Diagnosis and Management of HELLP Syndrome Complicated by Liver Hematoma

Spontaneously ruptured huge hepatic subcapsular hematoma associated with preeclampsia: A case report and literature review

Hepatic subcapsular hematoma (HSH) is an uncommon complication of pregnancy and is associated with elevated rates of maternal and foetal mortality. The rupture of an HSH is a critical situation that necessitates immediate and timely intervention to prevent loss of life. We present here, a case of a spontaneously ruptured massive HSH caused by preeclampsia. In addition, we conducted a comprehensive review of existing literature, encompassing 49 cases of HSH associated with pregnancy. If a pregnant woman with gestational hypertension experiences right upper abdominal pain with shoulder pain or radiating shoulder pain, it is crucial for her to have an urgent abdominal ultrasound because of the potential development of HSH and/or rupture. Our review of current literature suggests that opting for a caesarean section may offer notable advantages in preventing HSH rupture.

Spontaneous idiopathic liver hemorrhage: a systematic review of a rare entity

BACKGROUND

Spontaneous idiopathic liver hemorrhage (SILH) is a rare life-threatening condition occurring without a clear and specific etiology. A systematic review was performed to provide guidelines for the perioperative management of patients affected by SILH. A case report was also included.

METHODS

A systematic search of the last 24-year literature was conducted and the manuscript was structured following point-by-point the PRISMA guidelines.

RESULTS

After an initial selection of 6995 titles, 15 articles were considered for the final qualitative analysis (n = 22 patients, including the present report). Conservative treatment was chosen in 12 cases (54.5%) with stable clinical conditions, while 9 patients (40.9%) required a primary operative approach for emergency presentation at diagnosis. Direct liver resection was the preferred surgical treatment (n = 6), mostly major hepatectomies (n = 4). Hepatic arterial embolization was performed as the primary operative approach in three patients, followed by emergency laparotomy during the same hospitalization because of rebleeding in one case. Contrast-enhanced CT scan was the gold standard for diagnosis (n = 19).

CONCLUSIONS

Conservative treatment of SILH is mainly based on stable clinical conditions and may be considered even in case of a limited arterial blush found on imaging. The absence of underlying hepatic or systemic disorders seems to correlate with favorable outcomes and no mortality.

Hepatic Rupture Associated With HELLP (Hemolysis, Elevated Liver Enzymes, and Low Platelets) Syndrome: A Report of Two Cases and Literature Review

Hepatic rupture is a rare complication of severe preeclampsia. A high index of suspicion is required in the presence of abdominal pain accompanied by hemodynamic decompensation in a pregnant woman. Hepatic rupture constitutes a medical emergency that demands immediate intervention, often with the support of other medical disciplines, in a highly specialized hospital setting. Unruptured hepatic hematomas can be managed conservatively. Immediate delivery and surgical repair of the liver are necessary for maternal survival. Spontaneous liver rupture in pregnancy is often unrecognized, highly lethal, and not completely understood with few cases having been reported in the literature. Therefore, we present two cases of HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome with hepatic rupture, emphasizing their clinical presentation and therapeutic approaches.

HELLP Syndrome and Differential Diagnosis with Other Thrombotic Microangiopathies in Pregnancy

Thrombotic microangiopathies (TMAs) comprise a distinct group of diseases with different manifestations that can occur in both pediatric and adult patients. They can be hereditary or acquired, with subtle onset or a rapidly progressive course, and they are particularly known for their morbidity and mortality. Pregnancy is a high-risk time for the development of several types of thrombotic microangiopathies. The three major syndromes are hemolysis, elevated liver function tests, and low platelets (HELLP); hemolytic uremic syndrome (HUS); and thrombotic thrombocytopenic purpura (TTP). Because of their rarity, clinical information and therapeutic results related to these conditions are often obtained from case reports, small series, registries, and reviews. The collection of individual observations, the evolution of diagnostic laboratories that have identified autoimmune and/or genetic abnormalities using von Willebrand factor post-secretion processing or genetic-functional alterations in the regulation of alternative complement pathways in some of these TMAs, and, most importantly, the introduction of advanced treatments, have enabled the preservation of affected organs and improved survival rates. Although TMAs may show different etiopathogenesis routes, they all show the presence of pathological lesions, which are characterized by endothelial damage and the formation of thrombi rich in platelets at the microvascular level, as a common denominator, and thrombotic damage to microcirculation pathways induces "mechanical" (microangiopathic) hemolytic anemia, the consumption of platelets, and ischemic organ damage. In this review, we highlight the current knowledge about the diagnosis and management of these complications during pregnancy.

