A fatal case of complicated HELLP Syndrome and

Antepartum Eclamptic Fit with ruptured

Subcapsular Liver Hematoma

Case Report

A fatal case of complicated HELLP syndrome andantepartum eclamptic fit with rupturedsubcapsular liver hematoma

Ahmed Samy Elagwany*, Islam Koreim, Ziad Samy Abouzaid

Department of Obstetrics and Gynecology, Alexandria University, Egypt

a r t i c l e i n f o

Article history:

Received 30 July 2013

Accepted 4 October 2013

Available online xxx

Keywords:

Mortality

HELLP syndrome

Antepartum eclamptic fit

Ruptured subcapsular liver hema-

toma

Abdominal packing and B-lunch

suture

a b s t r a c t

Objective: To describe a fatal case of ruptured subcapsular liver hematoma as regards

diagnoses and management.

Design: Case report.

Setting: Department of Obstetrics and Gynecology.

Patient: A 25-year-old woman developed HELLP syndrome and antepartum eclamptic fit

complicated with ruptured subcapsular liver hematoma during the 28th week of

pregnancy.

Intervention: Midline abdominal exploratory laparotomy, with delivery by caesarean sec-

tion. Tight abdominal packing for the hematoma and Pringle maneuver were done. Partial

couvelaire uterus was managed by prostaglandins and B-Lynch brace sutures to minimize

uterine bleeding and atony. The patient developed postoperative hepatic, renal failure,

coagulopathy, deterioration and finally death.

Conclusion(s): Ruptured subcapsular liver hematoma is a life-threatening condition that

should be considered in pregnant women with HELLP syndrome and severe preeclampsia

presenting with symptoms and signs of hemorrhagic shock, hemoperitoneum and the liver

should be evaluated with ultrasound before delivery. In these patients delivery of the fetus

is the first step and the best approach is a midline abdominal incision. Also, regular

antenatal care is very important through all trimesters.

Copyright ª 2013, Indraprastha Medical Corporation Ltd. All rights reserved.

1. Introduction

Subcapsular hematoma and hepatic rupture are very unusual

catastrophic complication of preeclampsia/eclampsia and

HELLP (hemolysis, elevated liver enzymes, and low platelets)

syndrome.1 The reported incidence of this condition varies

from 1 in 40,000 to 1 in 2,50,000 deliveries.2 There is no

agreement on the best approach to treat this severe compli-

cation of pregnancy and optimalmanagement is still evolving.

A multidisciplinary approach to the management of these

patients can lead to remarkable decrease in the usual high

mortality rate. We present a fatal case of severe preeclampsia,

which rapidly progressed to HELLP syndrome, liver rupture,

disseminated intravascular coagulation (DIC) and renal failure.

* Corresponding author. El-Shatby Maternity Hospital, Alexandria University, Alexandria, Egypt. Tel.: þ20 1228254247.E-mail address: ahmedsamyagwany@gmail.com (A.S. Elagwany).

Available online at www.sciencedirect.com

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Please cite this article in press as: ElagwanyAS, et al., A fatal case of complicatedHELLP syndrome and antepartum eclamptic fitwith ruptured subcapsular liver hematoma, Apollo Medicine (2013), http://dx.doi.org/10.1016/j.apme.2013.10.001

0976-0016/$ e see front matter Copyright ª 2013, Indraprastha Medical Corporation Ltd. All rights reserved.http://dx.doi.org/10.1016/j.apme.2013.10.001

2. Case report

A 25-year-old primigravida female at 28 weeks of gestation

was admitted to the emergency department of the maternity

department of El-Shatby University Hospitals with hemor-

rhagic shock and history of antepartum fit 4 h before

admission.

Prenatal care had not been provided since the second

trimester and the pregnancy was uneventful until two days

before admission where the patient complained of severe

headache, epigastric pain and blurred vision with hyperten-

sion and proteinuria. Oral antihypertensive drugs were given

by family doctor as alleged by relatives, for follow up. But the

condition deteriorated and antepartum convulsions occurred.

On admission, clinical examination revealed a pale and

dull patient with disturbed level of consciousness. Multiple

tongue bites were evident. The patient’s parameters were as

follows HR 140 beat/min, ABP 90/30mmHg. Local examination

revealed the following, painful abdominal distention, fundal

level nearly 34 weeks, and the cervix was closed with severe

vaginal bleeding with clots. Laboratory parameters were as

follows: hemoglobin 3 gm/dl, platelets 60,000/mm3, peripheral

blood film showing hemolytic smear, INR 4, aspartate

aminotransferase 500 IU/L, alanine aminotransferase 500 IU/

L, proteinuria of 3þ.

