Ruptured subcapsular liver hematoma in pregnancy: a case report of nonsurgical management

doi:10.1016/S0002-9378(03)00759-2

American Journal of Obstetrics and Gynecology

Volume 190, Issue 2, February 2004, Pages 558-560

https://doi.org/10.1016/S0002-9378(03)00759-2 Get rights and content

Abstract

Ruptured subcapsular liver hematoma in pregnancy is a rare condition that is usually managed surgically. Recently, however, surgical and obstetric literature has discussed conservative management. We describe successful conservative management of ruptured subcapsular liver hematoma in a woman with preeclampsia who had hemoperitoneum seen at cesarean section.

Section snippets

Case report

A 27-year-old primigravid woman with no prenatal care was seen in the labor and delivery department for possible ruptured membranes and labor. On the basis of the last known menstrual period, gestational age was estimated at 34.4 weeks. Laboratory studies gave the following results: serum creatinine level, 0.9 mg/dL (79.6 μmol/L); serum aspartate aminotransaminase (AST) level, 208 U/L; uric acid level, 10.6 mg/dL (0.6307 mmol/L); hemoconcentration (hematocrit, 50% [0.50]); platelet count, 143×10

Comment

Abercrombie¹ first described liver hematomas in pregnancy in 1844. Liver hematomas are most commonly associated with preeclampsia and HELLP syndrome but can also be found with biliary disease, infection, aneurysms, and hepatic neoplasms. Liver hematomas occur in 1 in 45,000 deliveries.² The morbidity involves disseminated intravascular coagulation in up to 90% of cases, massive transfusions, pulmonary edema and/or pleural effusions, and acute renal failure.³ In their 1976 review, Bis and Waxman⁴

References (7)

J.R. Barton et al.
HELLP and the liver diseases of preeclampsia
Clin Liver Dis
(1999)
L.T. Hibbard
Spontaneous rupture of the liver in pregnancy: a report of eight cases
Am J Obstet Gynecol
(1976)
J. Abercrombie
Case of hemorrhage of the liver
Lond Med Gaz
(1844)

There are more references available in the full text version of this article.

Cited by (30)

