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Positional Hypotension in HELLP Syndrome
Abstract Number: SUN-24
Abstract Type: Case Report/Case Series
Introduction: HELLP Syndrome is best known for its mnemonic: hemolysis, elevated liver enzymes, and low platelets (thrombocytopenia). Here we detail a case of HELLP syndrome with positional hypotension heralding one of its most dangerous complications.
Description: A 31-year-old G3P1 at 38 weeks was transferred from an outside hospital with HELLP syndrome. She endorsed 2 weeks of right shoulder pain that she assumed was from her sleep position. She also had right upper quadrant (RUQ) pain, lab evidence of hemolysis, transaminitis (AST 324, ALT 353), and thrombocytopenia (80K). Induction was started with Oxytocin and an epidural was placed.
At 6cm dilation, the patient became hypotensive to 70/30. She responded to fluids, 50-100mcg boluses of phenylephrine, and trendelenberg position. Each time the patient sat up she became hypotensive, nauseated, and the fetal heart rate would decelerate. Pelvic ultrasound was performed but the posterior placental location was difficult to assess for abruption.
An interdisciplinary discussion was held and decision was made for cesarean delivery. While moving from labor bed to OR table, the patient endorsed severe, constant abdominal pain unrelated to contractions.
Upon incision, 1-2L of blood rushed out from the RUQ. The liver bed was packed and Surgery was paged. A healthy neonate (APGARS 7, 8) was delivered. General anesthesia was induced, an arterial line was inserted, and transfusion via massive transfusion protocol was initiated. Rupture of a 21x19x5cm liver hematoma was discovered, and bleeding was controlled. The abdomen was packed and the patient was monitored in the ICU for 2 days until her coagulopathy resolved. She returned to the OR for closure and was extubated without difficulty.
Discussion: Subcapsular liver hematoma in HELLP is rare, with literature reports of < 2% of all cases. The pathogenesis is unclear, and signs and symptoms are nonspecific. Patients may present with RUQ or epigastric pain, nausea/vomiting, or hypotension. Ultrasound can be used for diagnosis, but is often difficult in the gravid patient. Management of stable patients is mostly conservative with close monitoring, fluids, and treatment of underlying HELLP/pre-eclampsia. Hepatic artery embolization can be utilized if the patient is hemodynamically unstable. Surgery is usually required. Uncontrollable bleeding from rupture can precipitate other complications such as disseminated intravascular coagulopathy, acute liver failure requiring transplant, and acute kidney injury.
Conclusion: This case discusses a rare complication of HELLP syndrome heralded by non-specific, persistent, and positional hypotension. Liver subcapsular hematoma rupture, although rare, should be on the differential for HELLP patients with RUQ pain and unexplained hypotension.
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