Surgical treatment of HELLP syndrome-associated liver rupture -- an update

Spontaneously ruptured huge hepatic subcapsular hematoma associated with preeclampsia: A case report and literature review

Hepatic subcapsular hematoma (HSH) is an uncommon complication of pregnancy and is associated with elevated rates of maternal and foetal mortality. The rupture of an HSH is a critical situation that necessitates immediate and timely intervention to prevent loss of life. We present here, a case of a spontaneously ruptured massive HSH caused by preeclampsia. In addition, we conducted a comprehensive review of existing literature, encompassing 49 cases of HSH associated with pregnancy. If a pregnant woman with gestational hypertension experiences right upper abdominal pain with shoulder pain or radiating shoulder pain, it is crucial for her to have an urgent abdominal ultrasound because of the potential development of HSH and/or rupture. Our review of current literature suggests that opting for a caesarean section may offer notable advantages in preventing HSH rupture.

Subcapsular liver hematoma complicating HELLP syndrome: A case report and review of management strategies

Subcapsular liver hematoma is a life-threatening complication of pregnancy. It is associated with preeclampsia and HELLP syndrome. We present the case of a 36-year-old Caucasian nulliparous woman who was diagnosed at 29 weeks and 6 days of gestation with mild preeclampsia. After brief hospitalization she was discharged. During a daily follow-up, at 31 weeks and 3 days of gestation, she complained of mild abdominal pain and blood tests revealed HELLP syndrome. The cervix was unripe. A healthy baby was delivered by emergency cesarean section. The following day, the patient complained of persistent abdominal pain, and at the same time the hepatic cytolysis worsened dramatically. A computed tomography (CT) scan revealed a significant subcapsular hematoma without any active bleeding or breach of Glisson's capsule. We treated the patient conservatively and she was discharged home 10 days after the diagnosis was made. The symptoms of subcapsular liver hematoma are non-specific. They include nausea, vomiting and epigastric pain, and pain in the right upper quadrant or shoulder. Biological analyses can show hepatic cytolysis, haemolysis and coagulation disorders. Medical imaging can confirm the diagnosis. The management of subscapular liver hematoma may depends on whether there is hemodynamic stability, active bleeding or breach of Glisson capsule's. If the patient is stable and in the absence of active bleeding, management should be purely symptomatic.

Conservative Treatment of Huge Hepatic Subcapsular Hematoma Complicated with Hepatic Infarction after Cesarean Section Caused by HELLP Syndrome - a Case Report and Literature Review

Hepatic subcapsular hematoma and hepatic infarction in labor are mostly secondary to HELLP syndrome and preeclampsia. There are few reported cases with a complicated diagnosis and treatment and high mortality. Here, we present a case of a huge hepatic subcapsular hematoma complicated with hepatic infarction after cesarean section that was secondary to HELLP syndrome and the patient was treated conservatively. Further, we have discussed the diagnosis and treatment of hepatic subcapsular hematoma and hepatic infarction caused by HELLP syndrome.

COVID-19 related liver injuries in pregnancy

While severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) quickly spread across the globe, our understanding of its pathogenic mechanisms evolved. Importantly, coronavirus disease 2019 (COVID-19) is now considered a syndromic multisystem inflammatory disease involving not only the respiratory system but also the cardiovascular, excretory, nervous, musculoskeletal, and gastrointestinal systems. Moreover, a membrane-bound form of angiotensin-converting enzyme 2, the entry receptor for SARS-CoV-2, is expressed on the surface of cholangiocytes and hepatocytes, suggesting the potential of COVID-19 to involve the liver. With the widespread distribution of SARS-CoV-2 throughout the population, infection during pregnancy is no longer a rare occurrence; however, little is known about the course of hepatic injuries and related outcomes in pregnant SARS-CoV-2-positive women. Thus, the understudied topic of COVID-related liver disease during pregnancy poses a great challenge for the consulting gynecologist and hepatologist. In this review, we aim to describe and summarize potential liver injuries in pregnant women with COVID-19.

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.

Management of Ruptured Subcapsular Liver Hematoma as a Result of Hemolysis, Elevated Liver Enzyme, and Low Platelet Syndrome in a Rural Facility

Subcapsular liver hematoma is a rare complication of hemolysis, elevated liver enzyme, and low platelet (HELLP) syndrome. This case depicts a previously healthy 27-year-old primigravida at 39 weeks' gestation who presented with severe abdominal pain and was diagnosed with HELLP syndrome based on vital signs and laboratory values. While arranging transport to a regional perinatal care facility she became acutely unstable with maternal hypotension and resultant fetal bradycardia. An emergent cesarean section was performed and a ruptured subcapsular liver hematoma was diagnosed intraoperatively. She was successfully managed with supportive care and surgical intervention and was discharged from the hospital on postoperative day 6. Here we review the indications and methods of conservative and surgical management of subcapsular liver hematoma as a result of HELLP syndrome.

