Conservative Management of Postpartum HELLP Syndrome and Intraparenchymal Liver Hematoma; A Case Report

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Abstract

The HELLP syndrome is an important variant of pre-eclampsia which is known by triad of hemolysis (H), elevated liver enzymes (EL) and low platelet count (LP). Intraparenchymal liver hematoma is a rare and important complication of HELLP syndrome which is a life threatening condition. The incidence of intraparenchymal hematoma of the liver has been reported to vary from 1 in each 40,000 to 250,000 deliveries worldwide. Herein we report a case of intraparenchymal liver hematoma following HELLP syndrome. An 18 year- old woman with moderate to severe preeclampsia after delivery, presented with Right upper quadrant (RUQ) pain and tachycardia and significant drop in hemoglobin level. Ultrasonography revealed intraparenchymal liver hematoma. This finding was also confirmed by computerized tomography (CT)-scan. Conservative treatment was applied and the patient improved without need of any surgical intervention. Spontaneous hepatic hematoma should always be considered as a life threatening and important complication of HELLP syndrome during pregnancy and it can be managed conservatively in a hemodynamically stable patient.

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The HELLP syndrome: Clinical issues and management. A Review

Kjell Haram, Einar Svendsen, Ulrich Abildgaard (2009)

Background The HELLP syndrome is a serious complication in pregnancy characterized by haemolysis, elevated liver enzymes and low platelet count occurring in 0.5 to 0.9% of all pregnancies and in 10–20% of cases with severe preeclampsia. The present review highlights occurrence, diagnosis, complications, surveillance, corticosteroid treatment, mode of delivery and risk of recurrence. Methods Clinical reports and reviews published between 2000 and 2008 were screened using Pub Med and Cochrane databases. Results and conclusion About 70% of the cases develop before delivery, the majority between the 27th and 37th gestational weeks; the remainder within 48 hours after delivery. The HELLP syndrome may be complete or incomplete. In the Tennessee Classification System diagnostic criteria for HELLP are haemolysis with increased LDH (> 600 U/L), AST (≥ 70 U/L), and platelets < 100·109/L. The Mississippi Triple-class HELLP System further classifies the disorder by the nadir platelet counts. The syndrome is a progressive condition and serious complications are frequent. Conservative treatment (≥ 48 hours) is controversial but may be considered in selected cases < 34 weeks' gestation. Delivery is indicated if the HELLP syndrome occurs after the 34th gestational week or the foetal and/or maternal conditions deteriorate. Vaginal delivery is preferable. If the cervix is unfavourable, it is reasonable to induce cervical ripening and then labour. In gestational ages between 24 and 34 weeks most authors prefer a single course of corticosteroid therapy for foetal lung maturation, either 2 doses of 12 mg betamethasone 24 hours apart or 6 mg or dexamethasone 12 hours apart before delivery. Standard corticosteroid treatment is, however, of uncertain clinical value in the maternal HELLP syndrome. High-dose treatment and repeated doses should be avoided for fear of long-term adverse effects on the foetal brain. Before 34 weeks' gestation, delivery should be performed if the maternal condition worsens or signs of intrauterine foetal distress occur. Blood pressure should be kept below 155/105 mmHg. Close surveillance of the mother should be continued for at least 48 hours after delivery.

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Liver disease in pregnancy.

Michael J. M. Hay (2008)

