Background: Subcapsular liver hematoma is spontaneous bleeding between the Glisson's capsule and the liver parenchyma. It is estimated to occur in 1-2% of patients with pre-eclampsia. Case presentation: A 39-year-old woman, gravida 7, para 6, at 27+3 weeks gestation, with a known case of gestational diabetes, was transferred by ambulance from the primary clinic to the emergency department as a case of pre-eclampsia. In the primary clinic, she complained of epigastric pain and vomiting that started 1 day ago. She denied headache, visual changes, chest pain, dyspnea, edema or per vaginal bleed. On physical examination, she was hypertensive, her abdomen was tender to palpation, with no peritoneal signs or hepatomegaly, and her cardiorespiratory examination was unremarkable. However, her neurologic exam showed brisk deep tendon reflexes. Initial Investigations revealed thrombocytopenia (platelet count: 78,000/mL), transaminitis (AST: 2882 IU/L and ALT: 1825 IU/L), LDH elevation (>1800 IU/L), and 3+ proteinuria on urinalysis. She also had a deranged coagulation profile and kidney functions consistent with disseminated intravascular coagulation and acute kidney injury, respectively. Fetal heart rate abnormalities were seen with prolonged deceleration, and the patient’s mental status was deteriorating, so she was rushed for an emergency caesarean delivery. There was evidence of hemoperitoneum when the pelvis surrounding structures were explored, likely due to liver subcapsular haemorrhage. A midline laparotomy incision was done, and the liver was drained and packed. A nonviable male infant was delivered. Her total estimated blood loss during the caesarean section was 5L. She received 5 units of packed red blood cells and 5 units of fresh-frozen plasma; nevertheless, she continued to lose blood. CT angiography of the abdomen before embolization showed subcapsular hematoma measuring 5.2 x 2.4 x 5.6 cm. Two sites were embolized successfully through the cystic artery and right hepatic artery branches supplying segments 7 and 8 of the liver by the interventional radiologist. She was then admitted to the ICU postoperatively for further monitoring. Then started on regular haemodialysis. Her ICU stay was complicated by a minimal subarachnoid haemorrhage for which she received Nifedipine. She was extubated on day 6 post-op, and her discharge on day 16 was uneventful. Discussion and conclusion: The probable mechanism of SLH in HELLP syndrome may be attributed to fibrin deposition and platelet activation, both of which lead to clot formation and subsequent occlusion of capillaries supplying the liver. Consequently, hepatic necrosis ensues, and hemorrhage occurs. Prompt recognition and treatment are crucial to optimizing the patient’s outcome. Management can be either conservative or surgical, depending on various factors.  

Keywords: Subcapsular liver hematoma (SLH) Hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome.