Hepatic rupture after cesarean section in a patient with HELLP syndrome: a case report and review of the literature

Optimizing pregnancy management of chronic hypertension: A case report of cerebrovascular accident in a pregnant woman and literature review

RATIONALE

The prevalence of chronic hypertension among pregnant women is steadily increasing worldwide. Besides chronic hypertension is a major risk factor for preeclampsia (PE). Therefore, the standardization of monitoring and management - focusing on early identification and the judicious use of antihypertensive medications to improve maternal and fetal outcomes - has become a critical concern for clinicians.

PATIENT CONCERNS

A 31-year-old pregnant woman with chronic hypertension exhibited repeated blood pressure of 160/110 mm Hg or higher throughout her pregnancy, and there were no laboratory or clinical signs indicative of PE. Fluctuations in her blood pressure resulted in an acute cerebrovascular accident during the period of expectant management.

DIAGNOSES

Chronic hypertension with severe PE.

INTERVENTIONS

The patient was admitted due to acute severe hypertension and received corticosteroids for fetal lung maturation. Expectant management was initially considered due to relatively stable condition during the first 3 days of hospitalization. However, on the 4th day, despite treatment with both oral and intravenous antihypertensive agents, blood pressure remained uncontrolled, even reaching 200/105 mm Hg or higher. Unfortunately, the persistent severe hypertension resulted in an acute stroke, necessitating emergency cesarean section and neurosurgical intervention at 31 + 5 weeks of gestation.

OUTCOMES

The neonate was transferred to the Neonatal Intensive Care Unit and remained there for 38 days before discharge. The patient was discharged by postoperative day 19 and continued with rehabilitation treatment. At the latest follow-up, muscle strength in her left limb remained at grade 1, with no significant recovery observed.

LESSONS

Pregnant women with chronic hypertension who present persistently elevated and uncontrollable blood pressure should be diagnosed with severe PE. Treatment regimens for hypertensive disorders of pregnancy typically involve oral antihypertensive medications, which should be administered judiciously based on clinical guidelines and trial evidence. For chronic maintenance treatment, labetalol and extended-release nifedipine are recommended as 1st-line agents by most international guidelines, with nifedipine being a viable initial option for severe hypertension. For women with severe PE, after corticosteroids have been administered for fetal lung maturation, an overall assessment of maternal and placental-fetal conditions should guide whether expectant management is feasible or if prompt delivery is required to minimize severe complications.

Spontaneous subcapsular hepatic hematoma in pregnant patients

Spontaneous subcapsular hepatic hematoma (SSHH) with or without previous history of preeclampsia and/or HELLP syndrome represents a very rare pathological condition in pregnancy and postpartum, (1/45,000-1/225,000 pregnancies). Its importance for the anesthesiologist lays in its association with high morbidity and mortality for the mother (60-86%, 39%) and newborn (42%). After a high clinical suspicion, the certainty clinical diagnosis is settled by different imaging techniques. However, in most cases the diagnosis of SSHH is a casual intraoperative finding associated to a maternal or foetal compromise. Nowadays the obstetric and anaesthetic management of a SSHH is not standardized and depends on its integrity, hemodynamic stability and the gestational period when diagnosed. The possibility of an acute critic haemorrhage with necessity of massive transfusion, makes advisable to provide updated protocols for the treatment of obstetric hemorrhage, adapting them to the clinical peculiarities of these patients. After the acute phase, close attention should be kept on thromboembolic complications.

Conservative management of a pregnancy complicated by preeclampsia and postpartum spontaneous hepatic rupture: A case report and review of the literature

INTRODUCTION AND OBJECTIVES

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.

METHODS

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.

RESULTS

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.

DISCUSSION/CONCLUSION

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"

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.

Ruptured Subcapsular Liver Hematoma: A Rare Complication of HELLP Syndrome

Subcapsular liver hematoma (SLH) is a rare complication of HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome. We report a previously healthy 16-year-old female presenting with pre-eclampsia requiring emergent C-section, who developed immediate postoperative bleeding and abdominal distention. Abdominal computed tomography angiography (CTA) revealed a large encapsulated liver hematoma with active extravasation. The patient was successfully treated with a multidisciplinary approach with medical and surgical management.

Management of Spontaneous Hepatic Rupture on Top of HELLP Syndrome: Case Report and Review of the Literature

Introduction

We report the case of a patient with antepartum HELLP syndrome and simultaneous rupture of the right liver lobe. An emergency caesarean section was performed and the liver rupture was managed surgically via perihepatic packing. The mother and her child recovered well and were discharged 19 days after admission.

