Hepatitis B surface antigen (HBsAg) positivity presents unique management challenges in pregnancy. We present the case of a 26-year-old HBsAg-positive woman who presented at 35 weeks gestational age with nausea, vomiting, and abdominal pain with markedly elevated liver enzymes. An elevated alpha feto-protein on antenatal screening had been misconstrued as fetal in origin. Magnetic resonance imaging and liver biopsy confirmed hepatocellular carcinoma. She died of fulminant hepatic failure two weeks after emergent delivery. This case highlights the importance of adequate evaluation and management of pregnant patients testing positive for HBsAg on routine antenatal testing.
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