Subcapsular liver hematoma complicating HELLP syndrome: A case report and review of management strategies

Subcapsular liver hematoma is a life-threatening complication of pregnancy. It is associated with preeclampsia and HELLP syndrome. We present the case of a 36-year-old Caucasian nulliparous woman who was diagnosed at 29 weeks and 6 days of gestation with mild preeclampsia. After brief hospitalization she was discharged. During a daily follow-up, at 31 weeks and 3 days of gestation, she complained of mild abdominal pain and blood tests revealed HELLP syndrome. The cervix was unripe. A healthy baby was delivered by emergency cesarean section. The following day, the patient complained of persistent abdominal pain, and at the same time the hepatic cytolysis worsened dramatically. A computed tomography (CT) scan revealed a significant subcapsular hematoma without any active bleeding or breach of Glisson's capsule. We treated the patient conservatively and she was discharged home 10 days after the diagnosis was made. The symptoms of subcapsular liver hematoma are non-specific. They include nausea, vomiting and epigastric pain, and pain in the right upper quadrant or shoulder. Biological analyses can show hepatic cytolysis, haemolysis and coagulation disorders. Medical imaging can confirm the diagnosis. The management of subscapular liver hematoma may depends on whether there is hemodynamic stability, active bleeding or breach of Glisson capsule's. If the patient is stable and in the absence of active bleeding, management should be purely symptomatic.

The Role of Endothelial Dysfunction in the Pathogenesis of Pregnancy-Related Pathological Conditions: A Review

In the recent decades, endothelial dysfunction (ED) has been recognized as a significant contributing factor in the pathogenesis of many pathological conditions. In interaction with atherosclerosis, hypercholesterolemia, and hypertension, ED plays a crucial role in the pathogenesis of coronary artery disease, chronic renal disease, and microvascular complications in diabetes mellitus. Although ED plays a significant role in the pathogenesis of several pregnancy-related disorders such as preeclampsia, HELLP syndrome, fetal growth restriction, and gestational diabetes mellitus, the exact pathogenetic mechanisms are still a matter of debate. The increased prevalence of these entities in patients with preexisting vascular diseases highlights the essential pathological role of the preexisting ED in these patients. The abnormal uteroplacental circulation and the release of soluble factors from the ischemic placenta into the maternal bloodstream are the main causes of the maternal ED underlying the characteristic preeclamptic phenotype. Besides the increased risk for maternal and fetal poor outcomes, the preexisting ED also increases the risk of development of future cardiovascular diseases in these patients. This study aimed to look deeper into the role of ED in the pathogenesis of several pregnancy-related hypertensive and liver diseases. Hopefully, it could contribute to improvement of the awareness, knowledge, and management of these conditions and also to the reduction of the adverse outcomes and additional long-term cardiovascular complications.

Spontaneous subcapsular hepatic hematoma in pregnant patients

Spontaneous subcapsular hepatic hematoma (SSHH) with or without previous history of preeclampsia and/or HELLP syndrome represents a very rare pathological condition in pregnancy and postpartum, (1/45,000-1/225,000 pregnancies). Its importance for the anesthesiologist lays in its association with high morbidity and mortality for the mother (60-86%, 39%) and newborn (42%). After a high clinical suspicion, the certainty clinical diagnosis is settled by different imaging techniques. However, in most cases the diagnosis of SSHH is a casual intraoperative finding associated to a maternal or foetal compromise. Nowadays the obstetric and anaesthetic management of a SSHH is not standardized and depends on its integrity, hemodynamic stability and the gestational period when diagnosed. The possibility of an acute critic haemorrhage with necessity of massive transfusion, makes advisable to provide updated protocols for the treatment of obstetric hemorrhage, adapting them to the clinical peculiarities of these patients. After the acute phase, close attention should be kept on thromboembolic complications.

Role of Plasmapheresis in Hemolysis, Elevated Liver Enzymes and Low Platelets (HELLP) Syndrome

Hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome is a rare abnormality comprising a series of symptoms that make up a syndrome. It usually happens during pregnancy or right after delivery. We describe a case of a 31-year-old female G4P2A2 (Gravida 4 Para 2 Abortions 2) who presented to the hospital for normal vaginal delivery but immediately postpartum developed HELLP syndrome. Acute fatty liver of pregnancy was a differential that the patient also met the criteria for. Her condition improved after starting her on plasmapheresis without considering hepatic transplantation. We emphasize distinguishing the overlap of symptoms between HELLP syndrome vs. acute fatty liver of pregnancy and the outcomes of plasmapheresis in managing HELLP syndrome without needing hepatic transplantation.

Conservative Treatment of Huge Hepatic Subcapsular Hematoma Complicated with Hepatic Infarction after Cesarean Section Caused by HELLP Syndrome - a Case Report and Literature Review

Hepatic subcapsular hematoma and hepatic infarction in labor are mostly secondary to HELLP syndrome and preeclampsia. There are few reported cases with a complicated diagnosis and treatment and high mortality. Here, we present a case of a huge hepatic subcapsular hematoma complicated with hepatic infarction after cesarean section that was secondary to HELLP syndrome and the patient was treated conservatively. Further, we have discussed the diagnosis and treatment of hepatic subcapsular hematoma and hepatic infarction caused by HELLP syndrome.

