation of severe hypertension range/severe features triggering magnesium and delivery planning — supports preeclampsia with severe features rather than gestational hypertension alone

Why It's NOT the Similar Diseases

NOT chronic hypertension — chronic hypertension predates pregnancy or appears before 20 weeks; Cynthia was normotensive earlier and became hypertensive at 32 weeks with proteinuria and severe features
NOT gestational hypertension alone — gestational hypertension is elevated BP after 20 weeks without proteinuria or severe features; Cynthia has proteinuria plus multiple severe features
NOT primary/idiopathic seizure disorder — she has no seizure; her neurologic symptoms (headache, visual change) occur in the setting of new hypertension, proteinuria, and organ dysfunction
NOT acute fatty liver of pregnancy — AFLP typically causes hypoglycemia, marked coagulopathy, and hyperbilirubinemia; Cynthia's picture is hypertension with proteinuria and modest lab derangements
NOT thrombotic thrombocytopenic purpura (TTP) — TTP features severe microangiopathic hemolysis, neurologic signs, fever, and renal failure without the hypertension/proteinuria pattern, and its thrombocytopenia is not explained by pregnancy hypertension

Differential Diagnosis List

Chronic hypertension — ruled out by normal BP before 20 weeks and new hypertension with proteinuria at 32 weeks
Gestational hypertension — ruled out by presence of proteinuria and severe features
HELLP syndrome — considered given low platelets and high liver enzymes, but the full HELLP triad (including hemolysis) is not confirmed here
Acute fatty liver of pregnancy — ruled out by absence of hypoglycemia and profound coagulopathy with the hypertension/proteinuria-dominant picture
Thrombotic thrombocytopenic purpura — ruled out by the hypertension-and-proteinuria pattern rather than the TTP pentad

Key Distinguishing Test

Diagnosis is clinical: repeated blood pressure ≥140/90 mm Hg on two occasions at least 4 hours apart after 20 weeks in a previously normotensive woman, plus proteinuria (≥300 mg/24 h, protein/creatinine ratio ≥0.3, or dipstick 2+).
In the absence of proteinuria, new hypertension with any severe feature (thrombocytopenia <100,000, transaminases >2× normal, creatinine >1.1 mg/dL or doubled, pulmonary edema, or new headache/visual symptoms) confirms preeclampsia; severe-range BP (≥160/110) or any severe feature defines preeclampsia with severe features.

Board Note

Classic associations/risk factors: nulliparity, age ≥35, obesity, chronic hypertension, pregestational diabetes, renal or autoimmune disease, multifetal gestation, and prior preeclampsia; the underlying mechanism is abnormal placentation causing systemic endothelial dysfunction
Magnesium sulfate is the drug of choice for seizure prevention (and treatment) in preeclampsia with severe features and eclampsia; monitor for toxicity (loss of deep tendon reflexes, respiratory depression) and treat toxicity with IV calcium gluconate
For acute severe-range hypertension (≥160/110), first-line agents are IV labetalol, IV hydralazine, or oral immediate-release nifedipine, treating within 30–60 minutes; ACE inhibitors and ARBs are contraindicated in pregnancy
Delivery is the definitive treatment: deliver at ≥37 weeks for preeclampsia without severe features and at ≥34 weeks for preeclampsia with severe features (sooner if maternal/fetal deterioration); give antenatal corticosteroids for fetal lung maturity when delivering before 34 weeks
Prevention: low-dose aspirin (81 mg/day) for those at high risk (or >1 moderate risk factor), started between 12 and 28 weeks (optimally before 16 weeks) and continued until delivery
When to escalate/refer: preeclampsia with severe features, HELLP, or eclampsia warrants management at a facility with maternal-fetal and neonatal resources; watch for peak postpartum BP on days 3–6 and postpartum preeclampsia/eclampsia

“Cynthia’s Story”