Atypical Presentation of Subcapsular Liver Hematoma With a Delayed Onset of Hemolysis, Elevated Liver Enzymes, Low Platelet Count (HELLP) Syndrome

Subcapsular liver haematoma in pregnancy, a rare and life-threatening condition, is more commonly associated with severe preeclampsia and haemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome. The common presenting symptom of subcapsular haematoma is acute-onset upper abdominal pain in patients suffering from preeclampsia; shock is the presenting feature in severe cases of rupture. Here we have discussed a case of subcapsular haematoma associated with HELLP syndrome in a patient who responded to conservative management. The diagnosis of subcapsular haematoma was delayed as the clinical presentation was atypical. A 30-year-old primigravida with an apparently uncomplicated pregnancy attended with sudden onset acute abdominal pain in Croydon University Hospital, London, UK. Due to associated cardiotocography (CTG) concerns, the initial diagnosis was placental abruption. An urgent caesarean section was performed, and a spontaneous hemoperitoneum of 500 ml was found during the surgery. Following the caesarean section, the blood pressure started to rise. Subsequently, the blood picture deteriorated to full-blown HELLP syndrome, and the pain worsened. Further imaging revealed a large subcapsular haematoma of the liver. The patient was managed conservatively in the intensive therapy unit (ITU) by a multidisciplinary team including intensivists, an upper gastrointestinal surgeon, and an obstetric team. She responded to conservative management and had an uneventful recovery. A high index of suspicion in cases of severe pain in the abdomen during pregnancy can help in early diagnosis. Moreover, further exploration in the case of spontaneous hemoperitoneum during caesarean section should be considered to avoid delay in diagnosis. Prompt intervention by the pertinent teams is the key to successful treatment.