Management of Ruptured Subcapsular Liver Hematoma as a Result of Hemolysis, Elevated Liver Enzyme, and Low Platelet Syndrome in a Rural Facility

Subcapsular liver hematoma is a rare complication of hemolysis, elevated liver enzyme, and low platelet (HELLP) syndrome. This case depicts a previously healthy 27-year-old primigravida at 39 weeks' gestation who presented with severe abdominal pain and was diagnosed with HELLP syndrome based on vital signs and laboratory values. While arranging transport to a regional perinatal care facility she became acutely unstable with maternal hypotension and resultant fetal bradycardia. An emergent cesarean section was performed and a ruptured subcapsular liver hematoma was diagnosed intraoperatively. She was successfully managed with supportive care and surgical intervention and was discharged from the hospital on postoperative day 6. Here we review the indications and methods of conservative and surgical management of subcapsular liver hematoma as a result of HELLP syndrome.

Obstetric Emergencies

Human gestation and birthing result in many deviations from usual physiology that are nonetheless normal to be seen. However, on occasion, certain complications in the obstetric patient can be life-threatening to both mother and fetus. Timely recognition of these disorders and allocation of the appropriate resources are especially important. These conditions often require an intensive care unit admission for closer monitoring and supportive care. They can affect an array of physiological systems and can lead to significant morbidity. Such complications are discussed in greater detail in this article.

A Retrospective Case-Control Study on the Diagnostic Values of Hemostatic Markers in Hypertensive Disorder of Pregnancy

Objective

The purpose of this study was to evaluate the diagnostic performance of the following hemostatic markers in hypertensive disorder of pregnancy (HDP): tissue-type plasminogen activator and inhibitor-1 complex (tPAI-C), thrombomodulin, thrombin-antithrombin complex, plasmin inhibitor-plasmin complex, D-dimer, and fibrinogen degradation products.

Methods

A total of 311 individuals diagnosed with HDP and 187 healthy controls (HC) of matched gestational age were admitted, including 175 subjects with gestational hypertension, 94 with mild preeclampsia, and 42 with severe preeclampsia.

Results

Compared with those of the HC group, the plasma concentrations of all the hemostatic markers continuously increased with the clinical severity of the hypertensive disorder, regardless of their statistical significance. In the receiver operating characteristic analysis, tPAI-C displayed the best discrimination performance.

Conclusion

The tPAI-C level was consistently and significantly elevated across the different HDP groups when compared with the HC group, suggesting aggravated fibrinolysis disorder increasing with the severity of the HDP.

HELLP syndrome manifesting as abnormal fetal umbilical artery blood flow and rapidly worsening laboratory indexes: A case report

RATIONALE

HELLP syndrome, a rare but serious obstetric complication, is often overdiagnosed due to its nonspecific symptoms and inappropriate clinical testing.

PATIENT CONCERNS

A 30-year-old nulliparous pregnant Chinese woman at gestational age of 28+1 weeks was admitted to our hospital because Doppler ultrasonography at a local hospital had detected loss of fetal umbilical artery end-diastolic blood flow lasting 12 hours. On admission to our hospital, the patient showed elevated blood pressure (148/84 mm Hg), but blood pressure and laboratory indicators after admission were normal. However, the patient developed abdominal pain during hospitalization.

INTERVENTIONS

Dexamethasone was given after admission to our hospital to promote fetal lung maturation, magnesium sulfate was given to protect fetal brain nerves, and maternal blood pressure was closely monitored. In addition, fetal umbilical artery blood flow was dynamically monitored. After three days in hospital with normal blood pressure, the patient developed abdominal pain accompanied by diarrhea. She was positive for Murphy's sign and laboratory tests showed no obvious abnormalities. Acute cholecystitis was suspected, but symptomatic and supportive treatment did not relieve abdominal pain and her blood pressure increased progressively to 212/130 mm Hg. Magnesium sulfate was given immediately to prevent spasm, and nitroglycerin was administered intravenously against hypertension. Liver enzymes, blood coagulation, and routine urinalysis were abnormal. The patient was diagnosed with HELLP syndrome, and an emergency cesarean section was performed.

DIAGNOSIS

HELLP syndrome.

OUTCOMES

After the cesarean section, platelet (PLT) count continuously decreased and transaminase and bilirubin levels continously increased. The newborn was transferred to the neonatal intensive care unit after birth and discharged at a corrected gestational age of 34 weeks. By postoperative day 6, laboratory indicators had returned to normal and the patient was discharged.

LESSONS SUBSECTIONS

Our case highlights that HELLP syndrome is a serious complication, and it should be diagnosed carefully and not arbitrarily on the basis of some abnormal indicators and stable clinical manifestations. Accurate early identification, active monitoring and management are essential for improving prognosis and avoiding maternal or infant mortality.

Pregnancy-Associated Liver Diseases

The liver disorders unique to pregnancy include hyperemesis gravidarum, intrahepatic cholestasis of pregnancy, acute fatty liver of pregnancy, and preeclampsia-associated hepatic impairment, specifically hemolysis, elevated liver enzymes, and low platelet count syndrome (HELLP). Their importance lies in the significant maternal and fetal/neonatal morbidity and mortality. Expeditious diagnosis and clinical evaluation is critical to ensure timely, appropriate care and minimize risks to the pregnant woman and her fetus/baby. A multidisciplinary approach is essential, including midwives, maternal-fetal-medicine specialists, anesthetists, neonatologists, and hepatologists.

