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Int J Surg Case Rep
Int J Surg Case Rep
International Journal of Surgery Case Reports
2210-2612
Elsevier

S2210-2612(24)01072-1
10.1016/j.ijscr.2024.110291
110291
Case Report
Transcatheter arterial embolization in postpartum HELLP syndrome: A case report
Zhou Xusheng a
Shi Qi a
Xie Zhijiang a
Wang Lei a
Gao Liuqin b
Dai Jiaying 837930929@qq.com
a⁎
a Department of Interventional Radiology, Anqing Municipal Hospital, Anqing 246000, Anhui, China
b Department of Gynaecology and Obstetrics, Anqing Municipal Hospital, Anqing 246000, Anhui, China
⁎ Corresponding author. 837930929@qq.com
12 9 2024
10 2024
12 9 2024
123 11029114 8 2024
6 9 2024
9 9 2024
© 2024 The Authors. Published by Elsevier Ltd on behalf of IJS Publishing Group Limited.
2024

https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction

Hemolysis, elevated liver enzyme levels, and low platelet count (HELLP) syndrome is a pregnancy-related clinical condition characterized by hemolysis, elevated liver enzymes, and thrombocytopenia, posing significant risks to maternal and fetal safety. Hepatic hematoma with spontaneous rupture and bleeding is a rare but severe complication of HELLP syndrome, with limited reports of hepatic artery intervention and embolization therapy.

Presentation of case

We present the case of a 35-year-old pregnant woman who developed worsening pain under the xiphoid process the night following a cesarean section. Her blood pressure dropped from 189/110 mmHg to 90/60 mmHg within 40 min. Vaginal exploration revealed no blood flow, and subsequent laparotomy uncovered multiple small liver surface lacerations actively bleeding. Emergency transcatheter arterial embolization (TAE) was promptly performed, stabilizing her condition. She was discharged 37 days post-admission.

Discussion

TAE plays an important role in the treatment of HELLP syndrome with spontaneous liver rupture, with characteristics of minimal trauma and good efficacy, but the evidence supporting this recommendation is somewhat limited.

Conclusion

This case underscores TAE as a potentially effective and less invasive alternative to surgical interventions for managing HELLP syndrome with spontaneous liver rupture. Further research is needed to better clarify the safety and efficacy of TAE in the treatment of HELLP syndrome with spontaneous liver rupture.

Highlights

• Hematomas and ruptures under the liver capsule are severe complications of HELLP syndrome

• Conservative treatment and surgical intervention are common treatment options for subcapsular hematoma in HELLP syndrome.

• The treatment of subcapsular hematoma rupture with TAE has the characteristics of minimal trauma and good efficacy.

Keywords

HELLP syndrome
Spontaneous hepatic rupture
Transcatheter arterial embolization
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pmc1 Introduction

Hepatoma beneath the liver capsule, leading to rupture and bleeding, represents a critical complication of HELLP syndrome, occurring at a low incidence of approximately 0.09 % to 0.6 % [1]. Conservative management is viable when the hematoma remains intact and the patient's vital signs are stable [2]. However, surgical intervention has traditionally been the preferred approach for patients experiencing rupture and bleeding of secondary liver hematomas in HELLP syndrome [3]. Hepatic artery embolization is a new method to replace surgical operation for hemostasis. As far as we know, there are only a few case reports. This work has been reported in line with the SCARE criteria [4].