Antenatal sonography revealed a living fetus nearly 28

weeks and massive abdominal collection, abdominal tapping

with spinal needle revealed bloody nonclotted fluid.

Resuscitation was started with colloids, a new blood sam-

ple was taken, eight units of whole blood were cross matched

and the patient was urgently transferred to the operating

theatre, it was decided to perform an immediate abdominal

exploratory laparotomy with delivery by caesarean section.

General anesthesia and endotracheal intubation was given

and abdominal exploratory laparotomy through lower

midline incision was done revealing massive hemoper-

itoneum, cesarean section was done and a living male baby

weighing 1.2 kg was delivered. The uterine incision was

closed. But, she developed atonic postpartum hemorrhage

from partial couvelaire uterus which was managed by using

prostaglandins and B-Lynch brace sutures to minimize uter-

ine bleeding and atony was corrected.

There was massive hemoperitoneum and about 3 L of

blood with clots were removed. Also, a continuous accumu-

lation of blood in the pelvis from the upper abdomen so,

exploration of the abdomen by manual palpation of the upper

abdominal organs revealed enlarged liver with blood clots

covering it and active bleeding from surface of the liver and so,

a ruptured subcapsular hepatic hematoma was suspected.

Extension of the abdominal incision upwards for explora-

tion confirming the initial diagnoses (Fig. 1a and b) so, inter-

vention through tight abdominal packing with 22 laparotomy

pads sized 30�30 cm, sutured together and Pringle’s maneu-

ver were done for controlling the bleeding from the liver sur-

face and compressing the hematoma preventing its

expanding in size and the bleeding was controlled.

The patient received eight units of whole blood, eight units

of fresh frozen plasma, and two units of platelets during the

operation which extended for 3 h. Her vital parameters were

as follows at the end of the operation, HR 120 beats/min, ABP

100/70 mmHg, CVP 6 cm H20, urine output nearly 100 cc.

Closure of the abdomen, leaving the packs to be removed after

stabilization of the condition of the patient. Two drains were

left intraperitoneal. The babywas transferred for NICU but the

baby died after six days because of respiratory distress syn-

drome and sepsis.

The patient was transferred to the intensive care unit on

mechanical ventilation. The patient continued blood, plasma

and platelet transfusions. There was no urine output even

with furosemide and dopamine infusions. Her laboratory pa-

rameters were as follows: hemoglobin 6 gm/dl, platelets

60,000/mm3, INR 2, aspartate aminotransferase 2000 IU/L,

alanine aminotransferase 1500 IU/L, serum blood urea was

120 mg/dl and serum creatinine 8 mg/dl over the next days

with the drains revealed 500 cc/24 h with altered blood clots.

CT brain revealed brain hypoxia and edema.

The patient remained haemodynamically unstable

requiring further transfusion of fresh frozen plasma, platelets

and blood. She developed acute kidney failure, respiratory

insufficiency, liver failure and major coagulopathy. The con-

dition deteriorated and eventually, the patient died after 48 h

following cardiac arrest from which she could not be

resuscitated.

Fig. 1 e Showing subcapsular liver hematoma.

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Please cite this article in press as: Elagwany AS, et al., A fatal case of complicated HELLP syndrome and antepartumeclamptic fitwith ruptured subcapsular liver hematoma, Apollo Medicine (2013), http://dx.doi.org/10.1016/j.apme.2013.10.001

3. Discussion

In spite of improvement in antenatal care maternal mortality

in developing countries is high. Hypertensive disorders,

including HELLP syndrome are one of the main causes of

maternal mortality.3 HELLP syndrome is a disease of variable

presentation with high mortality and morbidity.4 Liver

rupture and hemorrhage is the most unusual and serious

complication of HELLP syndrome.5 The cause of subcapsular

and intraparenchymal hepatic hematoma in HELLP syndrome

is not definitely known. Ultrasound scan is the quickest

means of diagnosis although computerized tomography is

more sensitive.

Hepatic rupture generally occurs during the last trimester

of pregnancy or, less commonly, in the first 24 h after de-

livery.6 The clinical presentation of acute persistent right

upper quadrant or epigastric pain associated with hypoten-

sion and elevated hepatic enzymes should prompt the clini-

cian to consider hepatic rupture, particularly if there is a

history of hypertension during pregnancy.6,7 However,

elevated hepatic enzymes may not be present, and although

liver transaminases normally fall during a healthy pregnancy,

the alkaline phosphatase level can rise up to 500 by the end of

the third trimester.6e8 The right lobe of the liver is affected

more often than the left.9 Hepatic rupture occurs in 1:45,000

live births,6 and the mortality is high. If it occurs before de-

livery the fetal mortality rate is approximately 60%.6 The

prognosis depends on early recognition of the possible diag-

nosis, prompt investigation and surgical intervention.

