A 37-year-old primigravida at 30 weeks' gestation has noted increasing pedal edema, headaches, confusion, and decreased urine output for the past 2 weeks. She now exhibits seizure activity and then lapses into a coma. On physical examination, her temperature is 36.8degC, pulse is 82/min, respirations are 24/min, and blood pressure is 145/95 mm Hg. Her heart rate is regular, and lung fields are clear. The abdomen is soft, and bowel sounds are present. There is pitting edema to the thighs. No vaginal bleeding is noted, and the cervix is not effaced. Laboratory findings show hemoglobin, 11.9 g/dL; hematocrit, 35.8%; platelet count, 63,500/ mm3; WBC count, 8180/ mm3; glucose, 151 mg/dL; total protein, 6.1 g/dL; albumin, 3.2 g/dL; total bilirubin, 2.3 mg/dL; AST, 88 U/L; ALT, 103 U/L; alkaline phosphatase, 253 U/L; and prothrombin time, 32 seconds (INR 2.8). Urinalysis shows specific gravity of 1.024, pH 6, 4+ proteinuria, 1+ glucosuria, and no blood. An ultrasound examination shows a viable 30-week fetus. What condition is most likely present in this patient?

Risk factors for HELLP (hemolysis with elevated liver enzymes and low platelets) syndrome, a variant of severe preeclampsia, include nulliparity, advanced maternal age, diabetes mellitus, preexisting hypertension, a prior history of preeclampsia, and renal disease. Patients with HELLP syndrome may progress to disseminated intravascular coagulation. Emergent delivery is indicated. Abruptio placentae is an acute event marked by severe abdominal pain and vaginal bleeding. Hepatic vein thrombosis in Budd-Chiari syndrome can produce liver necrosis with elevated enzymes; pregnancy is a risk factor, but this does not explain the neurologic and renal findings. Likewise, a dilated cardiomyopathy that can occur in pregnancy does not explain these findings. In hydatidiform mole, preeclampsia is more likely, but 30 weeks is a long time to have it, and a fetus would not be present. Acute fatty liver of pregnancy may resemble Reye syndrome (a disease that occurs in children) and may be preceded by preeclampsia. Sheehan syndrome is postpartum pituitary necrosis leading to hypopituitarism.