Subcapsular hematoma and hepatic rupture are very unusual catastrophic complication of preeclampsia/eclampsia and HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome. The reported incidence of this condition varies from 1 in 40,000 to 1 in 2,50,000 deliveries.There is no agreement on the best approach to treat this severe complication of pregnancy and optimal management is still evolving.

1. A fatal case of complicated HELLP Syndrome and
Antepartum Eclamptic Fit with ruptured
Subcapsular Liver Hematoma

2. a p o l l o m e d i c i n e x x x ( 2 0 1 3 ) 1 e3
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Case Report
A fatal case of complicated HELLP syndrome and
antepartum eclamptic fit with ruptured
subcapsular liver hematoma
Ahmed Samy Elagwany*, Islam Koreim, Ziad Samy Abouzaid
Department of Obstetrics and Gynecology, Alexandria University, Egypt
article info
abstract
Article history:
Objective: To describe a fatal case of ruptured subcapsular liver hematoma as regards
Received 30 July 2013
diagnoses and management.
Accepted 4 October 2013
Design: Case report.
Available online xxx
Setting: Department of Obstetrics and Gynecology.
Patient: A 25-year-old woman developed HELLP syndrome and antepartum eclamptic fit
Keywords:
complicated with ruptured subcapsular liver hematoma during the 28th week of
Mortality
pregnancy.
HELLP syndrome
Intervention: Midline abdominal exploratory laparotomy, with delivery by caesarean sec-
Antepartum eclamptic fit
tion. Tight abdominal packing for the hematoma and Pringle maneuver were done. Partial
Ruptured subcapsular liver hema-
couvelaire uterus was managed by prostaglandins and B-Lynch brace sutures to minimize
toma
uterine bleeding and atony. The patient developed postoperative hepatic, renal failure,
Abdominal packing and B-lunch
coagulopathy, deterioration and finally death.
suture
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 complication of pregnancy and optimal management 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).
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
Please cite this article in press as: Elagwany AS, et al., A fatal case of complicated HELLP syndrome and antepartum eclamptic fit
with ruptured subcapsular liver hematoma, Apollo Medicine (2013), http://dx.doi.org/10.1016/j.apme.2013.10.001

3. 2
2.
a p o l l o m e d i c i n e x x x ( 2 0 1 3 ) 1 e3
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 hemorrhagic 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 hypertension 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 90/30 mmHg. 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 sample 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 hemoperitoneum, 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 uterine bleeding and atony was corrected.
There was massive hemoperitoneum and about 3 L of
blood with clots were removed. Also, a continuous accumulation 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 exploration confirming the initial diagnoses (Fig. 1a and b) so, intervention through tight abdominal packing with 22 laparotomy
pads sized 30Â30 cm, sutured together and Pringle’s maneuver were done for controlling the bleeding from the liver surface 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
Fig. 1 e Showing subcapsular liver hematoma.
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 baby was transferred for NICU but the
baby died after six days because of respiratory distress syndrome 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 parameters 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 condition deteriorated and eventually, the patient died after 48 h
following cardiac arrest from which she could not be
resuscitated.
Please cite this article in press as: Elagwany AS, et al., A fatal case of complicated HELLP syndrome and antepartum eclamptic fit
with ruptured subcapsular liver hematoma, Apollo Medicine (2013), http://dx.doi.org/10.1016/j.apme.2013.10.001

4. a p o l l o m e d i c i n e x x x ( 2 0 1 3 ) 1 e3
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 delivery.6 The clinical presentation of acute persistent right
upper quadrant or epigastric pain associated with hypotension and elevated hepatic enzymes should prompt the clinician 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 delivery the fetal mortality rate is approximately 60%.6 The
prognosis depends on early recognition of the possible diagnosis, prompt investigation and surgical intervention.
Radiological imaging is helpful in establishing the diagnosis. 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
to monitor the recovery of the liver in the patients who survive
the initial hemorrhagic episode.10 Intra-arterial digital subtraction 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 haemodynamically unstable, prompt surgical intervention is recommended.6 A Pringle maneuver (i.e. occlusion of the hepatic
artery and portal vein) is useful to initially control the hemorrhage 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
3
essential to optimize the chance of successful control of
hemorrhage.
4.
Conclusion
This case report shows that ruptured subcapsular liver hematoma 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 preeclampsia presenting with symptoms and signs of hemorrhagic 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 patients 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.
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Please cite this article in press as: Elagwany AS, et al., A fatal case of complicated HELLP syndrome and antepartum eclamptic fit
with ruptured subcapsular liver hematoma, Apollo Medicine (2013), http://dx.doi.org/10.1016/j.apme.2013.10.001

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