Dengue and HELLP: Beware of the Masquerade

HELLP is a syndrome characterized by hemolysis, elevated liver enzymes, and low platelets. It is a rare complication of pregnancy and is usually associated with pre-eclampsia. However, 10–20% cases of HELLP can present without hypertension. Dengue fever is an arboviral-borne tropical illness that is characterized with fever, thrombocytopenia, and bleeding manifestations. We present a case of a primigravida with HELLP syndrome masquerading in the background of dengue fever. Unique features to this case report include delayed presentation of HELLP syndrome with normotension which can have overlapping features with dengue fever, especially in term pregnancy. This case highlights the need of strict vigilance in cases of dengue fever with pregnancy.

Hepatic Infarction in a Patient With Sickle Cell Trait Presenting With HELLP Syndrome

Hepatic infarction is uncommon due to the dual blood supply from the hepatic artery and portal vein. The majority of the cases are caused following liver transplant or hepatobiliary surgery, hepatic artery occlusion, or shock. Hepatic infarction is a rare complication of hemolysis, elevated liver enzymes, and low platelet (HELLP) syndrome. HELLP is an obstetrical emergency requiring prompt delivery. The presence of elevated liver enzymes, mainly alanine aminotransferase and aspartate aminotransferase in pre-eclampsia, should warrant diagnosis and treatment in the line of HELLP syndrome. Our patient with underlying sickle cell trait presented with features of HELLP syndrome in her third trimester of pregnancy. She underwent cesarean delivery on the same day of the presentation. The liver enzymes continued to rise following delivery and peaked on postoperative day two. Contrast computed tomography scan showed multifocal hepatic infarctions. Pre-eclampsia by itself is a state of impaired oxygenation and can lead to hepatic hypoperfusion, and appeared to be a clear contributor to the hepatic infarction in this case. However, this case also raises the question of whether the underlying sickle cell trait might have potentiated the hepatic infarction. Although sickle cell disease is well known to cause hepatic infarctions, it is unknown whether the sickle cell trait affects the liver to a similar extent as sickle cell disease. In addition, there have been case reports of sickle cell trait causing splenic infarcts and renal papillary necrosis, but it remains unclear if it can be directly associated with hepatic infarction.

Managing hepatic complications of pregnancy: practical strategies for clinicians

Liver disorders specific to pregnancy are rare but can have potentially serious consequences for mother and fetus. Pregnancy-related liver disorders are the most common cause of liver disease in otherwise healthy pregnant women and pose a challenge to physicians because of the need to take into account both maternal and fetal health. A good knowledge of these disorders is necessary as prompt diagnosis and appropriate management results in improved maternal and fetal outcomes. This review will focus on pregnancy-specific disorders and will aim to serve as a guide for physicians in their diagnosis, management and subsequent monitoring.

Subcapsular Liver Hematoma: A Rare Complication of Hemolysis, Elevated Liver Enzymes, and Low Platelets (HELLP) Syndrome Managed Conservatively

HELLP syndrome is an acronym used, since 1982, to describe a combined disorder of the liver and coagulation cascade defined as pre-eclampsia in pregnant women with hemolytic anemia, an increase in liver enzymes, and a decrease in platelet count. Spontaneous liver rupture is an exceptionally rare and extremely severe, occasionally lethal, complication of pre-eclampsia - eclampsia and especially hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome. The following report describes a case of a 48-year-old woman diagnosed with HELLP syndrome complicated by spontaneous liver rupture who was treated conservatively.

Parturient with Acute Abdomen

Management of a parturient with an acute abdomen presents unique challenges. We aim to review the common obstetric and nonobstetric causes for acute abdomen in pregnancy, approach to diagnosis, the role of imaging, and management including the scope and timing of operative intervention.

Liver Bleeding Due to HELLP Syndrome Treated With Embolization and Liver Transplantation: A Case Report and Review of the Literature

Background: Liver bleeding secondary to haemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome is uncommon, but a life-threatening peripartum condition that needs a prompt multidisciplinary approach. Case Presentation: In this study, we presented a case of 28-year-old pregnant woman, who was presented to the obstetrics department with signs of preeclampsia and foetal growth restriction. An emergency caesarean section was performed, and the patient developed a HELLP syndrome complicated by spontaneous liver rupture. After radiological and surgical procedures, liver failure became evident and liver transplantation was successfully performed. The patient and her daughter are now alive. Conclusions: Despite the rarity of this disease, liver complications due to HELLP syndrome must be properly diagnosed and treated given the gravity of the possible evolution in young women. After diagnosis, the patients must be treated in specialised centres with gynaecological, liver surgery, and transplant skills.

Successful Management of Intraoperatively Diagnosed Ruptured Spontaneous Sub-Capsular Liver Hematoma in a Woman with Preeclampsia

Background

Ruptured subcapsular hematoma of the liver is one of the rare life-threatening complications of pregnancy and its incidence varies between 1/45,000 and 1/225,000 births.

