Diagnosis and surgical management of spontaneous hepatic rupture associated with HELLP syndrome

The role of point-of-care ultrasound (POCUS) in maternal medicine

Point-of-care ultrasound (POCUS) is an increasingly valuable tool in maternal medicine, offering rapid, bedside evaluation of critically ill pregnant patients. This study explores the expanding role of POCUS in obstetric care, particularly its application in assessing different organ systems. POCUS enables timely, accurate diagnoses and interventions, crucial for preventing maternal morbidity and mortality. While POCUS is widely used in emergency and intensive care, its potential in obstetric settings remains underexplored. Maternal and Fetal Medicine specialists, who already possess substantial ultrasound expertise, can easily integrate POCUS in daily practice.

Hepatic Rupture in HELLP Syndrome: Report of Two Patients and a Review of Peripartum Surgical Care and Transfusion

Herein, we report the cases of two patients with hemolysis, elevated liver enzymes, and low platelets syndrome who underwent emergent Cesarean sections that were complicated by massive hemorrhage due to undiagnosed hepatic rupture. Intraoperative General Surgery team intervention, early activation of massive transfusion protocol, hemostatic resuscitation, and transfer to ICU resulted in the survival of both patients.

Transcatheter arterial embolization in postpartum HELLP syndrome: A case report

INTRODUCTION

Hemolysis, elevated liver enzyme levels, and low platelet count (HELLP) syndrome is a pregnancy-related clinical condition characterized by hemolysis, elevated liver enzymes, and thrombocytopenia, posing significant risks to maternal and fetal safety. Hepatic hematoma with spontaneous rupture and bleeding is a rare but severe complication of HELLP syndrome, with limited reports of hepatic artery intervention and embolization therapy.

PRESENTATION OF CASE

We present the case of a 35-year-old pregnant woman who developed worsening pain under the xiphoid process the night following a cesarean section. Her blood pressure dropped from 189/110 mmHg to 90/60 mmHg within 40 min. Vaginal exploration revealed no blood flow, and subsequent laparotomy uncovered multiple small liver surface lacerations actively bleeding. Emergency transcatheter arterial embolization (TAE) was promptly performed, stabilizing her condition. She was discharged 37 days post-admission.

DISCUSSION

TAE plays an important role in the treatment of HELLP syndrome with spontaneous liver rupture, with characteristics of minimal trauma and good efficacy, but the evidence supporting this recommendation is somewhat limited.

CONCLUSION

This case underscores TAE as a potentially effective and less invasive alternative to surgical interventions for managing HELLP syndrome with spontaneous liver rupture. Further research is needed to better clarify the safety and efficacy of TAE in the treatment of HELLP syndrome with spontaneous liver rupture.

Systemic Disease and the Liver Part 2: Pregnancy-Related Liver Injury, Sepsis/Critical Illness, Hypoxia, Psoriasis, Scleroderma/Sjogren's Syndrome, Sarcoidosis, Common Variable Immune Deficiency, Cystic Fibrosis, Inflammatory Bowel Disease, and Hematologic Disorders

The liver is involved in many multisystem diseases and commonly may manifest with abnormal liver chemistry tests. The liver test perturbations may be multifactorial in nature, however, as patients are receiving many different medications and can also have intrinsic liver disease that may be exacerbated by the systemic disorder. Some disorders have typical histologic findings that can be diagnosed on liver biopsy, whereas others will show a more nonspecific histology. Clinicians should be aware of these conditions so as to consider the performance of a liver biopsy at the most opportune time and setting to help establish the diagnosis of acute or chronic liver disease.

