HELLP Syndrome
A 40-year-old woman, gravida 4 para 3, at 32 weeks presents with constant right upper quadrant pain and nausea. Blood pressure is 168/106 mm Hg, urine protein is 3+, platelets 78 × 10⁹/L, ALT 240 U/L, and lactate dehydrogenase is elevated. The gallbladder is normal on ultrasound. Which of the following is the most likely cause of her pain?
- A.Cholelithiasis with biliary colic
- B.Acute calculous cholecystitis
- C.Hepatic capsule distensionCorrect
- D.Spontaneous hepatic rupture
Explanation
This woman has HELLP syndrome, a severe variant of pre-eclampsia defined by haemolysis, elevated liver enzymes and low platelets, and her right upper quadrant pain comes from stretching of Glisson's capsule. Microvascular endothelial injury causes fibrin deposition in the hepatic sinusoids with periportal necrosis, haemorrhage and swelling; the liver parenchyma has no pain fibres, so pain arises only when the swollen liver distends its innervated capsule. The pain is therefore constant and epigastric or right upper quadrant, often with nausea and vomiting, and it is an important warning sign because it commonly precedes subcapsular haematoma formation and, rarely, hepatic rupture. Her severe hypertension, heavy proteinuria, thrombocytopenia, transaminitis and raised lactate dehydrogenase complete the picture. Management is stabilisation with magnesium sulfate for seizure prophylaxis, antihypertensives, blood products as needed, and delivery, which is the only definitive treatment; at 32 weeks corticosteroids may be given but must not delay delivery when disease is severe. Gallstone disease is common in multiparous women but the ultrasound is normal and it does not explain the thrombocytopenia and hypertension. Hepatic rupture is the feared endpoint and presents with sudden collapse, haemoperitoneum and profound shock rather than isolated pain.
Why each option
- A.
- Biliary colic is episodic, postprandial, and unaccompanied by hypertension, proteinuria or thrombocytopenia. Ultrasound shows no stones here.
- B.
- Cholecystitis causes fever, a positive Murphy sign and sonographic gallbladder wall thickening, none of which are present.
- C.
- Correct. Hepatic swelling from periportal necrosis and haemorrhage in HELLP stretches the liver capsule, producing constant right upper quadrant pain.
- D.
- Hepatic rupture causes sudden collapse with haemoperitoneum and profound hypotension. Capsular distension precedes it and fits this stable but symptomatic presentation.
Reference: ACOG Practice Bulletin No. 222, Gestational Hypertension and Preeclampsia, reaffirmed 2023
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