INTRODUCTION: Subcapsular liver hematoma (SLH) is a rare complication that occurs in about 1 in 45,000 pregnancies almost exclusively in the setting of preeclampsia or HELLP syndrome. Subcapsular and intraparenchymal hemorrhage can lead to hepatic capsular rupture which is associated with significant maternal and fetal mortality. We present a rare case of a pregnant woman who developed HELLP syndrome complicated by ruptured subcapsular liver hematoma. CASE DESCRIPTION/METHODS: A 33-year-old woman at 31 weeks of pregnancy presented with generalized abdominal pain. She was hypertensive and urinalysis showed proteinuria thus the clinical scenario was concerning for preeclampsia. Development of non-reassuring fetal heart tones led to an emergent C-section with delivery of a healthy infant. Within hours she became hypotensive and somnolent requiring vasopressors and intubation. The patient developed significantly elevated liver enzymes (peak ALT 15,463 U/L and AST 36,653 U/L), hyperbilirubinemia, oliguric renal failure, and hemolysis. A CT abdomen was obtained which demonstrated hepatomegaly with an extensive subcapsular and intraparenchymal hematoma and large volume hemoperitoneum, consistent with hepatic capsular rupture. Angiography showed extravasation of contrast from a branch of the right hepatic artery, which was embolized. The hospital course was complicated by disseminated intravascular coagulation, liver and bowel necrosis due to microthrombi requiring multiple laparotomies and resections, and persistent respiratory and renal failure. Ultimately the patient expired as a result of these complications. DISCUSSION: SLH can lead to rupture of the Glisson capsule and subsequent intraperitoneal bleeding and hemorrhagic shock. Hemodynamically stable patients can be managed conservatively. Unstable patients require hepatic artery embolization or surgical ligation, hepatic resection, or in severe cases liver transplantation. This case demonstrates a severe episode of hepatic rupture complicated by disseminated intravascular coagulation and thrombosis leading to patient mortality.