Imaging negative subcapsular liver hematoma in parturients with HELLP syndrome: a report of two cases

Abstract

Introduction and importance:

We report two cases of parturients with HELLP syndrome who were diagnosed with subcapsular liver hemorrhage (SLH) during an emergency cesarean section.

Case presentation:

In case 1, a 30-year-old woman who was pregnant at 34+ weeks was admitted because of fetal heart rate deceleration. On the third day of hospitalization, the patient experienced upper abdominal pain. Considering the diagnosis of HELLP syndrome, an emergency cesarean section was performed under general anesthesia. Multiple SLH sites were discovered during laparoscopic exploration, but no intervention was performed. After surgery, the patient’s platelet count, transaminase levels, and other indicators gradually returned to nearly normal levels. In case 2, a 30-year-old woman was admitted to the hospital at 34 + 1 weeks of pregnancy with elevated blood pressure for 1 week and thoracodorsal pain for 1 day. An emergency cesarean section was performed under general anesthesia. We performed laparoscopic exploration and identified SLH in the right liver near the diaphragm without obvious active bleeding. No further interventions were performed. The patient recovered well after surgery and was discharged on the fifth day after surgery.

Clinical discussion:

Our report suggests that thoracodorsal pain may be an early symptom of SLH, and the incidence of SLH may be underestimated. Even with negative imaging results, SLH cannot be ruled out, and clinicians need to pay sufficient attention to actively prevent and treat it.

Conclusions:

Even if the ultrasound examination is negative, SLH cannot be completely excluded, and conservative treatment is advisable under specific circumstances.

Keywords:

preeclampsia, HELLP syndrome, pregnancy, cesarean section, liver

Background

Gestational hypertension is a common obstetric disease, and preeclampsia and severe preeclampsia (SPE) require special attention. It has been estimated that preeclampsia complicates 2–8% of all pregnancies globally, leading to over 25% of maternal deaths in some regions^[1^]. Among pregnancies with preeclampsia, 10–20% are complicated by hemolysis, elevated liver enzymes, and low platelet (HELLP) syndrome, and approximately 2% develop subcapsular liver hematoma (SLH), a rare but life-threatening complication^[2^]. As the symptoms are atypical, misdiagnoses and missed diagnoses are common, posing challenges for clinicians. We report two cases of parturients with HELLP syndrome who were laparoscopically diagnosed with SLH during emergency cesarean section under the Surgical CAse REport (SCARE) guidelines 2025^[3^].

HIGHLIGHTS

• Subcapsular liver hematoma (SLH) is still a severe complication of HELLP syndrome.

• Imaging negative SLH should be taken into account.

• Chest or back pain may also be early symptoms of SLH.

Case presentation

Case 1

A 30-year-old woman, who was pregnant for the first time at 34+ weeks, was admitted to the obstetrics department because of fetal heart rate deceleration. Her blood pressure was 142/92 mmHg, but she did not report any discomfort, such as nausea, vomiting, or abdominal pain. Her urine protein level increased to 4+ the next day. On the third morning, the patient experienced persistent upper abdominal pain and mild nausea. Emergency bedside abdominal ultrasonography did not reveal any significant abnormalities in the liver or fetus. Blood tests showed a platelet count (PLT) of 87 × 10⁹/L, but liver function was still normal [alanine aminotransferase (ALT) 11 U/L, aspartate aminotransferase (AST) 15.1 U/L, lactate dehydrogenase (LDH) 178 U/L].

Considering the parturient had already progressed to SPE complicated by incomplete HELLP syndrome, an emergency cesarean section was performed under general anesthesia with tracheal intubation. The newborn’s Apgar score was 9 points (minus 1 point for skin color) at 1 minute and 10 points at 5 minutes, and the baby was transferred to the neonatology department. Laparoscopic exploration was performed based on the recommendation of the liver surgery consultant. We sutured a portion of the cesarean section incision, leaving only a small opening for laparoscopic exploration, and used lower pneumoperitoneum pressure and carbon dioxide flow rate (pneumoperitoneum pressure 10 mmHg, carbon dioxide flow rate 1 L/min). Multiple bleeding lesions were observed on the surface of the patient’s right liver (Fig. 1). No signs of active bleeding were detected after several minutes of observation. Therefore, no special treatment was administered. The surgery lasted for approximately 1 hour and 20 minutes, and the parturient successfully recovered 30 minutes after surgery.

