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Two Life-Threatening Cases of Subcapsular Liver Hematoma in Parturients
Abstract Number: RF6AI-148
Abstract Type: Case Report Case Series
Introduction: HELLP (Hemolysis, Elevated Liver enzymes, and Low Platelet count) syndrome is considered to be a complication of preeclampsia (PEC). 0.9% of patients with HELLP develop subcapsular liver hematoma (SLH), a life-threatening complication (1).We present two cases of SLH due to PEC.
Case #1: A 41-year-old woman was admitted at 30 weeks gestation for complete placenta previa and PEC. On day 4, she developed severe range pressures, transaminitis, and right upper quadrant (RUQ) pain. Bedside abdominal ultrasound was unremarkable. An urgent cesarean section (CS) was performed without issue. Within two hours, she became severely hypotensive, with a hematocrit drop from 36.7 to 20. Repeat ultrasound by the anesthesia team showed free abdominal fluid concerning for ruptured SLH. Massive transfusion protocol was activated, and trauma surgery performed an emergent laparotomy, hematoma evacuation and packing. She recovered uneventfully and was discharged on postpartum day 9.
Case #2: A 34-year-old woman at 39 weeks gestation admitted in labor reported new RUQ pain, prompting a diagnosis of severe PEC. RUQ and shoulder pain persisted despite placement of a labor epidural, leading to a bedside ultrasound by the anesthesiologist, revealing a large SLH (Fig.1). Her hematocrit quickly dropped from 35.7 to 28.3, with worsening transaminitis. A formal ultrasound showed a 800 mL hematoma in the right hepatic lobe. Massive transfusion protocol was activated, and trauma surgery performed an emergent laparotomy and hematoma evacuation, revealing liver capsular defects and a one liter hemoperitoneum. A CS was then performed. Her total estimated blood loss was 5L. Postpartum course was uneventful and she was discharge on day 6.
Discussion: SLH occurs in patients with PEC and/or HELLP syndrome when blood accumulates between the liver parenchyma and the capsule of Glisson. Maternal mortality in SLH rupture may be as high as 50% (2). Patients typically present in the third trimester with nonspecific findings, including RUQ pain, transaminitis, and anemia. Stable patients can be managed conservatively, but urgent surgery is required if unstable. High suspicion by the anesthesia provider can prompt early diagnosis, with bedside ultrasound as a valuable, noninvasive tool for timely recognition.
1. Am J Obstet Gynecol 1993, 169(4): 1000-6.
2. Am J Obstet Gynecol 2004, 190(1): 106-12.