Topic: Hepatic subcapsular haematoma with atypical HELLP and ITP- A case Report

 

Introduction:

 

Subcapsular hepatic haematoma is a rare and life-threatening complication of pregnancy.

 

The pathogenesis is not well understood. It is usually seen in cases of severe pre-eclampsia and HELLP.

 

This is a case report of an acute subcapsular hepatic haematoma and intra-uterine fetal death in a primigravidae postdated woman with atypical-PET and Idiopathic thrombocytopenic purpura.

 

Case Summary:

 

A 33yr old, primigravidae , with Idiopathic-thrombocytopenic-purpura, at 40+6 weeks of gestation presented to the A&E with acute right upper quadrant pain with bilious vomiting.

 

Simple analgesia and opiates couldn’t relieve the pain.

 

Interestingly, she had a similar history with gallstones in the past which was managed conservatively

 

The pain continued to increase despite a combination of analgesics. Regrettably, she had a sudden Intrauterine fetal death, confirmed by ultrasound scan after 8 hours of onset of pain

 

Examnination, investigation and management:

 

On examination, no uterine or right upper quadrant tenderness could be elicited.

 

Computerised-CTG preformed was normal with STV of 12.4.

 

Her observations were stable except for a borderline BP- 150/80 and a HR- 92bpm which were attributed to the pain.

 

Blood parameters were all normal, except a mildly raised ALT(ALT-70) and PCR-26

 

The woman suddenly developed features of hypovolaemic shock. On transferring to HDU, multidisciplinary input was acquired.

 

Bloods now revealed an astonishing level of Alkaline-transaminase- 1686 which further rose to 4171 in 6 hours. The drop in haemoglobin from 140 to 103 was at par with the clinical picture.

 

An urgent bedside upper abdominal scan confirmed large volume of free fluid within the pelvis.

On transferring to theatres, a midline laparotomy was performed.

 Haemoperitoneum but no couvelaire uterus was noted.

 

After delivering a fresh stillborn (clear liquor), a ruptured subcapsular hepatic haematoma was detected. After stabilization with blood and blood products and intraoperative-hepatic packing, a drain was inserted and she was transferred to ICU for re-laparotomy after 48hrs.  She was discharged after a month following a treacherous course.

 

During this period she developed haemothorax and pericardial effusion, was managed very well by our multidisciplinary team and made a complete recovery.

 

Discussion:

This lady had subcapsular-hepatic rupture and IUD with atypical HELLP with no symptoms of PET. 

A diagnostic dilemma, it taught us the importance of high clinical suspicion in cases where pain is out of proportion, cannot be managed by opiates, in order to avoid catastrophic sequelae.  

 

Conclusion:

This case is noteworthy as it highlights the cataclysmic events that can occur with atypical PET and the importance of a high clinical suspicion, quick diagnosis and treatment with multidisciplinary input to save the life of a young woman.

 

 

Refrences:

 

1. Bradke D, Tran A, Ambarus T, Nazir M, Markowski M, Juusela A. Grade III subcapsular liver hematoma secondary to HELLP syndrome: A case report of conservative management. Case Rep Womens Health. 2019 Dec 24;25:e00169. doi: 10.1016/j.crwh.2019.e00169. PMID: 31908974; PMCID: PMC6940712.

2. Luhning, K., MacCormick, H., Macaulay, B. et al. Subcapsular hepatic hematoma as a complication of severe preeclampsia: a case report. J Med Case Reports 15, 625 (2021). https://doi.org/10.1186/s13256-021-03166-w