Abnormal liver tests occur in 3%-5% of pregnancies, with many potential causes, including coincidental liver disease (most commonly viral hepatitis or gallstones) and underlying chronic liver disease. However, most liver dysfunction in pregnancy is pregnancy-related and caused by 1 of the 5 liver diseases unique to the pregnant state: these fall into 2 main categories depending on their association with or without preeclampsia. The preeclampsia-associated liver diseases are preeclampsia itself, the hemolysis (H), elevated liver tests (EL), and low platelet count (LP) (HELLP) syndrome, and acute fatty liver of pregnancy. Hyperemesis gravidarum and intrahepatic cholestasis of pregnancy have no relationship to preeclampsia. Although still enigmatic, there have been recent interesting advances in understanding of these unique pregnancy-related liver diseases. Hyperemesis gravidarum is intractable, dehydrating vomiting in the first trimester of pregnancy; 50% of patients with this condition have liver dysfunction. Intrahepatic cholestasis of pregnancy is pruritus and elevated bile acids in the second half of pregnancy, accompanied by high levels of aminotransferases and mild jaundice. Maternal management is symptomatic with ursodeoxycholic acid; for the fetus, however, this is a high-risk pregnancy requiring close fetal monitoring and early delivery. Severe preeclampsia itself is the commonest cause of hepatic tenderness and liver dysfunction in pregnancy, and 2%-12% of cases are further complicated by hemolysis (H), elevated liver tests (EL), and low platelet count (LP)-the HELLP syndrome. Immediate delivery is the only definitive therapy, but many maternal complications can occur, including abruptio placentae, renal failure, subcapsular hematomas, and hepatic rupture. Acute fatty liver of pregnancy is a sudden catastrophic illness occurring almost exclusively in the third trimester; microvesicular fatty infiltration of hepatocytes causes acute liver failure with coagulopathy and encephalopathy. Early diagnosis and immediate delivery are essential for maternal and fetal survival.

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Characteristics and treatment of hepatic rupture caused by HELLP syndrome.

Isabel M F Pereira, Patricia C F M Bezerra, Carolina Araújo … (2006)

The purpose of this study was to review the management of hepatic rupture caused by HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome and to assess maternal and perinatal outcomes of these cases. A retrospective study of HELLP syndrome cases that were complicated by hepatic rupture was conducted. Ten cases of hepatic rupture were identified. The median maternal age was 42.5 +/- 5.9 years (median +/- SD), and the median gestational age at delivery was 35.5 +/- 4.9 weeks. The most frequent signs and symptoms of hepatic rupture were the sudden onset of abdominal pain, acute anemia, and hypotension. Laboratory findings included low platelet count and increased hepatic enzymes. Surgery was performed in 9 cases. One case was treated nonsurgically. The maternal mortality rate was 10%, and the perinatal mortality rate was 80%. A combination of surgical treatment with hepatic artery ligation and omental patching with supportive measures was effective in decreasing the mortality rate in hepatic rupture caused by HELLP syndrome.

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Author and article information

Journal

Journal ID (nlm-ta): Bull Emerg Trauma

Journal ID (iso-abbrev): Bull Emerg Trauma

Journal ID (publisher-id): BEAT

Title: Bulletin of Emergency & Trauma

Publisher: Shiraz University of Medical Sciences (Shiraz, Iran )

ISSN (Print): 2322-2522

ISSN (Electronic): 2322-3960

Publication date (Print): April 2019

Volume: 7

Issue: 2

Pages: 196-198

Affiliations

[1 ] Department of Surgery, School of Medicine, Hamedan University of Medical Sciences, Hamedan, Iran

Author notes

[* ]Corresponding Author: Hamid Reza Makarchian, Address: Department of Surgery, School of Medicine, Hamedan University of Medical Sciences, Hamedan, Iran. Tel: +98-81-32640020, Fax: +98-81-32640020, e-mail: hr.makarchian@umsha.ac.ir

Article

DOI: 10.29252/beat-070218

PMC ID: 6555212

PubMed ID: 31198812

SO-VID: 2406b30b-9260-4c09-987b-0281aedbc140

License:

This is an Open Access article distributed under the terms of the Creative Commons Attribution License, ( http://creativecommons.org/licenses/by/3.0/) which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

History

Date received : 10 September 2018

Date revision received : 13 October 2018

Date accepted : 27 October 2018

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Conservative Management of Postpartum HELLP Syndrome and Intraparenchymal Liver Hematoma; A Case Report

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Karger: Oncology

Most cited references 16

The HELLP syndrome: Clinical issues and management. A Review

Liver disease in pregnancy.

Characteristics and treatment of hepatic rupture caused by HELLP syndrome.

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