A 38-year-old woman with a 40-week history of gestational diabetes mellitus was admitted to hospital due to hypertension, with 150/95 mmHg.
Treatment was performed with intravenous infusion of labetalol.
After the failure of induction of labor with prostaglandins, a cesarean section was performed, during which there was an intense hemorrhage due to atonia, before which it was decided to perform a subtotal hysterectomy.
In situations of intense hemodynamic instability and signs of coagulopathy, the patient was admitted to the intensive care unit where computed tomography (CT) revealed areas suggestive of hematoma × right hepatic lobe 19 cm suggestive of recent bleeding.
Due to the indication for surgery, conservative measures are used, leading to a stable hemodynamic situation of the patient, with a progressive decrease in hepatic hematoma as controlled by CT.
The analysis showed a decrease in hematocrit, 18%; total bilirubin, 5.1 mg/dl; AST, 815 U/l; and thrombocytopenia (55,000 platelets/ml), so transfusion was performed.
Given the favorable clinical and echographic evolution, it was decided to transfer the patient to the ward, and the day before discharge, 11 days after delivery, being lying down and talking to her husband, she began to feel unconscious.
After performing cardiopulmonary resuscitation maneuvers, the patient died and it was decided not to certify the death due to sudden death in a stable patient.
Autopsy findings
The external examination revealed a pale corpse with slightly intense lice.
Internal examination revealed:
- liquid blood hemoperitoneum of 950 cm3.
- enlarged liver of 2,390 grams, with a tear in the Glisson capsule in the upper portion of the anterior face of segments VII and VIII of the right lobe.
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- Large extended hematoma measuring approximately 22 cm in length, 15 cm in diameter and about 3 cm in thickness.
- Generalised visceral paleness.
Complete liver was referred for histopathological study, finding a very altered hepatic parenchyma with destruction of normal architecture, periportal and intraparenchymal necrosis, and intrasinusal fibrin deposit.
All findings are consistent with spontaneous liver rupture probably associated with HELLP syndrome.
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Therefore, hemorrhagic shock secondary to a spontaneous rupture of the liver caused by a hematoma was established as the cause of death in the context of HELLP syndrome.