Figure 1.

Subcapsular liver hematoma observed under laparoscopy in case 1.

The white arrows in the figures indicate subcapsular hematoma lesions on the surface of the right liver, as observed laparoscopically.

After returning to the ward, the patient’s laboratory tests were rechecked, and the PLT decreased to 49 × 10⁹/L with abnormal blood biochemistry results (ALT 478.6 U/L, AST 745.1 U/L, LDH 963 U/L, ALB 26.9 g/L). Subsequently, a therapeutic dose of platelets was administered. On postoperative day 1 (POD1), the PLT was not elevated (48 × 10⁹/L), but liver function improved significantly (ALT 315.6 U/L, AST 247.4 U/L, LDH 604 U/L), and no abnormalities were detected on liver ultrasound. On POD5, the patient’s liver function and PLT returned to normal, and the patient was safely discharged.

Case 2

A 30-year-old woman at 34 + 1 weeks of pregnancy was admitted to the hospital because of elevated blood pressure for 1 week and thoracodorsal pain for 1 day. Her blood pressure was 148/86 mmHg at admission. The 24-hour urine protein was 241.80 mg/24 h, with a PLT of 102 × 10⁹/L. After admission, the patient’s pain was relieved with oxygen therapy and bed rest. However, on the third day, the pain worsened, and the platelet count was urgently checked at 86 × 10⁹/L, with abnormal liver function (ALT 151.7 U/L, AST 139.3 U/L, and LDH 450 U/L). Abdominal ultrasound did not reveal any significant abnormalities; however, fetal heart monitoring indicated variable deceleration.

Considering the high possibility of developing HELLP syndrome, an emergency cesarean section was performed under general anesthesia. The newborn’s Apgar score was 10 points, and he was transferred to the Neonatology Department. An ovarian tumor was found and removed. Simultaneously, we conducted laparoscopic exploration, as in case 1, and found a subcapsular hematoma in the right liver near the diaphragm (Fig. 2). No active bleeding was observed, and no further processing was performed. The surgery lasted for approximately 2 hours and 40 minutes, and no abnormalities occurred during anesthesia recovery.

Figure 2.

Subcapsular liver hematoma observed during laparoscopy in case 2.

The white arrows in the figures indicate subcapsular hematoma lesions on the surface of the right liver, as observed laparoscopically.

The patient recovered well after surgery, and the chest and back pain were relieved. On the second day after surgery, follow-up showed a PLT of 125 × 10⁹/L, ALT of 50 U/L, and AST of 18.3 U/L. The patient was discharged on POD5.

Discussion

The risk factors for gestational hypertension typically include multifetal gestation, a history of preeclampsia, pregestational or gestational diabetes, body mass index > 30 kg/m², and maternal age ≥ 35 years. However, in these two cases, almost all of the risk factors mentioned above were excluded, yet proteinuria was still detected at 34+ weeks of pregnancy, and the parturient rapidly progressed to SPE and HELLP syndrome. This suggests that we must pay sufficient attention to parturients with proteinuria and provide adequate prenatal education.