First-Trimester Screening for HELLP Syndrome—Prediction Model Based on MicroRNA Biomarkers and Maternal Clinical Characteristics

We evaluated the potential of cardiovascular-disease-associated microRNAs for early prediction of HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome. Gene expression profiling of 29 microRNAs was performed on whole peripheral venous blood samples collected between 10 and 13 weeks of gestation using real-time RT-PCR. The retrospective study involved singleton pregnancies of Caucasian descent only diagnosed with HELLP syndrome (n = 14) and 80 normal-term pregnancies. Upregulation of six microRNAs (miR-1-3p, miR-17-5p, miR-143-3p, miR-146a-5p, miR-181a-5p, and miR-499a-5p) was observed in pregnancies destined to develop HELLP syndrome. The combination of all six microRNAs showed a relatively high accuracy for the early identification of pregnancies destined to develop HELLP syndrome (AUC 0.903, p < 0.001, 78.57% sensitivity, 93.75% specificity, cut-off > 0.1622). It revealed 78.57% of HELLP pregnancies at a 10.0% false-positive rate (FPR). The predictive model for HELLP syndrome based on whole peripheral venous blood microRNA biomarkers was further extended to maternal clinical characteristics, most of which were identified as risk factors for the development of HELLP syndrome (maternal age and BMI values at early stages of gestation, the presence of any kind of autoimmune disease, the necessity to undergo an infertility treatment by assisted reproductive technology, a history of HELLP syndrome and/or pre-eclampsia in a previous gestation, and the presence of trombophilic gene mutations). Then, 85.71% of cases were identified at a 10.0% FPR. When another clinical variable (the positivity of the first-trimester screening for pre-eclampsia and/or fetal growth restriction by the Fetal Medicine Foundation algorithm) was implemented in the HELLP prediction model, the predictive power was increased further to 92.86% at a 10.0% FPR. The model based on the combination of selected cardiovascular-disease-associated microRNAs and maternal clinical characteristics has a very high predictive potential for HELLP syndrome and may be implemented in routine first-trimester screening programs.

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.

Perioperative challenges following management of spontaneous hepatic rupture in a parturient with severe pre-eclampsia – A case report

Spontaneous hepatic rupture in pregnancy (SHRP) is a rare but often fatal condition associated with pre-eclampsia or HELLP (haemolysis, elevated liver enzymes, low platelets) syndrome. SHRP is linked to significant maternal and perinatal morbidity and mortality, and maternal complications can extend past the initial intraoperative period. This case report describes the challenging perioperative course of a 35-year-old woman with SHRP. She underwent five laparotomies during a prolonged and complicated course in the intensive care unit. Despite these challenges, maternal and fetal outcomes were good. This case report serves to highlight key perioperative multidisciplinary issues in the care of these patients.

Hypertensive disorders in pregnancy complicated by liver rupture or hematoma: a systematic review of 391 reported cases

BACKGROUND

Spontaneous liver rupture in pregnancy is often unrecognized, highly lethal, and not completely understood. The goal was to summarize and define the etiology, risk factors, clinical presentation, appropriate diagnostic methods, and therapeutic options for spontaneous hepatic rupture during pregnancy/puerperium (SHRP) complicated by the hypertensive disorder.

METHODS

Literature search of all full-text articles included PubMed (1946-2021), PubMed Central (1900-2021), and Google Scholar. Case reports of a spontaneous hepatic rupture or liver hematoma during pregnancy or puerperium as a complication of hypertensive disorders (preeclampsia, eclampsia, HELLP syndrome) were searched. There was no restriction of language to collect the cases. Additional cases were identified by reviewing references of retrieved studies. PRISMA guidelines for the data extraction and quality assessment were applied.

RESULTS

Three hundred and ninety-one cases were collected. The median maternal age was 31 (range 17-48) years; 36.6% were nulliparous. Most (83.4%) occurred in the third trimester. Maternal and fetal mortality was 22.1% and 37.2%, respectively. Maternal and fetal mortality was significantly higher 1) before the year 1990, 2) with maternal hemodynamic instability, and 3) eclampsia. The most important risk factors for SHRP were preeclampsia and HELLP syndrome. Most women had right lobe affected (70.9%), followed by both lobes in 22.1% and left lobe in 6.9%. The most common surgical procedure was liver packing. Liver transplantation was performed in 4.7% with 100% survival. Maternal mortality with liver embolization was 3.0%. Higher gestational age increases fetal survival.