Case Presentation

A 32-year-old woman who claimed 9 months amenorrhea, presented to our hospital with elevated blood pressure and pushing down pain. After evaluation she was admitted to the labor ward with a diagnosis of latent first stage of labor and preeclampsia with severe features. She gave birth by outlet vacuum. Immediately following delivery she developed hypotension with signs of intra-abdominal fluid collection. Surgical exploration revealed massive hemoperitoneum with ruptured subcapsular hepatic hematoma. She was managed conservatively with pressure packing and drainage tube. The patient improved and was discharged after 12 days of hospital stay.

Conclusion

Timely surgical intervention, multidisciplinary team, on-time availability of blood products, and proper postoperative follow up are crucial to optimize the patient outcome.

Conservative management of a pregnancy complicated by preeclampsia and postpartum spontaneous hepatic rupture: A case report and review of the literature

INTRODUCTION AND OBJECTIVES

Most spontaneous hepatic rupture cases are associated with a pregnancy-induced hypertensive disorder like preeclampsia and HELLP syndrome. Although it is a rare complication, it is still associated with high maternal and fetal morbidity and mortality rates. With this study, we aim to present a case report and review the available literature on hepatic rupture associated with hypertensive disorders of the pregnancy.

METHODS

We present a case report and a review of the literature of the last 20 years on hepatic rupture associated with pregnancy-induced hypertensive disorders. The selected cases were reviewed to collect information on maternal characteristics, clinical presentation, diagnostic studies, therapeutic modalities and maternal and fetal outcomes.

RESULTS

Our review has found 57 publications describing a total of 93 cases of hepatic hemorrhage with capsule rupture associated with pregnancy-induced hypertensive disorders. Most of the patients were less than 35 years old and primiparous and the first symptoms of hepatic rupture included epigastric and right upper abdominal pain. Most of the diagnoses were made during surgery without previous diagnosis and, in the majority of cases, a surgical approach was necessary to achieve hemostasis. Perihepatic packing was the most used surgical method.

DISCUSSION/CONCLUSION

Our clinical case and literature review reinforces the importance of closely monitoring all pregnancies complicated with hypertensive disorders, including in the postpartum period. Although hepatic rupture accounts for high maternal and fetal morbidity and mortality rates, it is possible to keep a conservative approach with good maternal and fetal outcomes, with a high index of suspicious, an early diagnosis and a multidisciplinary approach.

Transcatheter Arterial Embolization for Spontaneous Hepatic Rupture Associated with HELLP Syndrome: A Case Report

Background: Spontaneous hepatic rupture associated with the syndrome characterized by hemolysis, elevated liver enzymes, and a low platelet count (HELLP syndrome) is a rare and life-threatening condition, and only a few cases regarding the management of this condition through transcatheter arterial embolization (TAE) have been previously reported. Case summary: Herein, we report a case involving a 35-year-old pregnant woman who presented at 28 weeks of gestation with right upper quadrant pain, hypotension, and elevated levels of liver enzymes. Transabdominal ultrasound revealed fetal death. She required an emergency cesarean section, and hepatic rupture was identified after the fetus had been delivered. Hepatic packing and TAE were performed. The postprocedural course was uneventful, and the patient was discharged 14 days after she had been admitted to our hospital. Conclusions: Spontaneous hepatic rupture associated with HELLP syndrome is a very serious condition that requires prompt and decisive management. The high maternal and fetal mortality rates associated with this condition can be reduced through early accurate diagnosis and adequate management. The findings in the reported case indicate that TAE may be an attractive alternative to surgery for the management of spontaneous hepatic rupture associated with HELLP syndrome.

Acute Fatty Liver of Pregnancy

Acute fatty liver of pregnancy is a rare, but potentially fatal obstetric disorder characterized principally by varying degrees of hepatic failure with an onset typically in late pregnancy. This review outlines the etiopathogenesis and describes the multiorgan involvement that often results in a number of clinical and laboratory aberrations. These laboratory derangements provide distinct features to differentiate from other obstetric complications, such as hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome. Once recognized, central to the management of acute fatty liver of pregnancy is delivery planning and meticulous supportive care. One particularly dangerous complication is profound coagulopathy. After delivery, the coagulation defect resolves over 1-2 days, and hepatic and renal function are restored soon thereafter. This report offers anticipated recovery and management strategies for commonly associated complications. Application of these factors has served to decrease mortality from as high as 80% down to 10%; however, given the seriousness of this condition, severe maternal morbidities are frequently associated with this obstetric emergency.

Haemolysis, elevated liver enzymes and low platelets: Diagnosis and management in critical care

A thirty-year-old pregnant woman was admitted to hospital with headache and gastrointestinal discomfort. She developed peripheral oedema and had an emergency caesarean section following an episode of tonic-clonic seizures. Her delivery was further complicated by postpartum haemorrhage and she was admitted to the Intensive Care Unit (ICU) for further resuscitation and seizure control which required infusions of magnesium and multiple anticonvulsants. Despite haemodynamic optimisation she developed an acute kidney injury with evidence of liver damage, thrombocytopenia and haemolysis. Haemolysis, Elevated Liver enzymes and Low Platelets (HELLP) syndrome, a multisystem disease of advanced pregnancy which overlaps with pre-eclampsia, was diagnosed. HELLP syndrome is associated with a range of complications which may require critical care support, including placental abruption and foetal loss, acute kidney injury, microangiopathic haemolytic anaemia, acute liver failure and liver capsule rupture. Definitive treatment of HELLP is delivery of the fetus and in its most severe forms requires admission to the ICU for multiorgan support. Therapeutic strategies in ICU are mainly supportive and include blood pressure control, meticulous fluid balance and possibly escalation to renal replacement therapy, mechanical ventilation, neuroprotection, seizure control, and management of liver failure-related complications. Multidisciplinary input is essential for optimal treatment.

