Diagnostic Dilemmas in Obstetric Medical Emergencies: A Case Series

The differentiation among hepatic, hypertensive, and gastrointestinal disorders during pregnancy poses significant diagnostic challenges due to overlapping clinical manifestations and biochemical abnormalities. Conditions such as Intrahepatic Cholestasis of Pregnancy (IHCP), preeclampsia, HELLP syndrome, Acute Fatty Liver of Pregnancy (AFLP), and gallbladder disease share common symptoms—including pruritus, hypertension, right upper quadrant pain, and elevated liver enzymes—complicating timely and accurate diagnosis. This case series highlights the diagnostic dilemmas encountered across four distinct clinical presentations: (1) IHCP presenting with pruritus and elevated liver enzymes, initially raising suspicion for AFLP and viral hepatitis; (2) Preeclampsia with markedly elevated alkaline phosphatase, requiring differentiation from HELLP syndrome; (3) Gallbladder calculi mimicking IHCP and hypertensive disorders due to biochemical abnormalities and localised pain; and (4) An isolated 14-fold increase in alkaline phosphatase, which proved heuristically complex. A systematic, multidisciplinary approach—integrating detailed clinical assessment, laboratory investigations, and imaging—was essential for precise diagnosis and optimal management. Emphasising careful clinical judgment, the exclusion of severe conditions, and tailored interventions, this case series underscores the need for clear diagnostic algorithms and management guidelines to improve maternal and foetal outcomes in overlapping obstetric hepatobiliary and hypertensive disorders.