Case Report

We describe a case report and review the literature. Based on our own experience and the most common clinical presentations of such patients, we were able to establish an algorithm for managing such cases.

Conclusion

An association between liver rupture and HELLP syndrome is rare but was previously described in several case reports. In pregnant women with HELLP syndrome and acute onset abdominal pain, a potential spontaneous hepatic rupture should be taken into consideration.

Maternal and fetal outcome in de novo preeclampsia in comparison to superimposed preeclampsia: a two-year observational study

AIM

To assess the maternal and fetal outcome in women with de novo preeclampsia (PE) in comparison to superimposed PE.

STUDY DESIGN

This was a prospective 2-year observational study carried out at Menoufia University Hospital, Egypt, in which 164 patients out of 6472 pregnant women were diagnosed with PE (78 with de novo PE and 86 with superimposed PE). Enrolled patients were followed to assess the maternal and fetal outcome.

RESULTS

There was a significant higher women with liver impairment and delivery by caesarean section in the de novo PE group (p < 0.05), with more women with renal impairment and ECG changes in the superimposed PE group (p < 0.05). No significant difference between the two groups regarding the occurrence of eclampsia, blood transfusion, admission to ICU and venous thromboembolism (p > 0.05). There was a significantly higher small for gestational age, prematurity, NICU admission and perinatal mortality in the superimposed PE group (p < 0.05). No significant difference between the two groups regarding the occurrence of placental abruption and intrauterine fetal demise (p > 0.05).

CONCLUSIONS

Women with de novo PE have higher risks of liver impairment and delivery by cesarean section. On the other hand, women with superimposed PE have higher risks of poorer fetal outcome.

The management of the surgical complications of HELLP syndrome

INTRODUCTION

Complications from HELLP (Haemolysis, Elevated Liver enzymes and Low Platelet) syndrome may present as an emergency to any surgeon. We review the ten-year experience of a tertiary hepatobiliary centre managing HELLP patients. Three selected cases are described to highlight our management strategy and a systematic review of the recent literature is presented.

METHODS

All patients with HELLP syndrome were identified from a prospectively maintained database and their details collated. Subsequently, a detailed search of PubMed was carried out to identify all case series of HELLP syndrome in the literature in the English language since 1999.

RESULTS

On review of 1,002 cases, 10 patients were identified with surgical complications of HELLP syndrome. Seven of these patients had a significant liver injury. Only three of these required surgical intervention for liver injury although four other patients required surgical intervention for other complications. There was no maternal mortality in this series. Review of the literature identified 49 cases in 31 publications. The management approaches of these patients were compared with ours.

CONCLUSIONS

We have presented a large series of patients with surgical complications resulting from HELLP syndrome managed without maternal mortality. This review has confirmed that haemodynamically stable patients with HELLP syndrome associated hepatic rupture can be conservatively treated successfully. However, in unstable patients, perihepatic packing and transfer to a specialist liver unit is recommended.

HELLP Syndrome Complicated by Subcapsular Hematoma of Liver: A Case Report and Review of the Literature

Subcapsular liver hematoma (SLH) is a rare complication of severe preeclampsia and HELLP syndrome. These patients must be followed up in intensive care unit for advanced medical support with infused fluid, replacement of blood products, and treatment of underlying disorders. There are a lot of therapeutic options varying from conservative management to surgical treatment including hepatic resection, hepatic artery ligation, and liver transplantation. In this report we aimed to present a 26-year-old woman with SLH secondary to HELLP syndrome.

Hepatic rupture in hemolysis, elevated liver enzymes, low platelets syndrome

OBJECTIVE

Rupture of hepatic hematoma associated with hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome is a catastrophic complication of pregnancy. Maternal and fetal mortality rates are still high despite advances in diagnosis and treatment. We aimed to present our experience at two referral centers for hepatic disease and to compare it with cases from the literature.

METHODS

We reviewed nine cases that occurred over the past 6 years in our centers and made an extensive literature review covering the past 10 years. We reviewed and compared multiple outcomes for all these cases.

RESULTS

The median maternal age of our patients was 29 years (interquartile range 27-32). Embolization treatment was used with seven of nine (78%) of our patients compared with 5 of 88 (6%) in the literature (P<.001). Our maternal and fetal mortality rates were 0% (95% confidence interval [CI] 0-34%) and 30% (95% CI 7-65%), respectively, compared with 17% (95% CI 10-26%) and 38% (95% CI 31-52%]) from our review of the literature from 2000 to 2010.

CONCLUSION

The use of hepatic artery embolization to address hepatic rupture associated with HELLP syndrome may help minimize morbidity and maternal mortality.