2 Presentation of case

The patient, aged 35, delivered her first child five years prior and was 26 + 3 weeks menopausal at admission, with a history of hypertension spanning over three years. She was initially prescribed 2 tablets of labetalol orally bid, requiring a four-day hospitalization due to inadequate blood pressure control, subsequently adjusted to 2 tablets Q8H. With a three-year history of uremia managed by peritoneal dialysis, she reported a penicillin allergy and denied any relevant family genetic history. Upon admission, her physical examination revealed a body temperature of 36.3 °C, pulse rate of 92 times/min, respiratory rate of 18 times/min, and blood pressure of 152/115 mmHg, with no cardiopulmonary abnormalities noted upon auscultation. She exhibited marked lower limb edema (+++). Treatment post-admission focused on blood pressure reduction, spasmolysis, and fetal lung maturation. Subsequent laboratory assessments indicated improvements, with a 24-h urinary total protein of 0.07 g/d, positive urinary protein, negative urinary occult blood, and normal ranges for blood routine, liver function, and electrolytes. Uremic renal dysfunction was managed according to schedule. Ultrasound examinations revealed no abnormalities in the liver, spleen, bladder, bilateral thorax, bilateral deep and superficial veins of the lower limbs, or calf intermuscular veins, alongside both kidneys displaying atrophy. Left ventricular systolic function fell within normal limits, while fundus examination yielded unremarkable findings. Obstetric evaluation indicated a uterine height of 25 cm, abdominal circumference of 94 cm, fetal orientation LOA, and fetal heart rate at 142 beats/min. Admission diagnoses comprised chronic hypertension complicated by preeclampsia, uremia, and high-risk pregnancy supervision (G5P1 at 26 + 3 weeks of gestation).

On the morning of the 29th day after admission, the patient reported decreased fetal movement but no dizziness, palpitations, chest tightness, abdominal pain, or vaginal bleeding. Physical examination revealed a body temperature of 36.4 °C, a pulse of 82 beats per minute, a respiration rate of 20 breaths per minute, and a blood pressure of 184/102 mmHg. Fetal heart rate monitoring showed a reactive pattern, and the fetal umbilical artery S/D value was elevated (amniotic fluid depth: 69 mm; umbilical artery S/D = 5.18). Departmental discussion and analysis concluded that the reduced fetal movement and significantly increased S/D value could indicate fetal distress, with the risk of fetal death imminent. It was recommended that the patient undergo a cesarean section. The cesarean section was performed successfully, delivering a live male infant with the aid of LOA head support. The amniotic fluid was grade II contaminated, the umbilical cord was not entangled, and the placenta and fetal membranes were delivered completely. The uterine incision was explored, showing no extended tearing, and was sutured routinely. The intraoperative blood loss was 200 mL, with no need for blood transfusion.

Seven hours after delivery, the patient experienced mild pain under the xiphoid process and a sensation of hunger. Monitoring indicated a blood pressure of 188/110 mmHg, oxygen saturation of 98 %, and a heart rate of 68 beats per minute. Forty-two minutes later, the patient's upper abdominal pain worsened, and she became pale, sweaty, and restless. Her blood pressure dropped to 90/60 mmHg. A vaginal examination revealed no significant bleeding. The abdomen was soft, with a firm fundus and umbilicus. Emergency blood tests showed WBC 20.78 × 10^9/L, Hb 68 g/L, PLT 169 × 10^9/L. Biochemical tests revealed AST 24 IU/L, ALT 27 IU/L, TP 52.2 g/L, ALB 30.6 g/L, BUN 22.10 mmol/L, Cr 589 μmol/L, TBIL 6.8 μmol/L, carbon dioxide 18.4 mmol/L, and LDH 287 U/L. Coagulation tests indicated PT 12.7 s, TT 18.4 s, FIB 3.51 g/L, APTT 28.2 s, D-dimer 4.88 mg/L, FDP 15.12 μg/L, PCT 1.23 μg/L, and BNP 20309.0 pg/mL. Blood gas analysis showed a pH of 7.31, a standard base excess of −4.80 mmol/L, and a whole blood base excess of −4.9 mmol/L. The patient was critically ill and in shock. An emergency CT scan suggested a possible hemoperitoneum, primarily around the liver (Fig. 1). The diagnoses were HELLP syndrome, hypovolemic shock, acidosis, hypoproteinemia, and abdominal and pelvic effusion indicating internal bleeding, predominantly around the liver. Laparotomy exploration revealed a large hematoma in the right liver lobe, with a 6 cm long, 2 cm deep capsule tear and several smaller tears with active bleeding. The hematoma was removed using sutures and electrocoagulation. An abdominal drainage tube was placed after closing the abdominal wall incision layer by layer.Fig. 1 Computed tomography (CT) scan after cesarean section shows mixed density lesions under the capsule of the right lobe of the liver, indicating subcapsular hematoma and infarction (A and B).

