Introduction: HELLP syndrome (hemolysis, elevated Liver enzymes, low platelets) is a life threatening complication of pregnancy that carries a 1% mortality. Hepatic subcapsular hemorrhage and rupture is a rare and often fatal complication of HELLP syndrome.Case: A 23 year-old pregnant woman at 33 weeks gestational age was admitted with symptoms of pre-eclampsia and underwent emergent cesarean section. She developed hemorrhagic shock and abdominal ultrasound revealed intra-abdominal free fluid and perihepatic hematoma. CT angiogram did not reveal active bleeding. She was aggressively managed with fluids, vasopressors and blood product replacement. Subsequently, she developed acute renal failure and Klebsiella pneumonia bacteremia and septic shock. Patient expired on day 15 of hospitalization.Discussion: The incidence of hepatic rupture is approximately 1 : 45,000 to 1 : 225,000 deliveries. Risk factors include older age, multigravida and pre-eclampsia. Patients without active bleeding can be managed with close hemodynamic monitoring and blood product transfusion. The mortality associated with liver rupture is 10–30%.Conclusion: Hepatic rupture is a potentially fatal complication of HELLP syndrome. Right upper quadrant pain with hypotension in a patient with HELLP syndrome should alert the physician to this condition. Introduction Liver disorders complicate up to 3% of all pregnancies and the spectrum of disease varies from mild to gross derangements. HELLP syndrome is a life threatening complication of pre-eclampsia with a mortality rate of 1%. It is characterized by hemolysis, elevated liver enzymes and low platelet counts. Other manifestations of HELLP syndrome include: disseminated intravascular coagulation (DIC) in 21%, acute renal failure in 7.7%,pulmonary edema in 6% and subcapsular liver hematoma in 0.9% of cases. [1]. Spontaneous hepatic rupture was first described by Abercrombie in 1844, it is a rare event with an incidence of 1:45,000 to 1:225,000 deliveries. The incidence of spontaneous hepatic rupture with self-contained hematomas is unknown [2]. This large variation in incidence could reflect under-reporting of the condition and failure to recognize the milder cases with self-contained hematomas. The maternal mortality is as high as 60% with a fetal mortality of 56 to 75% [2]. A systematic literature review published by Haram et.al. found that hepatic rupture had an incidence of 1% to <2% in patients with HELLP syndrome[3]. We present a pregnant patient with severe HELLP and hepatic rupture . Case A 23 year-old woman with medical history of intermittent asthma and ectopic pregnancy was admitted with headache, abdominal pain and vomiting of two days duration. She was at 33 weeks gestational age; gravida 3, para 0, abortions 2;antenatal care was done at Dominican Republic and was reported to be uneventful. She did not take medications and she denied any toxic habits.Her examination at the time of presentation was remarkable for elevated blood pressure (150/95 mmHg), mild lower abdominal tenderness and trace pedal edema. Fetal exam revealed a 32 week 3 day-old fetus in cephalic position with anterior placenta, bio- physical profile of 8/8, amniotic fluid index (AFI) of 7 cm and estimated fetal weight of 1919g. Urine dipstick was strongly positive for proteins. She was admitted to the labor and delivery unit with a diagnosis of pre-eclampsia, started on magnesium, steroids and labetalol. Laboratory (labs) results on admission are shown in table 1. During the next two days she continued to have intermittent abdominal pain and headaches. A cesarean section was performed 68 hours after admission. In the recovery room, the patient was noted to be hypotensive, tachycardic and anuric. Repeat labs (Table 1) revealed new onset thrombocytopenia and worsening liver function. She had worsening right upper quadrant pain and on examination the surgical site was clean with a tender right upper quadrant. Bedside ultrasound showed pos
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