New York University Langone Medical Center New York, NY, United States
Zoe Lawrence, MD1, Johann Hasbun, MD1, Abhinav Vij, MD1, Saikiran M. Kilaru, MD2 1New York University Langone Medical Center, New York, NY; 2New York University School of Medicine, New York, NY
Introduction: In a postpartum patient with elevated transaminases, the typical differential diagnosis includes HELLP, AFLP, and preeclampsia. When the clinical picture is not consistent with these classic pathologies, a broader differential must be investigated to evaluate for less common diagnoses. We report a rare case of aortic dissection complicated by hepatic ischemia in a postpartum patient who presented with features of preeclampsia.
Case Description/Methods: The patient is a previously healthy 30-year-old woman who presented in labor with abdominal pain and vomiting found to have hepatic ischemia and aortic dissection.
The patient initially presented at 35 weeks gestation in labor and had a normal spontaneous vaginal delivery. Her postpartum course was complicated by significant nausea, emesis, and abdominal pain with guarding and rebound tenderness, and her labs were notable for AST/ALT 706/1127 IU/L, alkaline phosphatase 180 IU/L, normal bilirubin, and INR 1.3.
On the day of delivery, a CTAP with IV contrast demonstrated ileus thought to be related to her enlarged uterus, a normal liver, and a patent, normal caliber aorta. On hospital day 2, SpO2 decreased to low 90s and she complained of persistent severe abdominal pain out of proportion to her exam, so CT angiography was obtained and demonstrated aortic dissection from the thoracic aorta to the bilateral iliac arteries with SMA thrombus causing bowel ischemia and multiple liver infarcts. She was emergently taken to the operating room for repair and bowel resection.
Discussion: In a peripartum patient with elevated transaminases, there is a relatively small range of common pathologies including AFLP, HELLP, and preeclampsia. Without hypoglycemia or encephalopathy, this patient does not meet Swansea criteria, making ALFP unlikely. Her constellation of symptoms could not be explained solely by HELLP either. The presumed diagnosis is therefore preeclampsia, but her LFT elevation and abdominal pain were more significant than would be expected for preeclampsia alone. In this situation, alternative etiologies should be investigated such as hepatic rupture related to eclampsia or vascular complications including aortic dissection. There are very few reports of aortic dissection occurring in a patient with preeclampsia, making this a rare complication but one that is frequently catastrophic and must be recognized without delay.
Figure: Figure 1: CT angiography abdomen and pelvis (A) aortic dissection with aortic thrombus (B) liver infarcts and stomach wall pneumatosis (C) ascending colon wall pneumatosis
Zoe Lawrence indicated no relevant financial relationships.
Johann Hasbun indicated no relevant financial relationships.
Abhinav Vij indicated no relevant financial relationships.
Saikiran Kilaru indicated no relevant financial relationships.
Zoe Lawrence, MD1, Johann Hasbun, MD1, Abhinav Vij, MD1, Saikiran M. Kilaru, MD2. P2889 - Preeclampsia Presenting With Acute Liver Injury and Aortic Dissection, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.