P058: CESAREAN DELIVERY AND PERIOPERATIVE MANAGEMENT FOR RUPTURED HEPATIC CAPSULE: A RARE COMPLICATION OF HELLP SYNDROME
Kevin P Dazen, MD; Camila M Funatsu, MD; Andres F Ocampo-Salazar, MD
Jackson Memorial Hospital/University of Miami Health System
Introduction/Background: Preeclampsia is a hypertensive disorder of pregnancy that involves placental dysfunction and release of antiangiogenic factors. Preeclampsia is considered severe if certain criteria are met and necessitates delivery by 34 week per American College of Obstetricians and Gynecologists (ACOG) guidelines. Hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome is a potentially severe feature of preeclampsia but may be a separate etiology that involves hepatic inflammation and coagulation cascade activation. Delivery is recommended immediately. In 1% of patients who develop HELLP syndrome subcapsular liver hematomas may form and rupture with life threatening consequences.
Case Presentation (Methods/Results): The patient is a 33-year-old Gravida 3 Para 2 who presented at 28.4 weeks pregnant and found to have preeclampsia with severe features (PEC w/ SF) diagnosed by severe-range blood pressures. No past medical history and past obstetric history included 1 full term vaginal delivery and 1 full term cesarian section (CS) due to failed induction of labor.
She received expected management for PEC w/ SF. Labs remained unremarkable and biophysical profile was normal.
At 31.5 weeks vague right upper quadrant pain developed, and labs showed a mild increase in liver enzymes. 24 hours later the RUQ pain was now severe with complaints of blurry vision. Labs were refused. The decision was made for CS but the patient refused. Mental status rapidly deteriorated and fetal heart tracing showed bradycardia. Stat CS was called for worsening maternal condition and fetal distress.
General anesthesia was induced with ketamine and succinylcholine. Intubation with video laryngoscopy and incision were made in rapid succession. Hemoperitoneum was drained and radial pulses were no longer palpable. Advanced cardiopulmonary life support was initiated and return of spontaneous circulation was achieved after 2 rounds of CPR. Echocardiography showed a hyperdynamic left ventricle with obliteration of systolic cavity. Lacerations to the liver capsule were noted and general surgery was consulted. Labs showed significantly elevated liver enzymes, thrombocytopenia, profound anemia, and severe coagulopathy. Resuscitation continued with blood products and crystalloids. The abdomen was left open and patient transported to the ICU intubated. The fetus was delivered without neonatal complications.
Recovery was complicated by liver dysfunction, coagulopathy, and reintubation for hypoxic respiratory failure secondary to pneumonia. The patient was discharged from the hospital after 2 weeks. The neonate spent 2 weeks in the NICU for monitoring with no significant complications.
Discussion/Conclusion: Preeclampsia confers risks on both mother and baby and should be identified. Patients at high risk of developing preeclampsia are started on aspirin. Screening is based on medical history, but some organizations advocate the use of biomarkers. HELLP syndrome develops in some patients regardless of preeclampsia diagnosis. Abdominal pain is multifactorial in pregnancy and MRI can be helpful but if HELLP syndrome is suspected delivery should not be delayed. There is currently no therapy that reduces the risk of HELLP syndrome but eculizumab, a compliment inhibitor, has shown clinical improvement when given early. After delivery patients are still at risk for complications from preeclampsia and HELLP syndrome and should be monitored.