Complicated Post-Partum HELLP Syndrome Causing Acute Renal Failure and a Spontaneous Acute Subdural Hematoma

HELLP syndrome is characterized by hemolysis, elevated liver enzymes, and thrombocytopenia. It is a devastating illness that typically occurs in the third trimester of gestation. We present a unique case of complicated post-partum HELLP syndrome.

The patient was a 34-year-old Caucasian G1PO woman at 40 weeks’ gestational age who presented for induction of labor. She underwent successful vaginal delivery. However, postoperatively the patient developed HELLP syndrome complicated by acute renal failure. She was transferred to the intensive care unit, where her renal function continued to decline, ultimately necessitating hemodialysis. She subsequently spontaneously developed an acute subdural hematoma.

Most cases of HELLP syndrome occur in the third trimester, whereas fewer manifest post-partum. The pathophysiology of HELLP syndrome is poorly understood. While the defining organ of injury in HELLP syndrome is the liver, both kidney injury and spontaneous subdural hematomas can occur, as seen in this patient. The gold standard therapy for HELLP syndrome is prompt delivery of the fetus.

HELLP syndrome continues to be a serious constellation of symptoms that can affect women late in their gestational period. As illustrated in this case report, prompt diagnosis of HELLP syndrome and appropriate management is critical.

Microvascular thrombosis: experimental and clinical implications

A significant amount of clinical and research interest in thrombosis is focused on large vessels (eg, stroke, myocardial infarction, deep venous thrombosis, etc.); however, thrombosis is often present in the microcirculation in a variety of significant human diseases, such as disseminated intravascular coagulation, thrombotic microangiopathy, sickle cell disease, and others. Further, microvascular thrombosis has recently been demonstrated in patients with COVID-19, and has been proposed to mediate the pathogenesis of organ injury in this disease. In many of these conditions, microvascular thrombosis is accompanied by inflammation, an association referred to as thromboinflammation. In this review, we discuss endogenous regulatory mechanisms that prevent thrombosis in the microcirculation, experimental approaches to induce microvascular thrombi, and clinical conditions associated with microvascular thrombosis. A greater understanding of the links between inflammation and thrombosis in the microcirculation is anticipated to provide optimal therapeutic targets for patients with diseases accompanied by microvascular thrombosis.

Late first trimester circulating microparticle proteins predict the risk of preeclampsia < 35 weeks and suggest phenotypic differences among affected cases

We hypothesize that first trimester circulating micro particle (CMP) proteins will define preeclampsia risk while identifying clusters of disease subtypes among cases. We performed a nested case–control analysis among women with and without preeclampsia. Cases diagnosed < 34 weeks’ gestation were matched to controls. Plasma CMPs were isolated via size exclusion chromatography and analyzed using global proteome profiling based on HRAM mass spectrometry. Logistic models then determined feature selection with best performing models determined by cross-validation. K-means clustering examined cases for phenotypic subtypes and biological pathway enrichment was examined. Our results indicated that the proteins distinguishing cases from controls were enriched in biological pathways involved in blood coagulation, hemostasis and tissue repair. A panel consisting of C1RL, GP1BA, VTNC, and ZA2G demonstrated the best distinguishing performance (AUC of 0.79). Among the cases of preeclampsia, two phenotypic sub clusters distinguished cases; one enriched for platelet degranulation and blood coagulation pathways and the other for complement and immune response-associated pathways (corrected p < 0.001). Significantly, the second of the two clusters demonstrated lower gestational age at delivery (p = 0.049), increased protein excretion (p = 0.01), more extreme laboratory derangement (p < 0.0001) and marginally increased diastolic pressure (p = 0.09). We conclude that CMP-associated proteins at 12 weeks’ gestation predict the overall risk of developing early preeclampsia and indicate distinct subtypes of pathophysiology and clinical morbidity.

Ruptured Subcapsular Liver Hematoma: A Rare Complication of HELLP Syndrome

Subcapsular liver hematoma (SLH) is a rare complication of HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome. We report a previously healthy 16-year-old female presenting with pre-eclampsia requiring emergent C-section, who developed immediate postoperative bleeding and abdominal distention. Abdominal computed tomography angiography (CTA) revealed a large encapsulated liver hematoma with active extravasation. The patient was successfully treated with a multidisciplinary approach with medical and surgical management.

