Subcapsular liver haematoma: a rare complication of HELLP syndrome

Clinical History

A 34-year-old woman, gravid 2, parity 1, was admitted at 34 weeks of gestation. She complained of epigastric pain and headache.
The blood pressure measured 170/100 mmHg, the laboratory analysis revealed a hepatic dysfunction, haemolysis (ALAT: 280UI/l, Hb: 8.3mg/dl) and thrombocytopenia (platelet count: 43.000/mm3) consistent with HELLP.

Imaging Findings

Transabdominal ultrasound showed a hypoechoic, subcapsular and lentiform mass paralleling the right hepatic lobe.
A computed abdominal tomography (CT) examination was performed, and revealed a large well-circumscribed subcapsular liver haematoma in the right hepatic measuring 160x80x60mm (Fig. 2).
An emergency caesarean section was performed; a 2.4 kg male was born with Apgar score 7 at 5 min, and the supcapsular liver haematoma was confirmed (Fig. 3).
Following delivery, the patient’s clinical condition and laboratory was improved at the 10th postpartum day.
An enhanced CT of the liver 15 days postpartum showed a discrete regression of the subcapsular haematoma of the liver (Fig. 4).

Discussion

Subcapsular liver haematoma (SLH) is a rare complication of HELLP syndrome which increases the rate of both maternal and perinatal morbidity and mortality. It occurs in about 1-2% of all preeclampsia cases and HELLP syndrome, and the incidence is about 1/67000 deliveries [1]

The pathogenesis is not completely understood. It has been reported that preeclamptic syndrome induces fibrin deposition, hypovolaemia, hepatic ischaemia, and infarction causing haemorrhage [2].

The symptoms of SLH may include epigastric pain, right upper quadrant or shoulder pain, nausea and vomiting.

SLH may result in hepatic rupture and may cause life threatening problems, such as disseminated intravascular coagulation [3].

The strict criteria for HELLP syndrome are: haemolysis, elevated liver enzymes (serum ALT >70UI/l, serum bilirubin >1.2mg/ml, serum LDH >600UI/l), and low platelets (<100000/ml) [4].

Accurate diagnosis may not be possible on the basis of clinical presentations and laboratory evaluation alone.

Ultrasonography can be used as a screening tool and has a major advantage in haemodynamically unstable patients. However, CT of the liver appears to be the imaging modality of choice in the differential diagnosis of SLH, because it is more available and faster than MRI.

In patients presenting with a viable pregnancy, MRI has the additional advantage of avoid the radiation exposure of CT [5].

The ultrasonographic appearance of SLH is a crescent-shaped collection of echogenic fluid well-circumscribed by the liver capsule. Over time, the haematoma becomes more hypoechoic and cystic. In the case of hepatic capsular rupture, the echogenic matter will extend into the subphrenic and perihepatic spaces.
The CT configuration of a SLH is similar to the sonographic appearance, it typically looks like a lenticular, ellipsoid, perihepatic collection. The density depends on the age of the haematoma. If acute blood is present, the collection would be hyperdense relative to normal liver parenchyma on non-contrast-enhanced or contrast-enhanced scans. Over time, the collection would progressively become hypodense [6-7].

The follow-up with serial CT, MRI, or sonography in patients with subcapsular haematoma of the liver until the defect resolves is recommended [8].

Regardless of which imaging modality is used to detect SLH, rapid diagnosis and treatment are essential to patient survival. In the proper clinical setting, it is important for the radiologist to be aware of the HELLP syndrome, their possible severe complications, and the appearance of the haematomas on imaging.

Differential Diagnosis List

Final Diagnosis

Subcapsular liver haematoma (complication of HELLP syndrome)

URL:	https://eurorad.org/case/13478
DOI:	10.1594/EURORAD/CASE.13478
ISSN:	1563-4086