The answer is C. Preeclampsia with severe features
New hypertension after 20 weeks with proteinuria plus severe-range pressures, neurologic symptoms, thrombocytopenia, and transaminitis is preeclampsia with severe features — and the word that has not yet applied is seizure, which is what would make it eclampsia. Build the definitions in order and these questions become straightforward. Gestational hypertension is new hypertension at or after 20 weeks without proteinuria or end-organ involvement. Preeclampsia adds proteinuria — a protein-to-creatinine ratio of 0.3 or more, 300 mg or more in 24 hours, or 2+ on dipstick — or, importantly, end-organ dysfunction even when proteinuria is absent. Severe features are the list worth memorizing cold: systolic 160 or higher or diastolic 110 or higher, platelets under 100,000, transaminases at twice normal or right upper quadrant pain, creatinine above 1.1 or doubled, pulmonary edema, and new cerebral or visual symptoms. She has five of them. Her scotomata and clonus are the cerebral irritability that precedes seizure, and her right upper quadrant pain with an AST of 190 and platelets of 78,000 is the beginning of HELLP syndrome — hemolysis, elevated liver enzymes, low platelets — a severe variant that can present with normal blood pressure and must be checked for whenever a pregnant patient reports epigastric pain. Management has three simultaneous tracks and students routinely mix up which drug does which job. Magnesium sulfate is for seizure prophylaxis, not for blood pressure; monitor reflexes, respirations, and urine output, and keep calcium gluconate at hand for toxicity, which announces itself as loss of deep tendon reflexes before respiratory depression. Antihypertensives are separate, given for sustained severe-range pressures to prevent maternal stroke: labetalol, hydralazine, or oral nifedipine. ACE inhibitors and ARBs are contraindicated in pregnancy. Delivery is the only cure. At 34 weeks or beyond with severe features, deliver after stabilization; give betamethasone for fetal lung maturity if under 34 weeks and the situation permits brief expectant management at a tertiary center. Remember too that low-dose aspirin from 12 to 28 weeks reduces risk in high-risk patients, and that seizures can occur up to six weeks postpartum, so counsel her about headache and visual changes after discharge. The distractors: gestational hypertension lacks her proteinuria and end-organ findings; chronic hypertension predates 20 weeks and her booking pressure was 110/70; eclampsia requires a generalized seizure, which she has not had; and acute fatty liver of pregnancy presents with nausea, vomiting, and jaundice with hypoglycemia, a markedly elevated bilirubin, and coagulopathy with a prolonged PT, which is not this panel.
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