New York University Langone Medical Center New York, New York
Introduction: Pregnant patients with antiphospholipid syndrome (APLS) are at risk for thromboembolic complications. They are more likely to present with hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome. Hepatic infarction is a rare complication which can lead to hepatic rupture, fulminant liver failure and death. We present a case of a pregnant patient with known history of APS who presented with HELLP and a large liver infarction despite treatment with anticoagulation.
Case Description/Methods: A 36-year-old pregnant female with history of pulmonary embolism, prothrombin gene mutation and APLS, presented to an outside hospital with right upper quadrant pain. Labs showed AST 255, ALT 274 and platelets 116. Labs also showed evidence of hemolytic anemia. Her medications included enoxaparin and aspirin. Due to concern for HELLP syndrome she underwent an emergent cesarean section. Post-delivery her labs worsened with AST 2712, ALT 2783, and platelets 43. Abdominal CT showed a large ill-defined hypodensity within segment 3 of the liver concerning for hepatic infarcts. She was treated with plasmapheresis and methylprednisolone. Given concern for impending acute liver failure she was transferred to a liver transplant center. After transfer, MRI abdomen confirmed a large infarction of the liver which involved the entirety of segments 6 and 7, as well as adjacent portions of segments 5 and 8 (Figure 1). The hepatic and portal veins appeared normal. She was observed in the ICU and over several days her abdominal pain and labs improved, with repeat showing AST 577, ALT 975 and platelets 51. Additional workup including viral hepatitis panels were normal. She was continued on enoxaparin and transitioned to warfarin for long term anticoagulation. Her hepatic panel 1 month later showed AST 39, ALT 29.
Discussion: Hepatic infarction is a rare complication of APS due to the dual blood supply of the liver. 93% of reported cases of hepatic infarction in pregnant women with APS were associated with HELLP syndrome. Even when patients are on anticoagulation it is important to consider hepatic infarction as a complication in patients with APS and HELLP who presents with abdominal pain, worsening lab values and hepatic failure. Multidisciplinary care with maternal-fetal medicine, hematology, and hepatology, and transfer to a transplant center should be considered given the high morbidity associated with this condition.
