34 Year Old Pregnant Female Presents with Abdominal Pain

Abstract

Purpose: 34 year old female, gravida 4, para 0, at 16 weeks of gestation presented with abdominal pain for 3 days, epigastric/right upper quadrant, severe, with nausea and vomiting. Patient denied fever, arthralgias, or change in bowel habits. Her past medical history was significant for systemic lupus erythramatosus without active manifestations and antiphospholipid antibody syndrome. She denied any history of smoking, alcohol use, or illicit drug use. Her medications included asprin, enoxaparin, hydroxychloroquine, and prenatal vitamins. She was allergic to sulfa and penicillin. Physical exam revealed elevated blood pressure (150/84 mmhg), tenderness in right hypochondrium with voluntary guarding and a gravid uterus. Lab studies revealed thrombocytopenia, elevated transaminases (7 times above the normal value), LDH and decreased haptoglobin. Urinalysis revealed proteinuria with trace blood. Ultrasound of the abdomen revealed thickened gallbladder wall without gallstones. CT scan of the abdomen revealed densities throughout the liver consistent with hepatic infarctions/necrosis. Our patient was diagnosed with HELLP syndrome with hepatic infarctions/necrosis. Hepatic infarction in pregnancy is a rare condition, with an estimated incidence of 1 in 40,000 to 250,000 pregnancies. The hepatic infarction although rare, usually occurs after the 20th week of pregnancy and usually involves the right lobe of the liver. The diagnosis is established by abdominal ultrasound, CT scanning, MRI or angiography. Hepatic rupture is a dangerous complication that can causes mortality rates as high as 85 percent. Treatment is generally limited to conservative management and delivery of the fetus. Our case is unique in that the patient presented with this clinical syndrome in the 16th week of her pregnancy and her hepatic infarctions included most of her liver and her medical history included antiphospholipid antibody syndrome. Less than 30 such presentations have been reported in our literature search. Our patient had an uncomplicated dilatation and evacuation procedure.[figure1]Figure