P0850 - Severe Acute Liver Injury From Post-Partum HELLP Syndrome/Acute Fatty Liver of Pregnancy Overlap Improved With Plasmapheresis

Mujtaba Mohamed, MD¹, Wesam Frandah, MD², mai Thanda Han, MD^1
1Rutgers New Jersey Medical School, Newark, NJ; ²Marshall University Joan C. Edwards School of Medicine, Huntington, WV

Introduction: HELLP syndrome and acute fatty liver of pregnancy are rare third trimester complications of pregnancy. Despite being rare they can be fatal.

Case Description/Methods: 31year old Caucasian woman gravida 4Para2+2 abortions, with PMH of gestational DM during this pregnancy, who presented to hospital with labor. The previous pregnancies were normal without complications. The patient had a normal vaginal delivery on the day of admission. Her baseline labs at the time of admission shown in Table 1. Immediately post-partum, the patient had elevated BP to 190/110, with RUQ pain without seizure, asterixis, confusion or blurry vision. She was treated with IV magnesium and BP was controlled with Nifedipine and labetalol. She started to have bleeding from the IV lines. Her liver enzymes were found to be significantly increasing (Table1). As well, she also had myoglobinuria, low haptoglobin, few schistocytes on peripheral blood smear, ADAMTS13 was 64.5% ( >66.8%). She also developed acute kidney injury, elevated lipase suggesting pancreatitis, elevated ammonia and elevated uric acid. Abdominal CT scan of abdomen showed hepatomegaly with small amount of ascites without subcapsular hematoma, and hepatic vasculature was patent. She was diagnosed with HELLP syndrome however, she as well met Swansea criteria to support acute fatty liver of pregnancy. Given worsening of liver function and coagulopathy, patient was emergently listed for liver transplantation. She was then started on plasmapheresis on post-partum day three for six sessions. Fortunately, her liver enzymes continued to improve 48 hours later without requirement for liver transplantation.

Discussion: HELLP syndrome was first described in 1982 by Weinstein et al. It refers to an acronym used to describe the clinical condition that leads to hemolysis, elevated liver enzymes and low platelets. Incidence is about 0.6%. It usually occurs between 28 and 37 weeks of pregnancy. Almost 20-30% of cases occur after delivery. Ten to 20% of patients with severe preeclampsia develop HELLP syndrome. Clinically can present with non-specific symptoms such as headache, nausea, RUQ pain, and blurred vision. Pathophysiology remains unclear. Diagnosis is clinical using Tennessee or Mississippi criteria. This case has an overlap with acute fatty liver of pregnancy in coagulopathy, DIC, significantly elevated aminotransferases, and direct bilirubinemia. Treatment is to control BP, IV magnesium, induction of delivery. Plasmapheresis can be used in severe cases.



Disclosures:


Mujtaba Mohamed, MD¹, Wesam Frandah, MD², mai Thanda Han, MD¹. P0850 - Severe Acute Liver Injury From Post-Partum HELLP Syndrome/Acute Fatty Liver of Pregnancy Overlap Improved With Plasmapheresis, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.