SLH is a dangerous complication in these patients, usually occurring in the late second or third trimester, and can lead to 17–59% maternal mortality and 38–62% fetal mortality^[2,4,5^]. The parturient in this case (case 1) experienced abdominal pain and nausea during hospitalization, which are the main symptoms of SLH. Other possible clinical presentations include shoulder or neck pain, dyspnea or pain on inspiration, abdominal distention, sudden changes in the fetal heart, and signs of shock when rupture occurs. However, in case 2, the mother reported thoracodorsal pain, which may also be an early symptom of SLH but has been rarely mentioned in previous literature. Although ultrasound did not detect any signs of SLH, we still requested an emergency intraoperative consultation with a liver surgeon because of a similar case that occurred in our center recently^[6^], and multiple small hematomas under the liver capsule were discovered through laparoscopic exploration. This suggests that the incidence of SLH may be underestimated. Early and small bleeding lesions are difficult to detect using ultrasound, and the newly issued SLH may occur at any time. More sensitive methods, such as laparoscopy and magnetic resonance imaging, may reveal potential bleeding lesions that improve the positive detection ratio. Although laparoscopic surgery may bring additional risks, using a cesarean section incision as an observation port with smaller pneumoperitoneum pressure and carbon dioxide flow can reduce additional trauma and impact on patients. We believe this is beneficial for clarifying SLH and providing evidence for targeted postoperative monitoring and treatment. This also reflects the importance of multidisciplinary consultations in the treatment of such patients.

Currently, there is no consensus on the management of these patients. First, the choice of delivery method remains controversial, but some researchers believe that cesarean section might avoid SLH rupture^[7,8^]. Chen et al reported that nearly 50% of such mothers experience SLH rupture during vaginal delivery^[9^]. However, once diagnosed, close monitoring of the parturient is recommended to detect early signs of hematoma rupture. Conservative, nonsurgical methods can be considered for stable parturients, including supportive care and adequate infusion of fluids and blood products^[10^]. For parturients who experience hematoma rupture, multiple surgical options are available, including abdominal packing and drainage, ligation of the appropriate branch of the portal vein or hepatic artery, patching of the omentum, and partial liver resection^[2^]. In severe cases, liver transplantation can be considered when hepatic necrosis and irreversible deterioration of liver function occur; however, its benefits remain controversial^[11^]. In our cases, although a large number of hematoma lesions were found, each lesion had a limited range, and no signs of sustained bleeding were observed. Therefore, we opted for conservative treatment, and the patient had a relatively good prognosis.

We believe that further research on SLH is necessary, although, considering its low incidence rate, these studies might be relatively difficult to conduct. The factors that may lead to the occurrence of SLH and whether different treatment methods have different long-term prognoses for patients remain unclear. At the same time, we are also unsure whether such mothers still have a risk of developing SLH during their next pregnancy and whether the severity will worsen. In addition, we lack observational data on the impact of SLH on long-term quality of life and the risk of related liver diseases. All of these require further exploration.

Conclusion

For parturients with SPE and HELLP syndrome, the possibility of SLH must be considered when upper abdominal pain occurs, and thoracodorsal pain may also be an early symptom of SLH. Negative imaging results cannot completely exclude the possibility of SLH. Further research is needed to determine which treatments can benefit parturients.

Ethical approval

Not required for the case report at our institution.

Consent

The patient provided written informed consent to participate in this study.

Sources of funding

This research was supported by the Youth General Project Category of the Natural Science Foundation of Shandong Province, China (Grant No. ZR2024QH295).

Author contributions

Y.C.G and H.Q.Q contributed to the conception of the case report, acquired and interpreted the data, drafted the manuscript, and critically revised the article for important intellectual content. X.D.W and Y.J.Z contributed to the literature review and case discussion. H.Q.Q and X.D.W contributed to the acquisition and interpretation of the data and patient follow-up. Y.C.G drafted the manuscript and revised the article. All authors approved the final manuscript submitted.

Conflicts of interest disclosure

The authors declare that this study was conducted in the absence of any commercial or financial relationships that could be construed as potential conflicts of interest.

Research registration unique identifying number (UIN)

Not applicable, as this is a case report. Research registry: None. Unique identifying number or registration ID: None.

Guarantor

Haiqin Qu.

Provenance and peer review

Not commissioned; externally peer-reviewed.

Data availability statement

Research data supporting this publication are available from the corresponding author for scientific-research purposes.

Artificial intelligence (AI)

AI was not used in the research and manuscript development.