Sudden and unexpected deaths due to non-traumatic abdominal disorders: A forensic perspective
2022, Journal of Forensic and Legal Medicine
Citation Excerpt :
Rupture of the liver is a life-threatening emergency, with maternal and fetal mortality estimated as high as 86% and 70% respectively in the obstetric literature.167 The location of a liver rupture associated with pregnancy is typically the right hepatic lobe, although the left lobe and rarely the caudate lobe have also been involved.168 Histologic features may include occlusive fibrin deposits with hemorrhagic infiltration along the hepatic sinusoids, and occasionally in portal tract vessels, suggesting an important role of DIC.
Sudden and unexpected deaths due to non-traumatic abdominal disorders are a disregarded topic in the forensic field. These conditions are very heterogenous, accounting for 1–5% of sudden deaths. Specifically, acute gastrointestinal hemorrhages, bowel obstructions, liver cirrhosis, and necrotizing pancreatitis are frequently reported, whereas there are also unusual conditions which deserve careful analysis. Furthermore, the postmortem examinations of such disorders are not straightforward in the forensic setting since advanced putrefaction of the body, alleged medical malpractice, or the absence of any medical records could complicate autopsy procedures. Thus, the use of forensic histopathology, toxicology, microbiology, and postmortem radiology may help the pathologists to identify the abdominal cause of death. In this paper, the authors aim to discuss most of congenital and acquired abdominal conditions that have resulted in sudden and unexpected deaths. Hence, the discussion of the pathological features of each abdominal organ or system is prefaced with practical examples from caseworks of the Milan Institute of Legal Medicine. However, this paper also shows an extensive literature review with selected medicolegal articles to detailly describe the lethal mechanisms related to each condition, along with any associated risk factors or other diseases. Finally, each section shows a focus on either novel forensic approach (when available) or medicolegal implications, such as the use of postmortem radiology, peculiar histopathologic findings, or allegations in medical malpractices.
Conservative management of a pregnancy complicated by preeclampsia and postpartum spontaneous hepatic rupture: A case report and review of the literature
2021, European Journal of Obstetrics and Gynecology and Reproductive Biology
Citation Excerpt :
The majority of these cases have been associated with hypertensive disorders, although case reports have also been described in uncomplicated pregnancies [22,64]. Although it has been mainly associated with HELLP syndrome, it has also been described in pregnancies complicated by PE, without satisfying criteria for HELLP syndrome [21,23,28,45,54], as the one presented in the case report. PE and HELLP syndrome are most often seen in primigravid women.
Most spontaneous hepatic rupture cases are associated with a pregnancy-induced hypertensive disorder like preeclampsia and HELLP syndrome. Although it is a rare complication, it is still associated with high maternal and fetal morbidity and mortality rates. With this study, we aim to present a case report and review the available literature on hepatic rupture associated with hypertensive disorders of the pregnancy.
We present a case report and a review of the literature of the last 20 years on hepatic rupture associated with pregnancy-induced hypertensive disorders. The selected cases were reviewed to collect information on maternal characteristics, clinical presentation, diagnostic studies, therapeutic modalities and maternal and fetal outcomes.
Our review has found 57 publications describing a total of 93 cases of hepatic hemorrhage with capsule rupture associated with pregnancy-induced hypertensive disorders. Most of the patients were less than 35 years old and primiparous and the first symptoms of hepatic rupture included epigastric and right upper abdominal pain. Most of the diagnoses were made during surgery without previous diagnosis and, in the majority of cases, a surgical approach was necessary to achieve hemostasis. Perihepatic packing was the most used surgical method.
Our clinical case and literature review reinforces the importance of closely monitoring all pregnancies complicated with hypertensive disorders, including in the postpartum period. Although hepatic rupture accounts for high maternal and fetal morbidity and mortality rates, it is possible to keep a conservative approach with good maternal and fetal outcomes, with a high index of suspicious, an early diagnosis and a multidisciplinary approach.
“Hepatic rupture in preeclampsia and HELLP syndrome: A catastrophic presentation”
2020, Taiwanese Journal of Obstetrics and Gynecology
Citation Excerpt :
In one case, diagnosis was established on autopsy [38]. In this review, 18.2% cases (17/93) with stable condition and enclosed hematoma were managed conservatively with blood transfusion and watchful expectancy [12,13,15,19,23,26, 35,40–43,45,48]. Liver packing was the accustomed treatment to control liver hemorrhage in unstable patient and expanding liver hematoma.Hence, 51.6% patients (48/93) were managed by perihepatic packing along with use of various hemostatic agents [2,7–9,14,27,37,39,49].