Radiological imaging is helpful in establishing the diag-

nosis. Ultrasound scanning is quick and simple and often used

as a first line test, but contrast enhanced CT scanning is more

useful.6,7 Magnetic resonance imaging is appropriate in the

more stable patient.6,7 Serial MRI and CT scanning can be used

tomonitor the recovery of the liver in the patientswho survive

the initial hemorrhagic episode.10 Intra-arterial digital sub-

traction hepatic angiography is probably the gold standard as

it can be used not only to diagnose but also selectively to

embolise the bleeding area.6e8

If there is only a subcapsular hematoma and the patient is

stable, close observation of the patient may be all that is

needed.7 In cases where the patient becomes haemodynami-

cally unstable, prompt surgical intervention is recom-

mended.6 A Pringle maneuver (i.e. occlusion of the hepatic

artery and portal vein) is useful to initially control the hem-

orrhage from the liver and assess the areas of damage. Local

liver hemorrhage can then be controlled by a combination of

direct pressure and hematoma evacuation with packing,

Argon coagulator or diathermy hemostasis, hemostatic

wrapping, and over sewing of lacerations. In the presence of

severe liver damage, a limited liver resection or even liver

transplantation has been successfully performed.6e10 Early

involvement of a surgeon with experience of liver surgery is

essential to optimize the chance of successful control of

hemorrhage.

4. Conclusion

This case report shows that ruptured subcapsular liver he-

matoma is a serious, life-threatening condition. Therefore, a

high index of suspicion is necessary. It should be considered

in pregnant women with HELLP syndrome and severe pre-

eclampsia presenting with symptoms and signs of hemor-

rhagic shock, hemoperitoneum and the liver should be

evaluated with ultrasound before delivery. Regular antenatal

care is very important through all the trimesters. Treatment is

comparable with treatment of traumatic lesions of the liver

with special attention for the pregnant patient. In these pa-

tients delivery of the fetus is the first step and the best

approach is a midline abdominal incision.

Conflicts of interest

All authors have none to declare.

r e f e r e n c e s

1. Sheikh RA, Yasmeen S, Pauly MP. Spontaneous intrahepatichemorrhage and hepatic rupture in HELLP syndrome: fourcases and a review. J Clin Gastroenterol. 1999;28:323e328.

2. Corinna W, Pereira P. Subcapsular liver hematoma in HELLPsyndrome: evaluation of diagnostic and intrahepatic optionse a unicentric study. Am J Obstet Gynecol. 2004;190:106e112.

3. Araujo Ana CPF, Leao Marcos D. Characteristics andtreatment of hepatic rupture caused by HELLP syndrome. AmJ Obstet Gynecol. 2006;195:129e133.

4. Aldemir M, Bac B, Tacyldiz I. Spontaneous liver hematomaand hepatic rupture in HELLP syndrome: report of two cases.Surg Today. 2002;32:450e453.

5. Catriconi M, Aragiusto G, Ansalone M. Liver rupture in HELLPsyndrome. Report of a case. Minerva Chir. 2000;55:167e171.

6. Matsuda Y, Maeda T, Hatae M. Spontaneous rupture of theliver in an uncomplicated pregnancy. J Obstet Gynaecol Res.1997;23:449e452.

7. Moise Jr KJ, Belfort MA. Damage control for the obstetricpatient. Surg Clin North Am. 1997;77:835e852.

8. Hunter SK, Martin M, Benda JA. Liver transplant after massivespontaneous hepatic rupture in pregnancy complicated bypre-eclampsia. Obstet Gynecol. 1995;85:819e822.

9. Schwartz ML, Lien JM. Spontaneous liver haematoma inpregnancy not clearly associated with pre-eclampsia: a casepresentation and literature review. Am J Obstet Gynecol.1997;176:1328e1333.

10. Saura P, Blanch L. Spontaneous rupture of the liver duringpregnancy. Intensive Care Med. 1995;21:95e96.

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Please cite this article in press as: ElagwanyAS, et al., A fatal case of complicatedHELLP syndrome and antepartum eclamptic fitwith ruptured subcapsular liver hematoma, Apollo Medicine (2013), http://dx.doi.org/10.1016/j.apme.2013.10.001

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