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Atypical presentation of HELLP syndrome with large subcapsular liver hematoma
Abstract Number: SU-91
Abstract Type: Case Report/Case Series
A 43 y.o. G2P0111 at 32w5d with history of IVF pregnancy and myomectomy for fibroid removal presented to a local hospital with RUQ pain. Upon presentation, blood pressure was noted to be mildly elevated. An ultrasound revealed a large subcapsular liver hematoma. The patient was then transferred to our tertiary care facility for further management.
On arrival, liver enzymes were mildly elevated: AST 103 and ALT 72. Platelets were somewhat depressed at 115, while hemoglobin/hematocrit was normal at 12.3/37.7. Magnesium infusion was initiated immediately for seizure prophylaxis. Given the large size of the hematoma, ~15cm and surrounding the entirety of the right hepatic lobe, decision was made to proceed with cesarean delivery. This was the patient’s planned mode of delivery given her history of myomectomy.
In the operating room, an arterial line was placed and anesthesia was induced with combined spinal epidural using 10mg bupivacaine and 20mcg fentanyl. After a successful delivery, uterine closure and hemostasis, general surgery evaluated her liver hematoma. A large subcapsular hematoma was confirmed. There was no evidence of bleeding from the liver and the abdomen was closed without other intervention. The patient was taken to the surgical ICU for post-op care. She remained in the ICU for monitoring for 48 hours with the plan for VIR embolization if bleeding from her liver occurred.
Liver enzymes peaked at AST 119 and ALT 105 on POD 1. Platelets fell to a nadir of 108 on POD 1. A CT scan done on POD 1 showed stable subcapsular liver hematoma. The patient remained stable and was transferred out of the ICU on POD 3 and discharged home on POD 5. On follow up at 2 weeks, CT scan showed reduction in size of the hematoma. Liver enzymes and platelets had also returned to normal.
Subcapsular liver hematoma is a very rare complication of pregnancy, occurring in 1 in 67,000 pregnancies and 1 in 2000 pregnancies complicated by HELLP syndrome. The presentation in our patient was somewhat unusual in that liver enzymes did not rise to levels typically seen with subcapsular hemorrhage and platelet levels never fell below 100. There was no evidence of hemolytic anemia. Blood pressure was only mildly elevated on admission and never rose higher than SBPs of 140s.
This case highlights the importance of investigating complaints of epigastric and RUQ pain in pregnancy, even when laboratory values may not suggest severe preeclampsia or HELLP syndrome.
Vigil-De Garcia P, Ortega-Paz L. Pre-eclampsia/eclampsia and hepatic rupture. Int J Gyn Obstetrics. 2012;118:186-89.
Messerschmidt L, et al. Postpartum HELLP syndrome and subcapsular liver haematoma. BMJ Case Rep. 2014;bcr-2013202503.
Araujo ACPF, et al. Characteristics and treatment of hepatic rupture caused by HELLP syndrome. Am J Obstetr Gyn. 2006;195:129-33.