Hepatic infarction in HELLP

Case contributed by Dr Jacqui Keene

Presentation

Upper abdominal distension, 2 days post NVD. Prepartum hypertension and proteinuria.

Patient Data

Age: 30 years
Gender: Female
CT

Peripheral poorly defined liver non enhancement in keeping with liver infarction.

Associated hyperdense subcapsular hemorrhage and hemorrhagic ascites.

Bulky, heterogeneous uterus with prominent arcuate vasculature and moderate volume hematometra.  Small focus of enhancing intracavity material in keeping with retained products of conception.

Case Discussion

HELLP syndrome is a serious pregnancy complication characterized by the triad of:

  • hemolysis
  • elevated hepatic enzymes (LDH >600 U/L and AST ≥60 U/L)
  • low platelets (<100/109)

It may occur pre or post partum, in the setting of pre-eclampsia and uncontrolled high blood pressures.

Management of HELLP depends upon fetal gestation at presentation.

If over 34 weeks, then vaginal delivery is preferable due to the low platelets impairing wound healing.

If under 34 weeks, management consists of steroids for fetal lung maturation, careful monitoring of fetal wellbeing and control of maternal blood pressure. 

Hepatic rupture and infarction are rare but well recognized complications of HELLP syndrome. 

Hepatic infarction and rupture usually occur in the right lobe of liver. 

The three typical findings of hepatic infarction are:

  • wedge-shaped peripheral
  • rounded (may be peripheral or central)
  • adjacent to bile ducts (in setting of liver transplantation)

Hepatic infarction in the setting of HELLP syndrome however, is peripheral, low attenuation, non-enhancing with coursing vessels. 

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