Fig. 1

Twelve hours after the laparotomy, the patient remained in a state of shock, prompting a hospital-wide consultation. Enhanced CT imaging revealed an enhanced focus in the arterial phase of the S6 segment of the liver, suggesting the possibility of vascular lesions with bleeding (Fig. 2). Following a second consultation, it was decided to proceed with hepatic artery embolization. Selective arteriography and transcatheter hepatic artery embolization and were performed under local anesthesia 36 h after the exploratory laparotomy. During the procedure, the right hepatic artery was found to originate from the beginning of the superior mesenteric artery. Angiography of the right hepatic artery revealed a pseudoaneurysm-like contrast agent at the lowest pole of the S6 segment, which then extravasated (Fig. 3), confirming the bleeding site. The blood supply was from fine branches of the right hepatic artery. Under digital subtraction angiography (DSA), use a 0.018 microcoil (3 cm in length and 3 mm in diameter) to embolize the target artery. Then supplement the embolization with one-fifth bottle of 350-560 μm gelatin sponge particles. The angiographic result was satisfactory, and the procedure was concluded. The puncture site was pressurized and bandaged, and the patient was transferred back to the Intensive Care Unit (ICU).Fig. 2 Enhanced CT of the liver maximum intensity projection shows contrast agent extravasation in a branch of the right hepatic lobe artery, indicating a bleeding point (A, white arrow). The transverse axis shows high-density hematoma in segment VI of the right hepatic lobe (B, black arrow).

Fig. 2

Fig. 3 Selective hepatic angiography shows some contrast media extravasation (arrow) in the distal branch of the right hepatic artery (A), transcatheter arterial coil embolization (arrow) is successfully performed using the isolation technique (B).

Fig. 3

Following the intervention, the decline in hemoglobin levels slowed and then began to increase. The abdominal drainage volume gradually decreased, and vital signs stabilized. Six days post-operation, a CT reexamination showed significant improvement in lesions, with considerable absorption of perihepatic and splenic effusion, as well as abdominal and pelvic hematocele and effusion, compared to before the TAE (Fig. 4). The patient was discharged on the 37th day post-operation. Post-discharge, the patient was advised to continue taking labetalol tablets orally to control blood pressure. Regular follow-up CT scans indicated that the reduction of the hematoma suggested the formation of an old organized hematoma.Fig. 4 CT performed six weeks after the TAE reveals the near-complete resolution of the preexisting subcapsular hematoma (A). And a high-density embolic material coil was visible in the right lobe of the liver (B).

Fig. 4

3 Discussion

HELLP syndrome was first described in 1954 [5]. While most patients exhibit the classic manifestations of preeclampsia, some may present with minimal or no clinical symptoms. Research indicates that vascular spasm and endothelial damage are central to the disease, leading to complement system activation, platelet aggregation, fibrin deposition, and end-organ ischemia [6]. Hepatic vascular spasm and fibrin deposition can damage liver cells, resulting in elevated serum transaminases and hepatic congestion, often observed in the right lobe of the liver [7]. Clinical symptoms of HELLP syndrome are nonspecific, frequently including upper abdominal pain, nausea, vomiting, general discomfort, and occasionally headaches and blurred vision [8]. These symptoms often exacerbate at night [9].

