A 38-year-old woman, primigravida at 40 weeks, with a history of controlled gestational diabetes, was admitted to hospital with arterial hypertension of 150/95 mmHg. She was treated with intravenous infusion of labetalol. After failure of induction of labour with prostaglandins, she underwent caesarean section, during which intense haemorrhage due to atony occurred, leading to the decision to perform a subtotal hysterectomy. In a situation of intense haemodynamic instability and with signs of coagulopathy, she was admitted to the intensive care unit, where an abdomino-pelvic computerised tomography (CT) scan was performed, which revealed a subcapsular hepatic haematoma measuring 6.7 × 15 × 19 cm with areas suggestive of recent bleeding, compressing the right hepatic lobe. The patient's haemodynamics were stable, with progressive reduction of the hepatic subcapsular haematoma according to the CT scan. A blood test revealed a decrease in haematocrit, 18%; total bilirubin, 5.1 mg/dl; GOT, 815 U/l; and thrombocytopenia (55,000 platelets/ml), so a platelet transfusion was performed. Given the favourable clinical and ultrasound evolution, it was decided to transfer the patient to the ward, and the day before being discharged from the hospital, 11 days after delivery, while lying down and talking to her husband, she began to feel unwell, with a feeling of dyspnoea and loss of consciousness. After performing cardiopulmonary resuscitation manoeuvres, the patient died and it was decided not to certify death due to sudden death in a stable patient.
Autopsy findings
The external examination revealed a very pale corpse with a slight lividity. The internal examination revealed
- Haemoperitoneum of 950 cm3 of liquid blood.
- Liver increased in size and weight, weighing 2390 grams, with a tear of Glisson's capsule in the upper portion of the anterior face of segments VII and VIII of the right lobe.

- Large subcapsular haematoma extending over almost the entire upper and posterior aspect of the right hepatic lobe, measuring approximately 22 cm in longitudinal diameter, 15 cm in transverse diameter and about 3 cm in maximum thickness.
- Generalised visceral pallor.
The entire liver was submitted for histopathological study, revealing a very altered liver parenchyma with destruction of the normal architecture, periportal and intraparenchymal necrosis, and intrasinusoidal fibrin deposition. All findings are compatible with spontaneous liver rupture probably associated with HELLP syndrome.

The cause of death was therefore established as haemorrhagic shock secondary to spontaneous hepatic rupture caused by a subcapsular haematoma in the context of HELLP syndrome.