CONCLUSION

The diagnosis and treatment of SHRP are often delayed, leading to high maternal and fetal mortality. SHRP should be excluded in hemodynamically unstable patients with preeclampsia/eclampsia or HELLP syndrome and right upper abdominal pain. Liver embolization and liver transplantation contribute to maternal survival. Maternal and fetal mortality was significantly higher before the year 1990. Hemodynamic instability, preeclampsia, and eclampsia have a significant negative influence on maternal survival.

LEVEL OF EVIDENCE

Level V.

Pregnancy-Associated Liver Diseases

The liver disorders unique to pregnancy include hyperemesis gravidarum, intrahepatic cholestasis of pregnancy, acute fatty liver of pregnancy, and preeclampsia-associated hepatic impairment, specifically hemolysis, elevated liver enzymes, and low platelet count syndrome (HELLP). Their importance lies in the significant maternal and fetal/neonatal morbidity and mortality. Expeditious diagnosis and clinical evaluation is critical to ensure timely, appropriate care and minimize risks to the pregnant woman and her fetus/baby. A multidisciplinary approach is essential, including midwives, maternal-fetal-medicine specialists, anesthetists, neonatologists, and hepatologists.

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.

Transcatheter Arterial Embolization for Spontaneous Hepatic Rupture Associated with HELLP Syndrome: A Case Report

Background: Spontaneous hepatic rupture associated with the syndrome characterized by hemolysis, elevated liver enzymes, and a low platelet count (HELLP syndrome) is a rare and life-threatening condition, and only a few cases regarding the management of this condition through transcatheter arterial embolization (TAE) have been previously reported. Case summary: Herein, we report a case involving a 35-year-old pregnant woman who presented at 28 weeks of gestation with right upper quadrant pain, hypotension, and elevated levels of liver enzymes. Transabdominal ultrasound revealed fetal death. She required an emergency cesarean section, and hepatic rupture was identified after the fetus had been delivered. Hepatic packing and TAE were performed. The postprocedural course was uneventful, and the patient was discharged 14 days after she had been admitted to our hospital. Conclusions: Spontaneous hepatic rupture associated with HELLP syndrome is a very serious condition that requires prompt and decisive management. The high maternal and fetal mortality rates associated with this condition can be reduced through early accurate diagnosis and adequate management. The findings in the reported case indicate that TAE may be an attractive alternative to surgery for the management of spontaneous hepatic rupture associated with HELLP syndrome.

"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.

Manejo de la ruptura hepática espontánea en el síndrome de HELLP

Introducción. El síndrome de HELLP es una variante grave de la preeclampsia, con una baja incidencia, entre el 0,5-0,9 % de todos los embarazos. La ruptura hepática espontánea en el embarazo es infrecuente, presenta una alta mortalidad, y se ha relacionado con hemangiomas hepáticos, coriocarcinoma y síndrome de HELLP. Caso clínico. Mujer de 29 años con embarazo de 34,3 semanas, con actividad uterina progresiva, sufrimiento fetal agudo y hallazgos compatibles con síndrome de HELLP. Se practicó cesárea de urgencia encontrando hemoperitoneo y ruptura hepática del lóbulo derecho, por lo que se realizó empaquetamiento abdominal y posterior reintervención quirúrgica. Discusión. La ruptura hepática espontánea en el embarazo es una entidad infrecuente y potencialmente mortal. Es esencial un alto nivel de sospecha para realizar el diagnóstico y la rápida intervención. Requiere un manejo multidisciplinario para un resultado exitoso. Se han descrito múltiples tratamientos que dependen de las manifestaciones clínicas y extensión de la lesión, pero es claro que la laparotomía primaria y el taponamiento constituyen la mejor elección ante el hallazgo intraoperatorio

