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Atypical Presentation of HELLP Syndrome Resulting in Spontaneous Rupture of Subcapsular Hematoma
Abstract Number: SU-88
Abstract Type: Case Report/Case Series
This is a case report of a 35-year-old G1PO female with an atypical presentation of HELLP syndrome requiring emergent caesarean delivery at 27 wga following spontaneous rupture of a subcapsular liver hematoma.
This patient first presented to the ED at 25wga with epigastric pain and was found to have elevated liver enzymes. She was normotensive and her workup was negative with the exception of a 3cm hyperechoic right lobe liver lesion diagnosed as a hemangioma. The patient was seen in clinic the following day with resolution of symptoms and improvement in liver enzymes.
Two weeks later, the patient was admitted complaining of RUQ and epigastric pain. Patient remained normotensive but was thrombocytopenic and had an elevation of liver enzymes. Patient was hospitalized for three days while labs were monitored and workup completed. Abdominal ultrasound revealed an increase in the hyperechoic right lobe liver lesion to 9cm. Follow up with MRI did not reveal a hepatic mass and the sonographic abnormalities were attributed to fatty infiltration. Over the course of three days, all lab values began to normalize. Based on the lab values, radiographic findings and resolution of symptoms, the patient was discharged home with close follow up.
She presented back to the hospital the next day with increased abdominal pain. AST and ALT were again elevated but her platelets remained stable at 151,000/uL. Repeat abdominal ultrasound showed the right lobe liver lesion to be stable. CT of the abdomen was negative. 10 hours after admission, the patient began complaining of chest, back, and right shoulder pain accompanied by an episode of epistaxis. STAT labs revealed PLT of 20,000/uL. The patient became hypotensive, tachycardic, and the fetal heart rate dropped into the 60’s. She immediately went to the OR for emergent caesarean section under general anesthesia.
The patient was placed under general endotracheal anesthesia with a rapid sequence induction utilizing propofol and succinylcholine. She then underwent an emergent primary classical caesarean section with delivery of a viable 27 wga male. She had a hemoperitoneum of about 2 liters with a rupture of her right hepatic lobe. Once hemostasis was achieved, her abdomen was packed and she was transferred to the ICU intubated in stable condition. Intraoperatively, the patient received 13 units of packed red blood cells (PRBCs), 7 units of fresh frozen plasma (FFP), and 4 units of pooled platelets to achieve hemodynamic stability. An additional 4 units of FFP were given in the ICU. Labs were closely monitored and revealed evidence of shock liver. AST and ALT peaked on postop day 2 then gradually trended down, while platelets normalized over the first few days postpartum.
The patient returned to the OR on post operative day (POD) 3 to have packing removed. The patient was extubated on POD 5 and returned to the OR for wound closure on POD 8. She was discharged home 14 days following her caesarean delivery.