Nursing care
Why HELLP syndrome causes right upper quadrant pain: liver swelling and capsule stretch
Written and reviewed by Dana Whitfield, RN, MSN · 4 min read · Updated October 2026
Short answer
In HELLP syndrome, damaged small vessels in the liver collect fibrin, blood flow is obstructed and liver cells die around the portal areas. The swollen liver stretches its outer capsule, which is felt as epigastric or right upper quadrant pain. Because this pain can signal serious liver involvement, even without severe hypertension, the nurse reports it promptly.
Follow the chain from damaged vessels to a swollen liver
HELLP stands for haemolysis, elevated liver enzymes and low platelets. It sits on the spectrum of preeclampsia, where widespread endothelial injury and vasospasm reduce blood flow to organs. In the liver, fibrin is deposited in the sinusoids, the small channels that carry blood past liver cells. Flow through those channels becomes obstructed, and cells near the portal tracts are damaged.
Obstructed flow and cell injury make the liver swell. The liver is wrapped in a thin fibrous layer called Glisson's capsule, which has pain fibres and limited room to expand. As the swollen liver presses outward, the capsule is stretched, and the patient feels pain under the right ribs or in the upper middle abdomen. Raised liver enzymes are the laboratory sign of the same cell injury.
Why the pain can be mistaken for something minor
The pain may be described as heartburn, indigestion or a vague ache, and it is often accompanied by nausea, vomiting or general malaise. These symptoms overlap with common pregnancy complaints and with gastritis or a viral illness. A patient may even take an antacid before calling. That is why the location and the setting, a pregnant or recently delivered patient, matter more than the description.
Blood pressure and urine protein do not always match the severity of liver involvement. A recognised minority of patients with HELLP have little or no hypertension or proteinuria at presentation. An exam question that offers normal-looking blood pressure as a reason to dismiss new upper abdominal pain is testing exactly this trap. The pain itself is a finding to escalate, whatever the blood pressure shows.
Expected findings versus a dangerous change
Tenderness under the right ribs with rising liver enzymes and falling platelets fits active HELLP and needs prompt medical review. The concerning trend is worsening: pain becoming more intense, platelets continuing to drop, or new signs such as headache, visual change or reduced urine output. Each suggests progressing disease rather than a stable picture, and the laboratory trend should be reported alongside the symptom.
A rare but life-threatening complication is a blood collection under the liver capsule that can rupture. Rupture typically presents with sudden severe epigastric or right upper quadrant pain that may spread to the back or right shoulder, together with falling blood pressure and signs of blood loss. This is an emergency: the nurse calls for immediate help and supports circulation under the emergency protocol.
Turn the mechanism into nursing actions
When a pregnant or postpartum patient reports new epigastric or right upper quadrant pain, assess its onset and severity, check blood pressure, pulse and oxygen saturation, ask about headache and visual change, and review recent platelet and liver results. Report the full picture promptly rather than treating the pain as indigestion. Low platelets also mean watching injection sites, gums and urine for bleeding.
Monitoring continues after birth, because HELLP and preeclampsia can appear or worsen postpartum. Teach patients being discharged to report upper abdominal pain, severe headache, visual disturbance or breathlessness without waiting. Treatment decisions, such as timing of birth or medicines, belong to the obstetric team and local protocol; the nursing contribution is early recognition, accurate trends and fast escalation.
Work through a hypothetical exam-style scenario
Imagine a hypothetical patient at 35 weeks who calls the unit with heartburn under her right ribs and nausea since the morning. Her last blood pressure was mildly raised. The options are to advise an antacid and rest, to book a routine visit next week, or to tell her to come in now for assessment. Coming in now is the strongest answer.
The antacid option treats the symptom as benign, and the routine visit delays assessment of possible liver involvement. The mildly raised blood pressure does not reassure, because HELLP can be severe before pressure is very high. The reasoning tested is that new epigastric or right upper quadrant pain in late pregnancy is a warning sign of liver stretch, not a digestive complaint to manage at home.
Sources and further reading
PMC: The HELLP syndrome: clinical issues and management. A review. Sinusoidal fibrin, periportal necrosis, capsule stretch as the cause of pain, nonspecific presentation, absent hypertension in some cases and subcapsular haematoma rupture.
MSD Manual Professional: Preeclampsia and eclampsia. Epigastric or right upper quadrant pain reflecting hepatic ischaemia or capsular distention, and HELLP laboratory criteria.
NICHD: Preeclampsia and eclampsia condition information. Upper abdominal pain as a warning sign, components of HELLP and postpartum onset.
The next step on this is the same as on everything else here: answer questions and read the rationales. Our maternity and newborn practice questions are the closest set to what this page covers.
Common questions
What causes the right upper quadrant pain in HELLP syndrome?
Fibrin in the liver's small vessels obstructs blood flow and injures liver cells. The liver swells and stretches its outer capsule, which produces pain under the right ribs or in the epigastric area.
Can HELLP syndrome occur with normal blood pressure?
Yes. Some patients have little or no hypertension or proteinuria when HELLP is found, so new upper abdominal pain in pregnancy should be reported even if blood pressure looks acceptable.
What signs suggest a liver haematoma has ruptured?
Sudden severe epigastric or right upper quadrant pain, sometimes spreading to the back or right shoulder, with low blood pressure and signs of blood loss. This needs emergency escalation.