Managing a rare complication of HELLP syndrome in Australia: Spontaneous liver haematoma in pregnancy

Spontaneous subcapsular haematoma of the liver is a rare but life-threatening complication of pregnancy. Prevention of maternal and fetal death requires early identification and specialised management. We report three cases of spontaneous liver haematoma in pregnancy from our institution between 2011 and 2018. We conducted a systematic search of online databases using search terms, ('liver' AND 'pregnancy') AND ('haematoma' OR 'rupture') in order to present a narrative review of the literature and a systematic management framework. Our series is the first Australian report of spontaneous subcapsular haematoma in pregnancy with one fetal death in utero but no maternal deaths. Our systematic search of online databases revealed 45 similar reports in the last ten years. Individual patient data were available for 73 cases. The overwhelming majority of these reports were single cases or small case series. We estimate the mean maternal mortality rate to be 15% but fetal mortality was substantially greater than 15% (although data for neonatal outcomes was incomplete). There was one case report of liver transplantation with excellent maternal and fetal outcome. In the last five years, modern diagnostic techniques and therapeutic options have significantly reduced maternal and fetal mortality. Hepatic artery embolisation is a minimally invasive approach under guidance of imaging and is likely to achieve the best maternal and fetal outcomes. Based on our literature review, we have provided a systematic management framework for spontaneous liver haematoma in pregnancy.

Gastrointestinal diseases during pregnancy: what does the gastroenterologist need to know?

Pregnancy is characterized by numerous physiological changes that may lead to a diversity of symptoms and frequently to gastrointestinal complaints, such as heartburn, nausea and vomiting, or constipation. Chronic gastrointestinal diseases require treatment maintenance during this period, raising the challenging question whether outcomes beneficial to the mother may be harmful for the fetus. In addition, certain diseases, such as acute fatty liver of pregnancy, only develop during pregnancy and may require urgent procedures, such as fetus delivery. Even though they are not present in our day-to-day practice, knowledge of pregnancy-related diseases is fundamental and collaboration between gastroenterologists and obstetricians is often necessary. Herein, we review pregnancy-related diseases and systematize the most appropriate treatment choices according to the recent literature and guidelines, so that the article can serve as a guide to the gastroenterologist regarding the medical approach to pregnancy-related gastrointestinal and liver diseases and their therapeutic management.

Hepatic rupture associated with preeclampsia, report of three cases and literature review

BACKGROUND

Hepatic rupture is a complication during pregnancy that, although rare, accounts for high morbidity and mortality rates. It is mainly associated with severe preeclampsia and HELLP syndrome. Incidence is estimated to be at one per 67,000 births or one per 2000 patients with preeclampsia/eclampsia/HELLP, mainly in multiparous women; women in their 40s; after 32 weeks of gestation; and during the first 15 h postpartum.

CASES

This article exposes the institutional experience at Fundación Valle del Lili in Cali, Colombia, in managing and treating hepatic rupture associated with severe preeclampsia and HELLP syndrome in three patients in the 30th, the 26th, and the 27th week of gestation, not resulting in maternal death.

DISCUSSION

A search in Pubmed, Embase, and Ovid from 2000 to 2017 resulted in 35 cases reported in either pregnant or puerperal women. Hepatic rupture is a rare complication in pregnancy associated with preeclampsia and HELLP syndrome. Its pathophysiology is attributed to the presence of vasospasm due to an increase in concentration and sensitivity to circulating vasopressors during pregnancy. There is no standard management, but surgery reduces mortality significantly. It includes endovascular management, partial hepatectomy, or transplant (only one patient required a liver transplant in our search). The most used techniques have been ligation of the hepatic artery, embolization of the hepatic artery, and examination, packing, and drainage of hepatic lesion for bleeding control (27 cases were treated with laparotomy with evacuation of hematoma and hemostasis and four cases were treated with embolization of the hepatic artery). Hepatic artery occlusion both by surgery ligation and by embolization through interventional radiology has reported successful and failing results during pregnancy Conclusion: Management of pathologies as hepatic rupture associated with severe preeclampsia and HELLP syndrome has to be clearly protocolized for prompt diagnosis and early management. Furthermore, it has to be carried out through multidisciplinary teams in high-complexity obstetrics scenarios.

