HELLP SYNDROME AND ITS COMPLICATIONS: A CASE REPORT OF A GIANT SUBCAPSULAR HEPATIC HEMATOMA

Abstract

Introduction: Subcapsular hepatic hematoma is a rare but life-threatening complication of hypertensive disorders of pregnancy, particularly severe preeclampsia and HELLP syndrome. (Saad et al., 2025)  Although uncommon, it is associated with significant maternal and perinatal morbidity and mortality, especially in cases of delayed diagnosis or hepatic rupture. The underlying pathophysiology involves systemic endothelial dysfunction secondary to abnormal placentation, leading to an antiangiogenic state, hepatic microangiopathy, ischemia, and progressive subcapsular hemorrhage. (Kang et al., 2025)  Case Presentation: We report the case of a 39-year-old woman with a pregnancy conceived via in vitro fertilization who developed preeclampsia with severe features, stage I fetal growth restriction, and incomplete HELLP syndrome. In the immediate postpartum period, she presented with severe right upper quadrant pain radiating to the shoulder and progressive elevation of liver enzymes. Abdominal computed tomography revealed a giant right-lobe subcapsular hepatic hematoma measuring approximately 20 cm in maximal diameter, without evidence of active arterial bleeding on CT angiography. Given hemodynamic stability, a conservative management strategy in the intensive care unit was chosen, including close monitoring and multidisciplinary support. Her course was complicated by transient hematological, metabolic, and respiratory dysfunctions, all managed medically. Serial imaging demonstrated gradual resolution, with complete radiological resolution at six weeks postpartum. Discussion: The lesion was consistent with a grade III hepatic injury according to the American Association for the Surgery of Trauma (AAST) classification, reflecting involvement of more than 50% of the hepatic surface. (Gupta et al., 2021) Clinical presentation is often nonspecific, making early recognition challenging. Computed tomography remains the diagnostic gold standard for assessing extent and ruling out active bleeding, while ultrasound may underestimate lesion severity. (Moore et al., 2018) Management depends primarily on hemodynamic status; in stable patients without rupture, conservative management in an intensive care setting with hemodynamic optimization, correction of coagulopathy, and serial imaging is considered safe and effective. (Chahine et al., 2025)  Surgical or endovascular interventions, including hepatic artery embolization or abdominal packing, are reserved for cases of rupture or hemodynamic instability. (Augustin et al., 2022) Conclusion: Subcapsular hepatic hematoma associated with HELLP syndrome represents a rare but catastrophic obstetric emergency. Early diagnosis and individualized management are essential to improve outcomes. This case supports that even giant hepatic hematomas can be successfully managed conservatively in carefully selected hemodynamically stable patients, with favorable maternal outcomes.