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Delayed diagnosis of subcapsular hepatic hematoma in a patient with preeclampsia and HELLP syndrome
Abstract Number: F3D-4
Abstract Type: Case Report/Case Series
Background: Subcapsular hepatic hematoma (SCH) is a rare life-threatening complication of pregnancy, typically associated with preeclampsia and HELLP syndrome.1 Presentation includes epigastric, right upper quadrant, or shoulder pain, nausea and vomiting, dyspnea, and rarely, pleural effusion or renal hematoma.2 Timely diagnosis is critical, due to the extreme morbidity with ruptured SCH. Antepartum diagnosis requires treatment for severe preeclampsia with magnesium sulfate, blood pressure control, and emergent cesarean delivery. Conservative management is appropriate when diagnosed postpartum in clinically stable patients.
Case features: A previously well 40 year old primiparous woman presented at 39+6 weeks gestational age with a 3 day history of new onset severe pain throughout her right torso and normal vital signs. Her pain was attributed to radiculopathy, as she had a prior history in a similar distribution. The next day, she returned with the same pain, along with hypertension, tachycardia, and elevated transaminases. Treatment was initiated for severe preeclampsia with magnesium sulfate infusion and induction of labour. Platelet count was stable within the normal range, allowing placement of combined spinal-epidural at L3/4 for labour analgesia. Her right torso pain was unresponsive to acetaminophen and opioids, preventing her from pushing effectively. In the operating room, IV fentanyl boluses were used to facilitate positioning for assessment for a trial of forceps, and epidural lidocaine 2% with epinephrine and bicarbonate was titrated to obtain surgical anesthesia. With the vertex at station zero, cesarean delivery occurred. Uterine atony was treated with oxytocin and carboprost. Post-operatively, CT scan revealed a 16x7x14cm intact SCH. She was managed conservatively and discharged home after 5 days. On postpartum day 15, she required admission to thoracic surgery after developing a large right-sided pleural effusion, which required decortication. Her SCH remained stable throughout, and she continues to receive outpatient followup with general surgery.
Conclusion: This case illustrates the importance of maintaining high clinical suspicion for SCH in patients presenting with right sided torso pain, including the shoulder and neck region, especially in hypertensive disorders of pregnancy. Prior painful conditions can cloud the clinical picture, leading to missed or delayed diagnosis. Had this patient’s SCH been diagnosed upon initial presentation, management would have changed to proceed directly to cesarean delivery under neuraxial anesthesia, without induction of labour. Also of note is this patient’s development of a large pleural effusion without SCH rupture, which has not previously been reported to our knowledge.
1. IJGO 2012; 118(3):186-9.
2. JCU 1999;27(1):35-40.