Right hepatectomy after spontaneous hepatic rupture in a patient with preeclampsia: A case report

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Spontaneous hepatic rupture is a rare complication of preeclampsia and HELLP syndrome.

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It carries a high maternal and perinatal mortality.

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Multidisciplinary management is key to optimal outcomes.

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Usual management includes perihepatic packing or angioembolization but formal lobectomy may be required in special cases.

Introduction

Spontaneous hepatic rupture associated with preecalmpsia or HELLP syndrome is a rare and life threatining event, only 200 cases have been reported in the literature.

Presentation of case

We present a case of a 31 year old female with 28 weeks of gestation that presented with acute abdominal pain, elevated blood pressure and altered liver enzymes an abdominal ultrasound that showed a subcapsular hematoma occupying the whole right lobe and free abdominal fluid, she required emergent laparotomy, C-section, hepatic packing, followed by angioembolization and finally right hepatectomy.

Discussion and conslusion

Spontaneous hepatic rupture due to preeclampsia or HELLP syndrome is a medical emergency, it requires a prompt and decisive treatment. Multiple treatment modalities are available, from simple hepatic packing to endovascular embolization, but in extreme situations a formal hepatectomy might be required.

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.

[Ruptured subcapsular hematoma of the liver complicating acute fatty liver of pregnancy]

L'hématome sous-capsulaire du foie est une complication rare de la grossesse, survenant le plus souvent dans le cadre d'une pré éclampsie ou d'un HELLP syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelets Syndrome). Rare sont les cas décris au cours d'une stéatose hépatique aiguë gravidique. Nous rapportons le cas d'une parturiente de 33 ans, multipare, sans antécédents, admise aux urgences au terme d'une grossesse à 37 semaines d'aménorrhées, pour pré éclampsie compliquée d'une stéatose hépatique aiguë gravidique. L’échographie hépatique réalisée à l'admission était sans anomalie. Une césarienne a été réalisée en urgence devant une souffrance fœtale aiguë, au cours de laquelle a été mise en évidence une rupture de l'hématome sous capsulaire du foie s'accompagnant d'un état de choc hémorragique. La prise en charge a consisté à une polytransfusion et packing perihépatique. Le retrait du packing n'a été réalisé qu'au quatrième jour, après stabilisation clinicobiologique et régression de l'encéphalopathie hépatique. L’évolution en réanimation a été favorable avec sortie de la patiente au vingtième jour. La rupture de l'hématome sous-capsulaire du foie est extrêmement dangereuse et à haut risque materno-fœtal. L'association à la stéatose hépatique aggrave le pronostic.

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.

Management of hepatic rupture diagnosed after an emergency cesarean section

A careful management of hepatic capsular rupture, with massive hemoperitoneum which occurred 14 hours after an emergency cesarean section at 36 weeks of gestation, is meticulously reported. The grade of hepatic involvement varies from minor capsular laceration to extensive parenchymal rupture. Our management involved a combination of surgical interventions and aggressive supportive care. The patient was discharged after 53 days and 4 laparotomies and an unsuccessful attempt of superselective artery embolization. Ultrasound after 40 days from the last surgery showed uniform hepatic parenchyma free of focal lesions. Due to the rarity and the unpredictability nature of this devastating event we believe necessary to report our experience, reinforcing the importance of the postsurgery management.

