///2009 Abstract Details
2009 Abstract Details2018-05-01T17:45:11+00:00

Subcapsular hepatic hematoma in HELLP syndrome: not only a textbook entity!

Abstract Number: 222
Abstract Type: Case Report/Case Series

Ruth Landau MD, Professor1 ; Nicolas Mariotti MD2; Jean-Louis Blouin PhD3; Georges Savoldellii MD, MEd4

CASE REPORT

A healthy portuguese 27yo G2P0 at 35WA was admitted to the ER for thoracic and right upper quadrant pain (RUQP) irradiating to the right shoulder. BP was 150/93mmHg, liver function tests (LFTs) were elevated and platelet count was 149,000G/L. HELLP syndrome was diagnosed and the patient was transferred to the OB ward for an urgent CS. Fetal cephalic presentation was confirmed by US and a rapid liver scan did not show any abnormalities. IV magnesium was initiated. CS under spinal anesthesia was uneventful and a healthy 2020g girl was delivered. PACU course was favorable except for RUQP worsening 24h post-CS. LFTs further increased and platelet count and Hb decreased. A large subcapsular hepatic hematoma of 10x20cm and voluminous right pleural effusion were diagnosed by CT-scan. Patient was admitted to ICU for BP control (labetalol infusion) and coagulation support. ICU discharge occurred on D4. The pleural effusion required delayed drainage. Hospital discharge occurred at 4wks.

DISCUSSION

This case illustrates a wellknown but extremely rare complication of pregnancy (1/45000-225000) mostly associated with preeclampsia. Spontaneous liver hematoma followed by liver rupture and massive hemorrhage carries high maternal/fetal mortality. Symptoms include RUQP, epigastric or referred shoulder pain, nausea, vomiting, abdominal distension, hypertension or hypovolemic shock. Except for shoulder pain and shock, all other signs are frequently encountered in otherwise uncomplicated preeclampsia. This can partially explain why the diagnosis is often delayed and only discovered during surgery or collapse. Management can be divided in two groups depending on presentation. Conservative management (fluid resuscitation, blood product transfusion) or IR procedures or open surgery (packing, drainage, vascular ligation, hepatic resection) with ultimately liver transplantation.

Learning points are that the hepatic hematoma seemed to have occurred post-CS emphasizing the need to pursue strict postpartum monitoring and that it can resolve with conservative management even with such large hematoma.

In addition, this patient enrolled at 20 wks in a longitudinal study on preeclampsia. Genotyping for eNOS gene was Glu298Glu (not associated with HELLP1) and Arg16Gly-Gln27Gln for β2AR (associated with an intermediate risk post-MI2). Further study of available material will be undertaken (genetic and placental markers).

1. Medica, 2008

2. Lanfear, 2005



SOAP 2009