Intraoperatively diagnosed spontaneous rupture of a subcapsular liver hematoma with incomplete hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome: A case report and literature review.

RATIONALE: Subcapsular liver hematoma (SLH) during pregnancy is a rare but potentially life-threatening complication, often associated with hypertensive disorders such as preeclampsia and hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome.

PATIENT CONCERNS: We report the case of a 37-year-old primipara who presented at 39 weeks of gestation with severe preeclampsia (blood pressure, 166/106 mm Hg; proteinuria, 2+). Notably, her prenatal course was marked by normal blood pressure and 3 negative urine protein tests.

DIAGNOSES: The patient was diagnosed with incomplete HELLP syndrome and a ruptured SLH. This intraoperative diagnosis was confirmed by the identification of 800 mL of noncoagulated blood and a 4 × 2 cm left hepatic lobe subcapsular hematoma with semiactive bleeding.

INTERVENTIONS: Laparoscopic hematoma evacuation and hemostasis were successfully performed.

OUTCOMES: The patient had a stable postoperative recovery. A systematic review of 99 cases from 71 studies was conducted, which documented HELLP syndrome in 78 cases, with maternal and fetal mortality rates of 13.1% and 33.3%, respectively. Notably, 88.8% of patients presented with pain, predominantly right upper quadrant (46%), whereas our case exhibited atypical left-sided pain.

LESSONS: This case, along with a literature review, underscores the importance of vigilance for SLH in hypertensive pregnancies, even in the absence of classic HELLP criteria, and advocates for prompt imaging, individualized treatment, and multidisciplinary coordination to optimize outcomes.