Second trimester hepatic rupture in a 35 year old nulliparous woman with HELLP syndrome: a case report

A previously healthy 35 year old nulliparous woman conceived secondary to egg donation in-vitro fertilisation therapy on a background of primary infertility. Routine antenatal booking visit at 14 weeks gestation revealed a blood pressure of 146/81 with a normal urine specimen. At 18 weeks gestation, she was found to have +3 proteinuric asymptomatic hypertension (184/102 mm Hg) with HELLP syndrome [platelets 105 (150–400 × 109 per litre), alanine transaminase 2223 (5–40 IU/L), aspartate transaminase 2823 (10–40 IU/L), lactate dehyrogenase 14361(> 600 U/L), INR 1.6 (<1.0), activated partial thromboplastin time 186 (25–40 secs) and a 24 hour urine collection showed 2.8 gr of protein. She complained of some mild epigastric discomfort, but this settled with simple analgesia. She was promptly commenced on anti-hypertensive medicine.Her anti – hypertensive requirements gradually increased with an observable worsenening of peripheral oedema and proteinuria. Radiological investigations inclusive of ultrasound of kidneys, gallbladder, spleen and liver at that time were all normal. Multi-disciplinary investigation of underlying aetiologies for this early onset pre-eclampsia did not discern a cause. Connective tissue screening was negative.Although a normal multi-vessel Doppler was present, the estimated fetal weight was 184 grams (<3rd percentile). Two days post admission the patient's condition changed. She became acutely haemodynamically unstable complaining of severe epigastric pain and obvious hyperreflexia. Immediate transfer to the High Dependency Unit occurred. Ultrasound scan revealed a large liver haematoma (figure 1). The fetal heart beat was still present. She received 4 units of O negative blood. A repeat ultrasound one hour later revealed free blood in the abdominal cavity; the fetal heart beat was now absent.The patient was immediately transferred to the operating theatre for a laparotomy. The abdomen was opened through a midline incision. The bleeding was found