Comparing acute fatty liver of pregnancy from hemolysis, elevated liver enzymes, and low platelets syndrome

Acute fatty liver of pregnancy (AFLP) and hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome are both associated with significant maternal and perinatal morbidity and mortality. Because of the overlap of several clinical and laboratory findings differentiation can sometimes be difficult. Both disorders have been of interest for more than 100 years, however they were not completely characterized until the early 1980s. It was not until the 1980s that AFLP and HELLP syndrome, and more specifically their clinical, laboratory, and pathologic findings, were further differentiated in the literature. More recently, the pathophysiologic mechanisms have been elucidated. In this review, we outline the similarities and differences in the clinical presentation, laboratory findings, maternal and perinatal outcomes, and clinical recovery for women diagnosed with these two syndromes. From our observations, we suggest that levels of fibrinogen, creatinine, cholesterol, and total bilirubin be used to assist with differentiating AFLP from HELLP syndrome upon admission in women presenting with either suspected disease. The rationale for identifying the specific conditions is that clinical consequences for recovery vary considerably. Specifically, AFLP is associated with significantly more hepatic and renal dysfunction as well as coagulopathy. Fortunately, both conditions can be managed with supportive measures with overall improved perinatal outcomes including morbidity and mortality.

Rapidly progressing HELLP syndrome and massive liver destruction in a 22-year-old female pregnant with monochorionic diamniotic gemelli

Haemolysis Elevated Liver parameters and Low Platelets (HELLP) syndrome can present with abdominal pain as the only symptom. It can be rapid with failure of multiple organs and is a cause of maternal death. A 22-year-old female pregnant with twins contacted her local hospital due to abdominal pain. Within 20 hours of the debut of the abdominal pain, a caesarean section was performed, the patient was re-operated due to the suspicion of abdominal bleeding. Bescause she was hypotensive and blood tests showed signs of liver destruction and acidosis, she was transferred to the intensive care unit (ICU). During an admission of 40 days, the patient received 5 plasmapheresis treatments and 10 courses of haemodialysis. CT scans showed massive liver haematomas intraparenchymal and subcapsular. The CT scan images are very interesting and included in the case report.This case presents a good prognosis after a rapid progression of HELLP in spite of a dramatic clinical presentation. This topic is of great interest to a wide spectre of clinicians, as an early multidisciplinary approach is necessary.

Posterior reversible encephalopathy syndrome in preeclampsia and eclampsia: The role of hypomagnesemia

PURPOSE

Posterior reversible encephalopathy syndrome (PRES), defined by its clinical and imaging manifestations, is a critical maternal complication. The specific pathophysiological mechanism of PRES has not been fully elucidated and remains controversial. Recently, several case studies reported that hypomagnesemia is present in the acute phase of PRES regardless of its etiology. Moreover, magnesium sulfate is a conventional treatment for preeclampsia (PE) and eclampsia; therefore, we hypothesized that hypomagnesemia might play an important role in the cascades involved in PRES in PE or eclampsia.

METHOD

We consecutively collected PE and eclampsia patients who were examined via magnetic resonance imaging (MRI) and tested for magnesium levels between January 2013 and January 2017. All patients were grouped into PRES and non-PRES groups based on MRI results. Demographic data, magnesium levels and imaging features were collected retrospectively.

RESULTS

A total of 72 patients met the inclusion criteria; these participants were sorted into PRES (n = 38) and non-PRES (n = 34) groups. Twenty-four patients (63%) in the PRES group and 2 patients (6%) in the non-PRES group presented hypomagnesemia. Moreover, magnesium levels were significantly lower in the PRES group during both the acute phase (p < 0.001) and the post-phase (p = 0.04) than in the non-PRES group. However, there was no correlation between magnesium levels and edema severity during the acute phase.

CONCLUSIONS

These results demonstrate that hypomagnesemia frequently occurs in the acute phase of obstetric PRES and suggest a potential relationship between them. Such a connection would support the application of magnesium sulfate in PE and eclampsia patients to prevent PRES. However, additional randomized trials are needed.

Grade III subcapsular liver hematoma secondary to HELLP syndrome: A case report of conservative management

Subcapsular liver hematoma (SLH) is a rare condition that is associated with preeclampsia and HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome. A high level of suspicion, early diagnosis, and coordinated, intensive multidisciplinary management are necessary to monitor for serious complications and prevent death. Options include conservative management, hepatic resection, hepatic artery ligation and liver transplantation. This paper describes a 34-year-old woman with HELLP syndrome who developed a large grade III SLH that was managed conservatively.

Hepatic Complications in Preeclampsia

In cases of preeclampsia with severe features and hemolysis, elevated liver enzymes, and low platelet (HELLP) syndrome, hepatic complications portend significant short-term and long-term maternal health implications. In this section, we will discuss the physiology of normal hepatic function in pregnancy, the pathophysiology of the abnormalities noted in hepatic function during the process of preeclampsia development, the diagnosis and management of preeclampsia, imitators of HELLP syndrome, the utility of various biomarkers in the diagnosis and prognosis of the preeclampsia disease spectrum, possible underlying genetic factors predisposing women to developing hepatic abnormalities with preeclampsia, and finally prognosis and management of a subcapsular hematoma.