In patients with HELLP syndrome who exhibit significant right upper quadrant pain or signs of intra-abdominal bleeding before delivery, rupture of a hematoma under the liver capsule should be considered. For those who develop HELLP syndrome post-delivery, obstetricians may initially attribute symptoms to complications from cesarean section surgery, potentially overlooking the possibility of hematoma rupture. If a patient presents with unexplained upper abdominal pain and discomfort, bedside ultrasound should be the initial diagnostic tool to detect a large hematoma under the liver capsule. If free fluid is detected in the abdominal cavity, diagnostic abdominal puncture under ultrasound guidance is warranted. If non-coagulable blood is found during puncture or if unexplained blood accumulation is noted during cesarean section, the likelihood of a ruptured hematoma should be highly suspected. Enhanced CT of the upper abdomen can confirm the diagnosis and differentiate between abdominal bleeding from other sources, assisting in dynamic assessment and guiding subsequent treatment. In one case from this cohort, the patient received intramuscular dexamethasone, which improved platelet count and liver function, leading to overall clinical improvement and fetal lung maturation. The obstetrician then assessed the patient's condition and performed a timely cesarean section. Postoperatively, HELLP syndrome was confirmed, and exploratory laparotomy further validated the rupture and bleeding of a hematoma under the liver capsule. The hematoma was actively sutured and packed. Despite this, the patient's blood pressure decreased post-surgery. Following consultation with the interventional department, DSA angiography identified active bleeding, and hepatic artery embolization was performed to effectively control the bleeding. Post-treatment, the patient's liver function and general condition gradually improved, and she was eventually discharged from the hospital.

When diagnosing HELLP syndrome, a comprehensive assessment of both the mother and fetus is essential before proceeding with pregnancy termination, as expectant management is generally not advisable. Treatment options for hematomas under the liver capsule include conservative and surgical approaches. For patients with stable maternal and fetal conditions, unruptured hematomas, and stable hemodynamics, conservative treatment is appropriate. This includes fluid resuscitation and transfusion of blood products to address anemia and coagulopathy. During observation, if symptoms such as increasing abdominal pain, unstable hemodynamics, expanding hematomas, or signs of peritonitis develop, exploratory laparotomy should be considered. The operation should involve collaboration between obstetrics, surgery, anesthesia, and transfusion departments. For patients with significant rupture and active bleeding, suturing to control the hemorrhage is necessary. Hepatic artery embolization, either alone or combined with surgery, has shown efficacy in reducing operation time, surgical trauma, and postoperative complications [10], and has notable clinical benefits.

In summary, hematomas and ruptures under the liver capsule are severe complications of HELLP syndrome, Due to its frequent occurrence in late pregnancy and early postpartum period, close and vigilant monitoring are crucial for high-risk pregnant women with HELLP syndrome who experience abdominal symptoms, in order to timely detect and treat hematomas and ruptures. Hepatic rupture can lead to life-threatening complications such as disseminated intravascular coagulation and acute renal failure. Therefore, it is essential to enhance understanding of this condition, keep up with relevant advancements, improve diagnostic accuracy and treatment outcomes, and minimize adverse pregnancy outcomes.

Ethical approval

Ethical clearance was not necessary by Research Committee of Anqing Municipal Hospital as the format of this paper is a case report.

Funding

This research received no external funding.

Author contribution

Xusheng Zhou, Jiaying Dai – data curation; analysis and interpretation of data; original draft; review & editing; final approval of version submitted.

Qi Shi – conceptualization, data curation; methodology; original draft; review & editing; final approval of version submitted.

Zhijiang Xie – analysis and interpretation of data; original draft; review & editing; final approval of version submitted.

Lei Wang – data curation; analysis and interpretation of data; review & editing; final approval of version submitted.

Liuqin Gao – conceptualization, design; data curation.

Guarantor

Jiaying Dai.

Registration of research studies

Not applicable.

Declaration of competing interest

The authors declare that there are no competing interests.

Acknowledgment

Nil.

Consent

Written informed consent was obtained from the patient for publication and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Consent for publication

Not applicable.
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