P3918 - A Rare Case of HELLP Syndrome Complicated by Hepatic Capsular Rupture

Sharon Slomovich, MD¹, Neal Shah, DO¹, Mahnoor Khan, DO², Pruvthi Patel, MD^3
1Mount Sinai South Nassau, Oceanside, NY; ²ISMMS Mt. Sinai South Nassau, Oceanside, NY; ³Mount Sinai Hospital, New York, NY

Introduction: Hepatic rupture with hemoperitoneum during pregnancy is an uncommon, yet severe complication linked to HELLP (hemolysis, elevated liver enzymes and low platelets) syndrome. Here we present a rare case of HELLP complicated by hepatic capsular rupture.

Case Description/Methods: A 31-year-old female gravida 4, para 1 and history of preeclampsia presented to the labor and delivery ward at 38.6 weeks gestation with elevated blood pressures, consistent with preeclampsia. Upon arrival, blood pressure was 190/100. The physical exam was unremarkable. One hour later, she underwent a spontaneous rupture of membranes and vaginal birth. One day postpartum, the patient endorsed severe right upper quadrant pain and vomiting and developed HELLP syndrome as evidenced by platelets of 54 K/uL, aspartate transaminase 262 U/L, alanine aminotransferase 279 U/L, lactate dehydrogenase 499 U/L and hemoglobin of 6.3 g/dL. Bilirubin and coagulation studies were normal. CTA abdomen with intravenous contrast and liver protocol, showed a moderate subcapsular hematoma with hemoperitoneum consistent with capsular rupture, without active bleeding and infarction of the right hepatic lobe (Figure 1). The patient remained hemodynamically stable, and surgery was deferred. She received two units of red blood cells and one unit of platelets for correction of anemia and thrombocytopenia. Four days following the onset of her symptoms liver enzymes and platelets normalized. MRI abdomen three weeks later showed a much-improved hematoma.

Discussion: Hepatic hematoma is estimated to occur in approximately 0.9-1.6% of cases of HELLP syndrome, with hepatic capsular rupture considered the most devastating complication (1). The proposed mechanism is related to ischemia from prolonged vasospasm of the hepatic microvasculature and subsequent reperfusion and microvascular hemorrhage that tracks to the capsule leading to rupture (2). While surgery is the mainstay of treatment, supportive care may be considered for hemodynamically stable patients. Further studies are needed to determine optimal management, follow-up time and considerations for subsequent pregnancies.


1. Ditisheim, A., & Sibai, B. M. (2017). Diagnosis and management of HELLP syndrome complicated by liver hematoma. Clinical obstetrics and gynecology, 60(1), 190-197.
2. McCormick PA, Higgins M, McCormick CA, Nolan N, Docherty JR. Hepatic infarction, hematoma, and rupture in HELLP syndrome: support for a vasospastic hypothesis. J Matern Fetal Neonatal Med. 2022;35(25):7942-7947.



Disclosures:


Sharon Slomovich, MD¹, Neal Shah, DO¹, Mahnoor Khan, DO², Pruvthi Patel, MD³. P3918 - A Rare Case of HELLP Syndrome Complicated by Hepatic Capsular Rupture, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.