Bleeding Liver Masses: Imaging Features With Pathologic Correlation and Impact on Management

OBJECTIVE. The purposes of this article are to discuss a variety of liver masses that can present with hemorrhage, including their characteristic imaging features, and to propose a diagnostic approach. CONCLUSION. A broad spectrum of pathologic conditions can present as spontaneous hemorrhage within or surrounding the liver and may present acutely or as a chronic or incidental finding. Imaging characteristics and clinical history can often narrow the differential diagnosis and guide management.

Hepatic rupture from haematomas in patients with pre-eclampsia/eclampsia: a case series

Hepatic rupture from haematomas is a rare complication of severe preeclampsia/eclampsia especially when complicated with the haemolysis, elevated liver enzymes and low platelet count (HELLP) syndrome. It is associated with poor maternal and foetal outcomes as demonstrated by three cases we describe. The first case had eclampsia at 31 weeks gestation with features of abruptio placentae and at caesarean section we found haemoperitoneum of 1.5 litres, a 10cm liver rupture and a still birth. She subsequently died in ICU within 24 hours of surgery; the second case had eclampsia at 35 weeks and ended up as a table death during emergency caesarean section. She had 4 litres of haemoperitoneum, hepatic rupture, placental abruption and a stillbirth; the third case had pre-eclampsia at 33 weeks with markedly elevated liver enzymes. She had one litre haemoperitoneum, right lobe hepatic rupture and a stillbirth. She recovered after conservative management. Severe pre-eclampsia/eclampsia associated hepatic rupture calls for rapid and aggressive intervention with prompt multidisciplinary management to avert adverse outcomes.

Recurrent spontaneous hepatic rupture in pregnancy: A case report

RATIONALE

Spontaneous and repeated hepatic ruptures caused by hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome are uncommon but life-threatening conditions that rarely occur early in the second trimester of pregnancy.

PATIENT CONCERNS

We describe a patient who experienced spontaneous hepatic ruptures in the absence of hypertension during the early second trimesters of both her first and second pregnancies.

DIAGNOSES

A 34-year-old multiparous woman without hypertension was admitted at 21 weeks' gestation because of a spontaneous hepatic rupture with hemoperitoneum. Four years previously, the patient had undergone an exploratory laparotomy during her first pregnancy that involved the ligation of bleeders, because a hepatic capsule rupture had caused hemoperitoneum development.

INTERVENTIONS

Unlike the first pregnancy, she was managed nonsurgically and conservatively during the second pregnancy, and she underwent frequent laboratory analyses and magnetic resonance imaging follow-up. On day 11 of the patient's hospital admission, we decided to deliver the baby at 23 weeks' gestation, because her condition had deteriorated.

OUTCOMES

Non-surgical management improved the patient's outcome, and the baby was born alive, even though the pregnancy was in the early second trimester and the maternal condition was deteriorating rapidly.

LESSONS

HELLP syndrome without hypertension and the recurrence of an intrahepatic rupture at an extremely premature gestational age are rare. This patient's findings suggested HELLP syndrome, which was subsequently diagnosed. This patient's clinical course highlights the difficult decisions made by clinicians for mothers and fetuses.

Isolated Arteries Originating from the Intrahepatic Arteries: Anatomy, Function, and Importance in Intervention

Isolated hepatic arteries are defined as hepatic terminal arterioles that are not accompanied by portal venules or bile ductules and penetrate the liver parenchyma and distribute to the hepatic capsule and intrahepatic hepatic veins. Abundant communications exist between intra- and extrahepatic arteries through isolated arteries and capsular arterial plexus. They play a principal role in the development of subcapsular hemorrhage and arterial collateral formation following transcatheter arterial chemoembolization for liver cancers. The anatomy, function, and clinical importance of isolated hepatic arteries in interventional radiology, especially regarding subcapsular hemorrhage and arterial collateral formation, are highlighted in this article.

Intensive Care Unit issues in eclampsia and HELLP syndrome

Preeclampsia, eclampsia and HELLP syndrome are life-threatening hypertensive conditions and common causes of ICU admission among obstetric patients The diagnostic criteria of preeclampsia include: 1) systolic blood pressure (SBP) ≥140 mmHg or diastolic blood pressure (DBP) ≥90 mmHg on two occasions at least 4 hours apart and 2) proteinuria ≥300 mg/day in a woman with a gestational age of >20 weeks with previously normal blood pressures. Eclampsia is defined as a convulsive episode or altered level of consciousness occurring in the setting of preeclampsia, provided that there is no other cause of seizures. HELLP syndrome is a life-threatening condition frequently associated with severe preeclampsia-eclampsia and is characterized by three hallmark features of hemolysis, elevated liver enzymes and low platelets. Early diagnosis and management of preeclampsia, eclampsia and HELLP syndrome are critical with involvement of a multidisciplinary team that includes Obstetrics, Maternal Fetal Medicine and Critical Care. Expectant management may be acceptable before 34 weeks with close fetal and maternal surveillance and administration of corticosteroid therapy, parenteral magnesium sulfate and antihypertensive management. Worsening condition requires delivery. Complications that can be related to this spectrum of disease include disseminated Intravascular coagulation (DIC), acute respiratory distress syndrome, stroke, acute renal failure, hepatic dysfunction with hepatic rupture or liver hematoma and infection/sepsis.