Transient Liver Masses during Pregnancy: An Unusual Presentation of HELLP Syndrome

Abstract

Introduction: HELLP (microangiopathic hemolytic anemia, elevated liver enzymes, low platelet count syndrome) and acute fatty liver of pregnancy (AFLP) are liver diseases unique to pregnancy primarily affecting women in their third trimester. Early diagnosis and prompt treatment is crucial for maternal and fetal survival. We present a case of HELLP syndrome with unusual focal fatty liver lesions that resolved completely after delivery. Case Report: A 37-year-old healthy female, G1P0 at 27 week gestation, was transferred from an outside hospital with a week of severe right upper quadrant abdominal pain bloating, nausea and vomiting and liver masses concerning for malignancy. Ultrasound of the abdomen performed one week prior to the transfer showed two predominantly echogenic right hepatic lesions measuring 2.9 cm and 3.5 cm. A non-contrast MRI was also performed and demonstrated two right hepatic lobe lesions measuring 3.2 cm and 3 cm in diameter. Both lesions had slightly decreased signal intensity on the T1 weighted images and slightly increased signal intensity on the T2 weighted images. Repeat RUQ ultrasound at admission demonstrated a normal gallbladder and biliary tree. There were now five echogenic areas within the liver with lobular or indistinct margins measuring between 1.2 and 7.2 cm. There was no displacement of the vasculature surrounding these echogenic areas which were suggestive for fatty infiltration or hemangiomas. Laboratory abnormalities included mild leukocytosis, low platelets, elevated LDH, hypoglycemia, elevated transaminases (AST 99 U/L, ALT 132 U/L) and normal alkaline phosphatase. Pregnancy was complicated by prolonged fetal deceleration/bradycardia despite resuscitative efforts and positional changes, resulting in an emergent cesarean section. She recovered uneventfully, and her liver transaminases normalized within 5 days after delivery. A repeat MRI 1 month post delivery, showed complete resolution of her previously seen liver lesions. Conclusion: Focal fatty infiltration of the liver may closely mimic nodular hepatic disease. Although metastatic disease is the most common cause of multiple nodular lesions of the liver, focal fatty infiltration should be considered in pregnancy. Typical MRI findings include drop out of fat on the out of phase T1 images with respect to the T1 in phase images. Common hepatic manifestations in HELLP syndrome include hemorrhage, hematoma or liver rupture. It is uncommon to have significant focal fatty infiltrates in liver during HELLP. The significant overlap between HELLP and AFLP and the focal fatty infiltrates in liver during HELLP may reflect a common pathogenic pathway between the two.