Tower Health System West Reading, PA, United States
Oluwaseun Shogbesan, MD, MPH1, Anish Paudel, MBBS, MD2, Andrew Lee, MD1, Philip Elbaum, DO3, John Altomare, MD3 1Tower Health System, West Reading, PA; 2Reading Hospital, Tower Health, Wyomissing, PA; 3Digestive Disease Associates, Wyomissing, PA
Introduction: Elevated liver enzymes are a component of the HELLP syndrome that complicates less than 1% of pregnancies. Lactate dehydrogenase with mild aminotransferases elevation and indirect hyperbilirubinemia are typical. Hepatic infarction is a rare complication of HELLP syndrome and results in a markedly abnormal liver test.
Case Description/Methods: A 19-year-old female presented at 34 weeks gestation with intermittent RUQ pain, headache, worsening leg swelling over two weeks. She was hypertensive with proteinuria, diagnosed with severe preeclampsia, and underwent an emergent cesarean section. Laboratory testing revealed elevated aminotransferases with AST of 487 IU/L (Normal 13-39 IU/L), ALT of 426 IU/L (Normal 7-52 IU/L) with normal bilirubin, alkaline phosphatase and INR. She denied any acetaminophen, alcohol, illicit intravenous drug use or family history of liver disease or clotting disorder.
Physical examination was remarkable for the absence of jaundice, encephalopathy or asterixis. Abdomen was post-partum and otherwise unremarkable.
Right upper quadrant ultrasound on the day of delivery showed extensive hepatic steatosis without discrete mass or hematoma. CT abdomen with contrast done a day after delivery showed multifocal hepatic infarctions without subcapsular hematoma with a small splenic infarction. Doppler US showed patent hepatic veins.
Over the next 48 hours post-delivery, AST trended up to 4367 IU/L, ALT peaked at 1903 IU/L with indirect bilirubinemia. LDH and uric acid also trended up and peaked at 5362 IU/L (Normal 140-271 IU/L) and 8.4 mg/dl (Normal 2.3-6.6 mg/dl) respectively. Haptoglobin remained persistently low. There was associated leukocytosis with progressive thrombocytopenia (153000/µl to 43000/µl) and anemia (11.5 g/dl to 8.3 g/dl) over 48 hours. Fibrinogen and fibrin split products were both elevated with INR peaking at 1.6. Peripheral blood smear showed 2+ schistocytes. Extensive viral and autoimmune hepatitis panel were negative.
Complete blood count and liver function test stabilized after 48 hours and improved daily until discharge.
Discussion: Hepatic complications of HELLP include subcapsular hematoma with or without rupture and liver infarction. Hepatic infarction is uncommon due to dual blood supply and should be suspected with right upper quadrant pain and markedly elevated aminotransferases in a patient with severe preeclampsia and HELLP. Diagnosis is confirmed by computerized tomography scan and management is supportive with emergent delivery.
Figure: Computerized tomography scan of the abdomen showing multifocal hepatic infarction
Oluwaseun Shogbesan indicated no relevant financial relationships.
Anish Paudel indicated no relevant financial relationships.
Andrew Lee indicated no relevant financial relationships.
Philip Elbaum indicated no relevant financial relationships.
John Altomare indicated no relevant financial relationships.
Oluwaseun Shogbesan, MD, MPH1, Anish Paudel, MBBS, MD2, Andrew Lee, MD1, Philip Elbaum, DO3, John Altomare, MD3. P1831 - HELLP With Hepatic Infarcts, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.