Roshni Sreedharan, MD, , FASA,FCCM
Anesthesiologist Intensivist
Cleveland Clinic Foundation
Cleveland, Ohio
Disclosure information not submitted.
Philip Ramirez, MD
Anesthesia CCM Fellow
The Cleveland Clinic
Cleveland, Ohio
Disclosure information not submitted.
Title: HELLP - Subcapsular Liver Hematoma in a Critically Ill Post-partum Patient
Introduction: HELLP syndrome is a life-threatening complication associated with pre-eclampsia. We present a patient with postpartum HELLP syndrome complicated by rupture of a subcapsular liver hematoma.
Description: A 34-year-old G4P3 was admitted for induction of labor for severe preeclampsia. Admission lab work was notable for transamenitis. Soon after delivery, she developed worsening epigastric, RUQ and shoulder pain. A CT scan revealed large hepatic subcapsular hematomas with multiple foci of bleeding and ischemia of segments IV and VII. Repeat labs revealed a platelet count of 55k and Hgb 7.9 g/dl. Despite aggressive resuscitation progressive hypotension ensued necessitating an emergency exploratory laparotomy. In the OR, peritoneal and subscapular hematoma evacuation was performed with repair of a liver laceration. The estimated blood loss was 8L resulting in activation of the massive transfusion protocol (MTP). Upon return to the ICU, pressors were weaned off and laboratory values looked acceptable. 5 hours later her hemodynamics deteriorated in conjunction with worsening lab values. Her hemoglobin dropped from 12 to 6.7g/dl and labs revealed coagulopathy. Pressors were restarted and MTP was again activated in route to the OR. Bleeding was noticed from a liver laceration which was not amenable to repair prompting ligation of the left hepatic artery. Postoperatively she was weaned off pressors and liberated from mechanical ventilation. A high index of suspicion remained for acute hepatic failure given ligation of the hepatic artery eliciting immediate evaluation for liver transplantation. Fortunately, the synthetic function of her liver progressively improved. On POD 8 she returned to the OR for a washout and closure of fascia. She would eventually return home to her children without any further complications.
Discussion: Hemolytic anemia, thrombocytopenia and elevated liver enzymes indicate severe disease in patients with preeclampsia. Subcapsular hemorrhage, a catastrophic consequence of HELLP syndrome, occurs in about 2% of these patients. Although hemorrhage without rupture can be managed conservatively, acute abdominal pain or shock should increase suspicion of rupture. Rapid resuscitation, hemodynamic support and urgent delivery with control of hemorrhage through embolization or laparotomy are lifesaving.