Spontaneous Hepatic Rupture in a Pregnant Woman with Preeclampsia and HELLP Syndrome

Abstract

Spontaneous hepatic rupture is a rare complication associated with preeclampsia and is characterized by hemolysis, elevated liver enzymes, and a low platelet count (HELLP syndrome), with a nonspecific clinical presentation and high mortality rate. We present the case of a 34-year-old primigravida woman in whom spontaneous hepatic rupture associated with HELLP syndrome was accidentally detected during cesarean delivery. The patient was successfully managed with liver packing and transcatheter arterial embolization, followed by plasmapheresis. Spontaneous hepatic rupture should be considered in any HELLP syndrome patient presenting with epigastric or right upper quadrant pain and early signs of hemodynamic instability. A multimodal approach can help achieve good clinical outcomes in patients with this rare presentation.

Figure 1

Extravasation signs on DSA. (a) TAE was performed via the celiac artery and (b) spot signs showing extravasation contrast. DSA: digital subtraction angiography; TAE: transcatheter arterial embolization. In the ICU, the patient was managed with mechanical ventilation, broad-spectrum antibiotics, fluid and blood transfusions, vasopressors, tranexamic acid, and magnesium sulfate for eclampsia prophylaxis.

Figure 2

Progress of disease course. HR: heart rate; BP: blood pressure; SpO2: saturation of pulse oxygen; FiO2: fraction of inspired oxygen; PRBC: packed red blood cell; FFP: fresh frozen plasma; PLT: platelet; Cryo: cryoprecipitate; TPE: therapeutic plasma exchange; CVVHDF: continuous venovenous hemodiafiltration; IHD: intermittent hemodialysis; HFNC: high-flow nasal cannula; IMV: invasive mechanical ventilation; ICU: intensive care unit; bpm: beats per minute.

Figure 3

Variation of serum laboratory results over time.

Figure 4

Subhepatic hematoma and subscapular active bleeding on CT scan at ED. (a, c) Active bleeding signs (yellow arrow) and (b, d) other extravascular contrast (yellow arrow). CT: computed tomography; ED: emergency department.

Figure 5

Perihepatic hematoma without signs of active bleeding on follow-up computed tomography.