HELLP (Hemolysis, Elevated Liver Enzymes, and Low Platelets)-Associated Subcapsular Hepatic Hematoma Presenting as Postoperative Hemorrhagic Shock: A Case Report

Subcapsular hepatic hematoma is a rare and life-threatening complication of HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome associated with substantial maternal morbidity and mortality. We report the case of a 23-year-old primigravida at 27 weeks and 3 days of gestation who presented with severe frontal headache, nausea, vomiting, and hypertension and was initially diagnosed with preeclampsia with severe features. On hospital day three, clinical deterioration prompted emergency cesarean delivery, and postoperative laboratory findings confirmed HELLP syndrome. On the first postoperative day, the patient developed hypovolemic shock and signs of acute abdomen. Point-of-care ultrasonography revealed free intra-abdominal fluid, prompting urgent surgical re-exploration. An extensive subcapsular hepatic hematoma with active bleeding was identified, and damage control surgery with hepatic packing and temporary abdominal closure was performed. After 48 hours of clinical stabilization, planned re-exploration with pack removal and definitive abdominal wall closure was completed. Liver enzymes subsequently showed progressive normalization through hospital discharge. This case highlights the importance of recognizing hepatic complications of HELLP syndrome in patients with abrupt postoperative deterioration and demonstrates the role of coordinated multidisciplinary management in severe hemorrhagic presentations. In hemodynamically unstable patients with evidence of ongoing intra-abdominal hemorrhage, the absence of definitive cross-sectional imaging may not preclude urgent surgical exploration.