A 30-year-old primigravida with pre-eclampsia at 37 weeks develops sudden epigastric pain, nausea, and right shoulder tip pain. Labs show: platelets 68,000, AST 280 U/L, LDH 1800 U/L. She is hemodynamically stable. What is the most likely acute complication, and what is the pathogenesis?
- A Hepatic infarction due to fibrin thrombi in portal tracts
- B Subcapsular hepatic hematoma due to periportal hemorrhage and hepatic capsular distension ✓
- C Budd-Chiari syndrome due to thrombosis of hepatic veins
- D Acute fatty liver of pregnancy due to mitochondrial beta-oxidation defect
Explanation
The clinical presentation of severe HELLP syndrome with epigastric/RUQ pain and right shoulder tip pain (referred diaphragmatic irritation) along with markedly elevated LDH and transaminases points to subcapsular hepatic hematoma, a rare but life-threatening complication. The pathogenesis involves periportal hemorrhagic necrosis from fibrin microthrombi causing obstruction of hepatic sinusoids, leading to hepatocyte necrosis, bleeding into the hepatic parenchyma, and distension of Glisson's capsule (hepatic capsule). Capsular rupture is catastrophic. Acute fatty liver of pregnancy would show microvesicular steatosis, hypoglycemia, and elevated ammonia rather than this degree of hemolysis/thrombocytopenia.
Reference: Williams Obstetrics, 26th ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.