*Purpose: Liver rupture and infarction are rare but serious complications of hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome. We report successful utilization of liver transplantation for HELLP syndrome complicated by the development of HLA antibodies.

*Methods: A 40 year old female with pregnancy complicated by pre-eclampsia underwent emergent C-section of 32 week gestation twins. Her postpartum course was complicated by HELLP syndrome with liver rupture and hemorrhagic shock requiring multiple exploratory laparotomies for hemoperitoneum. On transfer to tertiary hospital, her labs showed thrombocytopenia (16K), hyperbilirubinemia (15.2), and evidence of hemolysis (LDH 381 and haptoglobin <30). CT scan demonstrated infarcted right lobe of the liver. The patient was listed for liver transplantation with a MELD of 35. Pre-operative evaluation demonstrated development of antibodies requiring HLA-matched platelets. Her mother was found to be the only complete HLA match, and she donated platelets prior to potential operation. When a suitable organ became available, the patient was taken to the operating room for deceased donor liver transplant. Upon completion of the arterial anastomosis, the patient was coagulopathic so the abdomen was packed to allow anesthesia time to resuscitate. After 20 minutes, the abdomen was unpacked and there was frank exsanguination of all raw surfaces requiring catastrophic transfusion protocol. The patient was packed, unpacked and resuscitated in this fashion repeatedly over the next 8 hours. At the completion of the case, total blood product resuscitation consisted of 112 units of packed red blood cells (41,400mL), 24 units of platelets (4800mL), 207 units of fresh frozen plasma (62,750mL), 34,224mL of cell saver, and 1968mL of cryoprecipitate. The patient also received topical hemostatic agents, prothrombin complex concentrates, factor VII and Amicar. The abdomen was temporarily closed and the patient transferred to the ICU overnight. The biliary anastomosis was completed on the following day.

*Results: The patient had a prolonged recovery complicated by kidney failure, respiratory insufficiency, severe protein calorie malnutrition, sepsis requiring a prolonged IV antibiotic course and postpartum depression. The patient was eventually progressed to a long-term acute care hospital followed by an acute rehab, then discharged home on outpatient dialysis.

*Conclusions: Liver transplantation can be a successful treatment of the severe complications of HELLP syndrome. In this case study, we also present a method for overcoming coagulopathy exacerbated by thrombocytopenia refractory to non-HLA matched platelet transfusions.

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