Multiple intraplacental hematomas preceding clinical deterioration in preeclampsia with severe features: A case report

Preeclampsia (PEC) spectrum disorders, including HELLP syndrome, are significant causes of maternal morbidity and mortality, affecting 2%-8% of pregnancies. While clinical signs and symptoms are pathognomonic, imaging can play a crucial role in diagnosis. We present a case of a 25-year-old primigravida at 27 weeks 4 days gestation who presented with severe upper abdominal pain and mild hypertension without other initial signs of PEC. Initial evaluation revealed early-onset fetal growth restriction with elevated umbilical artery Doppler ratios. Due to uncontrolled pain despite multimodal management, MRI was performed, revealing multiple T2 hypointense, T1 hyperintense lesions with diffusion restriction, suggesting multifocal intraplacental hematomas or villous infarcts. These findings prompted increased fetal surveillance and closer monitoring for PEC progression. Subsequently, the patient developed laboratory abnormalities consistent with PEC with severe features, including thrombocytopenia and elevated liver enzymes. Following antenatal corticosteroids and magnesium prophylaxis, she underwent urgent cesarean delivery at 28 weeks due to concerning fetal status. Histopathologic analysis confirmed features of maternal vascular malperfusion with multiple infarcts. The patient's laboratory values normalized postpartum, and she was normotensive at 6-week follow-up. This case highlights the potential role of MRI in identifying placental pathology that may precede clinical manifestations of PEC spectrum disorders, potentially allowing for earlier intervention and improved outcomes.