2023 FSA Podium and Poster Abstracts

P039: CONSERVATIVE MANAGEMENT OF AN UNCOMMON CASE OF HELLP SYNDROME COMPLICATED BY LIVER HEMATOMA CAUSING GASTRIC OUTLET OBSTRUCTION
Miguel E Perez-Viloria, MD; Charles Caltagirone, MD; Carolina De La Cuesta, MD; Mount Sinai Medical Center

Introduction: HELLP syndrome, characterized by hemolysis, elevated liver enzymes and low platelets, is a multisystemic disorder with an incidence of up to 0.9% in all pregnancies and occurs in about 25% of pre-eclamptic patients. It can lead to life-threatening complications for both the mother and the fetus.

Subcapsular liver hematoma is a rare complication of HELLP syndrome, occurring in <2% of patients. The pathogenesis of hepatic hematoma formation is complex and not well understood.

Gastric outlet obstruction (GOO) is a clinical syndrome characterized by epigastric abdominal pain and postprandial vomiting due to mechanical obstruction.

In this case report, we present a unique and rare case of a pregnant patient who developed HELLP syndrome complicated by a subcapsular hematoma that caused gastric outlet obstruction.

Case Description: 37yo G3P1, at 34 weeks 5 days of pregnancy complicated by pregnancy induced hypertension, gestational diabetes, and a short cervix requiring cerclage during the current pregnancy, who was admitted to the L&D floor for induction of labor due to presentation of HELLP syndrome (SBP of 160mmHg, elevated liver enzymes (AST/ALT 574/1004) and platelets of 42 10^3/uL). Patient was started on magnesium for seizure prevention along with betamethasone for fetal lung maturity. The patient delivered the following day via normal spontaneous vaginal delivery.

In the postpartum period, the patient endorsed RUQ abdominal pain, increasing abdominal distention, and decreased tolerance to oral intake. She then became hypotensive and a drop in her hemoglobin from 12.9 g/dL to 10g/dL was noted. A RUQ US showed a subcapsular fluid collection (Fig. 1) and a CT abdomen and pelvis (CTAP) confirmed a large subcapsular hematoma with active extravasation and mass effect on multiple organs, specifically the pylorus causing a gastric outlet obstruction (Fig. 2). A nasogastric tube was placed, the patient was transferred to the SICU, and interventional radiology was consulted for embolization of the suspected bleeding vessel.

Patient then underwent successful embolization of 2 small vessels in liver segments 7 and 8, as well as bilateral embolization of uterine arteries. Over the next few days, she continued to require PRBC transfusions for Hb levels as low as 6.4g/dL.

With conservative management of NPO and NGT, her abdominal pain began to improve and on post-embolization day 6, the patient’s LFT began to downtrend AST/ALT 266/888. She was still unable to tolerate oral intake and was started on TPN. On day 9, repeat CTAP showed interval decrease in size of perihepatic hematoma with no mass effect on the pylorus. LFT’s downtrend (AST/ALT 72/97) and platelets normalized (238 10^3/uL). The patient was started on and tolerated a clear liquid diet and was progressively advanced to solid food; ultimately being discharged home.

Conclusion: This case report will provide insight into the management of HELLP syndrome complicated by a subcapsular hematoma and gastric outlet obstruction, a situation that is poorly described in the medical literature.