Interpretation and management of hepatic abnormalities in pregnancy

The spectrum of liver disease in pregnancy includes liver disease unrelated to pregnancy, liver diseases that occur with increased frequency or severity in pregnancy, and liver disease specific to pregnancy. Diseases of the liver unique to pregnancy reliably occur at specific points in the gestational spectrum. Thus, gestational age, a comprehensive history, and a clinically driven diagnostic evaluation is critical in approaching a pregnant patient with abnormal liver chemistries or function. Early recognition of these conditions is important and although management may be expectant, some patients require targeted therapy or necessitate prompt delivery, which can be life-saving to both mother and child.

Spontaneous hemopertitoneum - a matter of life and death

Spontaneous hemopertitoneum in pregnancy (SHiP) is a rare but potential catastrophic complication with high maternal and fetal mortality. The main cause of morbidity and mortality is delayed diagnosis and treatment. In this paper we will document the findings of an interesting case managed in our unit. We also discuss the etiology, diagnosis and management of this condition with high potential to lead to medico‐legal cases.

Pre-eclampsia/eclampsia and hepatic rupture

OBJECTIVE

To review case reports of hepatic hematoma/rupture in women with pre-eclampsia/eclampsia.

METHODS

MEDLINE, SciELO, and LILACS databases were searched for case reports of pre-eclampsia/eclampsia with hepatic hematoma/rupture. Only articles written in English, Spanish, French, or Portuguese and published between 1990 and 2010 were reviewed.

RESULTS

In total, 180 cases of hepatic hematoma or rupture were identified: 18 (10.0%) with subcapsular hematoma without hepatic rupture; and 162 (90.0%) with capsule rupture. Twelve (6.7%) cases were associated with eclampsia plus hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome. Average age was 30.9 ± 5.0 years, 74/129 (57.4%) women were parous, and cesarean delivery was performed in 132/162 (81.5%) cases. The right lobule was the most frequently affected 77/100 (77.0%). The total maternal mortality rate was 22.2% during the 21 years; however, it decreased to 16.4% in the last decade studied. The perinatal mortality rate was 30.7% and was very similar during the 2 decades.

CONCLUSION

HELLP syndrome is a frequent diagnosis (92.8%) in hepatic hemorrhage/rupture. The major reduction in maternal mortality rate was probably associated with advances in resuscitation, intensive-care medicine, and surgical intervention, including liver transplantation and arterial embolization.

[Hepatic subcapsular hematoma: a case report and management update]

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.

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.

Liver diseases unique to pregnancy: a 2010 update

Liver disorders occurring during pregnancy may be specifically pregnancy-related, or may be due to an intercurrent or chronic liver disease, which may present in anyone, pregnant or not. This review focuses on the liver diseases unique to pregnancy. Hyperemesis gravidarum, which occurs during early pregnancy, may be associated with liver dysfunction. Intrahepatic cholestasis of pregnancy typically occurs during the second or third trimester. Pruritus and the associated biological signs of cholestasis improve rapidly after delivery. Mutations in gene encoding biliary transporters, especially ABCB4 encoding the multidrug resistance 3 protein, have been found to be associated with this complex disease. Ursodeoxycholic acid is currently the most effective medical treatment in improving pruritus and liver tests. Pre-eclampsia, which presents in late pregnancy frequently involves the liver, and HELLP syndrome (Hemolysis-Elevated Liver enzymes-Low Platelets) is a life-threatening complication. Prognosis of acute fatty liver of pregnancy has been radically transformed by early delivery, and clinicians must have a high index of suspicion for this condition when a woman presents nausea or vomiting, epigastric pain, jaundice, or polyuria-polydipsia during the third trimester. Acute fatty liver of pregnancy has been found to be associated with a defect of long-chain 3-hydroxyacyl coenzyme A dehydrogenase in the fetus, and mothers and their offspring should undergo DNA testing at least for the main associated genetic mutation (c.1528G>C).