A Rare Hemorrhagic Complication in Hypertensive Pregnancy: Epistaxis in a Case of Preeclampsia with HELLP Syndrome

Background: Epistaxis is a rare but potentially dangerous side effect of pregnancy - related hypertension diseases. While mucosal congestion due to hormonal changes may contribute to minor nasal bleeding during pregnancy, spontaneous and refractory epistaxis, especially in association with preeclampsia and HELLP syndrome, is rare and underreported. Case: We have reported an incident of a 31 year primigravida at 33+3 weeks of gestation with chronic hypertension on labetalol and nicardipine, who presented with preeclampsia and HELLP syndrome. Labour induction was initiated with prostaglandin E2 following multidisciplinary clearance. During the latent phase, the patient experienced a sudden rise in blood pressure (170/110 mmHg) and developed spontaneous, persistent epistaxis. Initial measures, including escalation of antihypertensives, magnesium sulfate (Zuspan regimen), and ENT interventions (Trotter?s method, tranexamic acid), failed to control the bleeding. An emergency lower - segment cesarean section was carried out under general anesthesia due to fetal discomfort. Significant intraoperative and postoperative bleeding necessitated transfusion of platelets, packed cells, and fresh frozen plasma. Persistent uncontrolled hypertension (BP up to 200/100 mmHg) leading to nasal/oral bleeding required anterior and posterior nasal packing under general anesthesia. The patient was managed in the ICU with antihypertensive infusions and magnesium sulfate. Bleeding resolved after 48 hours, allowing gradual weaning from ventilatory and inotropic support. The patient was stabilized and discharged on dual oral antihypertensives. Conclusion: This case highlights epistaxis as a rare yet significant hemorrhagic manifestation in preeclampsia with HELLP syndrome. Prompt recognition, aggressive blood pressure control, ENT intervention, and a multidisciplinary approach are essential for optimal maternal outcomes.