The objective of index study is to review the available literature on hepatic rupture or hematoma in hypertensive disorders of pregnancy to find the incidence, associated risk factors, clinical presentation, mode of management and feto-maternal outcome. Electronic database was searched using hepatic rupture or hematoma in pregnancy, preeclampsia, eclampsia, and HELLP syndrome (Hemolysis, EL: elevated liver enzymes, LP: low platelet count) as key words and literature published since January, 2000 to December, 2018 which met the inclusion criteria was reviewed. A total of 56 articles were reviewed describing 93 cases of hepatic hemorrhage in hypertensive disorders of pregnancy. Treatment varied from conservative management to abdominal packing, hepatic artery embolization, and partial hepatectomy to liver transplantation. Seven out of 93 patients with liver rupture met mortality and in one of them diagnosis was established on autopsy. Unawareness of the hepatic rupture in pregnancy by an obstetrician demands high index of suspicion for diagnosis and requires specialized, focused and exhaustive management for optimal feto-maternal outcome. Laparotomy and perihepatic packing is a viable option in patients with unstable vitals and is feasible even in limited resource settings.Short interval between diagnosis and management may enhance the feto-maternal survival rate and prevent further morbidity or mortality.
Rupture of hepatic subcapsular haematoma in pregnancy: Case report and literature review
2017, Clinica e Investigacion en Ginecologia y Obstetricia
El síndrome de HELLP es una de las manifestaciones graves de la preeclampsia. En algunos casos se puede complicar con la aparición de un hematoma hepático subcapsular, cuya rotura se asocia a cifras elevadas de morbimortalidad materna y fetal. Aunque presenta signos y síntomas inespecíficos, la sospecha clínica es fundamental para su diagnóstico y tratamiento adecuado, siendo el manejo quirúrgico mediante una laparotomía la técnica de elección. Se presenta el caso de una paciente con una rotura de un hematoma hepático subcapsular en el tercer trimestre como primera manifestación de un síndrome de HELLP.
HELLP syndrome is a serious manifestation of pre-eclampsia. In some cases, it may be complicated by the emergence of a hepatic subcapsular haematoma, the rupture of which is associated with high levels of maternal and foetal morbidity and mortality. Although it presents nonspecific signs and symptoms, clinical suspicion is essential for diagnosis and proper treatment. The technique of choice is surgical management by laparotomy. We present the case of a patient with a ruptured hepatic subcapsular haematoma in the third trimester; the first manifestation of HELLP syndrome.
Subcapsular liver hematoma causing cardiac tamponade in HELLP syndrome
2012, International Journal of Obstetric Anesthesia
Citation Excerpt :
Liver transplantation has been reported when hemorrhage is uncontrolled or acute liver failure occurs.4 Non-surgical conservative management of a hemodynamically stable patient with a ruptured subcapsular hepatic hematoma in pregnancy has been reported.8 Postpartum follow-up should include serial assessment with ultrasound, CT or MRI scan until the defect resolves.9
HELLP (hemolysis, elevated liver enzymes and low platelets) syndrome is an obstetric complication with heterogeneous presentation, multisystem involvement and variable prognosis, but which usually resolves after delivery. We report a case of HELLP syndrome with subcapsular hematoma of the liver causing extrapericardial cardiac tamponade. The subcapsular hematoma and cardiac tamponade were managed conservatively.
Hepatic subcapsular hematoma: A case report and management update
2012, Journal de Gynecologie Obstetrique et Biologie de la Reproduction
L’hématome sous-capsulaire du foie (HSCF) est une complication rare de la grossesse qui présente une mortalité materno-fœtale élevée. Cela impose donc un diagnostic rapide et une prise en charge adaptée. Avant une mise au point actualisée sur la stratégie de la prise en charge de l’HSCF, nous illustrons l’article par un cas clinique rapportant une méthode d’exploration hépatique qui, à notre connaissance, n’a pas encore été décrite. Ainsi, devant la présence d’un hémopéritoine lors d’une césarienne réalisée pour un HSCF, l’introduction d’un cœlioscope par cette même incision a permis une évaluation satisfaisante de la cavité abdominale sans recourir à une laparotomie médiane délabrante.
Hepatic subcapsular hematoma (HSH) is a rare complication of pregnancy that keeps a materno-fetal high mortality rate. Given this severity, HSH management requires a prompt diagnosis and an appropriate care. Before focusing on the current management strategy of HSH, we illustrate this article with a clinical case presenting an original method of abdominal exploration, which has not been described to our knowledge. Thus, taking into account the presence of a moderate hemoperitoneum during a caesarean section procedure for HSH, introduction of laparoscopy through the same incision allowed a satisfactory evaluation of the abdominal cavity and hepatic area without performing an invasive midline laparotomy.

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Case reportRuptured subcapsular liver hematoma in pregnancy: a case report of nonsurgical management

Abstract

Section snippets

Case report

Comment

Clin Liver Dis

Am J Obstet Gynecol

Case of hemorrhage of the liver

Lond Med Gaz

Case report
Ruptured subcapsular liver hematoma in pregnancy: a case report of nonsurgical management