HELLP syndrome with postpartum hepatic infarction and subcapsular bleeding
Journal
Acta Obstetricia et Gynecologica Scandinavica
Journal Volume
91
Journal Issue
5
Pages
637-638
Date Issued
2012
Author(s)
Abstract
Sir, We would like to call attention to the case of a 38-year-old primigravida at 38 weeks' gestation, who required cesarean section because of severe pre-eclampsia two days before transfer to our hospital. During postpartum recovery, she had drowsy consciousness, transient blurred vision and internal bleeding. A distended, rigid abdomen was noted without postpartum hemorrhage. Her systolic and diastolic blood pressures were elevated, up to 220 and 130 mmHg, respectively. Laboratory results showed a low platelet count of 59,000/mL3, a high lactic dehydrogenase level of 22,094 units/L, and an extremely high level of aspartate aminotransferase of 10,279 units/L. Disseminated intravascular coagulation profiles were within normal limits initially. The contrast-enhanced CT scan revealed non-enhancing low attenuation at the right lobe of the liver (Figure 1a; arrow) and an arterial phase enhancing high attenuation over the subcapsular area (Figure 1a; arrowhead), compatible with massive right hepatic lobe infarction and active subcapsular hemorrhage. Anti-phospholipid antibodies, hematological profiles, and tests for hepatitis A, B and C were all negative. Owing to concerns about hepatic failure, the patient received conservative component therapy and consecutive days of hemodialysis and plasmapheresis rather than transarterial embolization in the intensive care unit. She recovered gradually, and follow-up abdominal CT two weeks later showed no change in size of the subcapsular hematoma and regenerated liver (Figure 1b). Total bilirubin decreased from 20.1 mg/dL (postpartum day 3) to 0.9 mg/dL (postpartum day 38). She was discharged on postpartum day 41 with normotensive blood pressure and normal liver function tests. Three months later, abdominal CT showed complete resolution of the subcapsular hematoma and regeneration of the right hepatic lobe (Figure 1c). To our knowledge, this may be the first postpartum case to clearly demonstrate an arterial phase CT picture of active subcapsular bleeding combined with massive hepatic infarction. Only a few cases of liver infarction combined with subcapsular hematoma during HELLP syndrome have been reported (1). Most of them have underlying autoimmune diseases and carry a high mortality rate (2). The purpose of surgical intervention is compression of the liver and drainage of the hemtoma rather than hepatic lobectomy. Sometimes this procedure will suddenly increase intra-abdominal pressure and result in life-threatening complications and should be reserved for hepatic rupture or hemodynamically unstable patients. Transarterial embolization is an alternative method for treatment of subcapsular bleeding. In our case, however, we chose conservative treatment because of concerns regarding the risk of hepatic failure. A team well experienced in conservative treatments, including massive blood transfusion, component therapies, hemodialysis, plasmapheresis and molecular adsorbent recirculating systems, will be conducive to a good outcome. (a) The contrast-enhanced CT scan showed non-enhancing low attenuation at the right hepatic lobe (arrow) and an arterial phase enhancing high attenuation over the subcapsular area, indicating active bleeding (arrowhead). (b) Two weeks later, repeat abdominal CT scan showed a stable-sized subcapsular hematoma and recovering right hepatic lobe. (c) Three months later, follow-up CT scan showed complete resolution of subcapsular hematoma and regenerated right hepatic lobe.
SDGs
Other Subjects
aspartate aminotransferase; bilirubin; lactate dehydrogenase; adult; aspartate aminotransferase blood level; bilirubin blood level; case report; cesarean section; diastolic blood pressure; female; follow up; HELLP syndrome; hemodialysis; human; infarction; lactate dehydrogenase blood level; letter; liver function test; liver hematoma; liver hemorrhage; liver infarction; plasmapheresis; priority journal; puerperium; systolic blood pressure; thrombocyte count; Adult; Female; Gestational Age; HELLP Syndrome; Hematoma; Humans; Infarction; Liver; Liver Diseases; Plasmapheresis; Postpartum Period; Pregnancy; Renal Dialysis; Tomography, X-Ray Computed
Type
letter