Spontaneous liver rupture following SARS-CoV-2 infection in late pregnancy: A case report

BACKGROUND

Coronavirus disease-2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is characterized by systemic inflammatory response syndrome and vasculopathy. SARS-CoV-2 associated mortality ranges from 2% to 6%. Liver dysfunction was observed in 14%-53% of COVID-19 cases, especially in moderate severe cases. However, no cases of spontaneous hepatic rupture in pregnant women with SARS-CoV-2 have been reported.

CASE SUMMARY

A 32-year-old pregnant patient (gestational age: 32 wk + 4 d) without any remarkable medical history or long-term medication presented with epigastralgia. Infectious, non-infectious, and pregnancy-related hepatopathies were excluded. Sudden onset of right subcostal pain with D-dimer and liver enzyme elevation was followed by shock with thrombocytopenia. While performing an emergency cesarean section, hemoperitoneum was observed, and the patient delivered a stillbirth. A 6-cm liver rupture at the edges of segments V and VI had occurred, which was sutured and drained. SARS-CoV-2 positivity on reverse transcription-polymerase chain reaction was confirmed. Further revisions for intrahepatic hematoma with hemorrhagic shock and abdominal compartment syndrome were performed. Subsequently, the patient developed hemoptysis, which was treated using bronchoscopic therapy and non-invasive ventilation. Liver tissue biopsy revealed hemorrhagic foci and necrosis with an irregular centrilobular distribution. Antiphospholipid syndrome and autoimmune hepatitis were also ruled out. Fetal death was caused by acute intrauterine asphyxia.

CONCLUSION

This case reveals that pregnant women with SARS-CoV-2 infection may be predisposed to liver parenchyma disease with liver rupture.

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.

Acute liver failure and HELLP syndrome: A clinical case and literature review

BACKGROUND

HELLP syndrome is a pregnancy-related liver disease associated with increased maternal and foetal mortality. In rare cases, it can lead to the development of a subcapsular hepatic haematoma as well as its rupture. This rupture is life-threatening if not urgently treated.

METHOD

We describe a clinical case of HELLP syndrome involving a ruptured subcapsular liver haematoma and contextualise this with a literature overview.

CLINICAL CASE

A 39-year-old woman of 40 weeks' gestation presented to her local Emergency Department with symptoms and serology classically associated with HELLP syndrome. However, she clinically deteriorated and developed a ruptured subcapsular haematoma. She underwent an emergency Caesarean section at her initial hospital. Upon clinical stabilisation, she was transferred to our transplant unit for an urgent liver transplant.

CONCLUSION

LT is a life-saving procedure for patients with acute liver failure secondary to HELLP syndrome. These patients should be immediately referred to a high-volume transplant centre.

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.

HELLP Syndrome or Acute Fatty Liver of Pregnancy: A Differential Diagnostic Challenge: Common Features and Differences

HELLP syndrome and the less common acute fatty liver of pregnancy (AFL) are unpredictable, life-threatening complications of pregnancy. The similarities in their clinical and laboratory presentations are often challenging for the obstetrician when making a differential diagnosis. Both diseases are characterised by microvesicular steatosis of varying degrees of severity. A specific risk profile does not exist for either of the entities. Genetic defects in mitochondrial fatty acid oxidation and multiple pregnancy are considered to be common predisposing factors. The diagnosis of AFL is based on a combination of clinical symptoms and laboratory findings. The Swansea criteria have been proposed as a diagnostic tool for orientation. HELLP syndrome is a laboratory diagnosis based on the triad of haemolysis, elevated aminotransferase levels and a platelet count < 100 G/l. Generalised malaise, nausea, vomiting and abdominal pain are common symptoms of both diseases, making early diagnosis difficult. Clinical differences include a lack of polydipsia/polyuria in HELLP syndrome, while jaundice is more common and more pronounced in AFL, there is a lower incidence of hypertension and proteinuria, and patients with AFL may develop encephalopathy with rapid progression to acute liver failure. In contrast, neurological symptoms such as severe headache and visual disturbances are more prominent in patients with HELLP syndrome. In terms of laboratory findings, AFL can be differentiated from HELLP syndrome by the presence of leucocytosis, hypoglycaemia, more pronounced hyperbilirubinemia, an initial lack of haemolysis and thrombocytopenia < 100 G/l, as well as lower antithrombin levels < 65% and prolonged prothrombin times. While HELLP syndrome has a fluctuating clinical course with rapid exacerbation within hours or transient remissions, AFL rapidly progresses to acute liver failure if the infant is not delivered immediately. The only causal treatment for both diseases is immediate delivery. Expectant management between 24 + 0 and 33 + 6 weeks of gestation is recommended for HELLP syndrome, but only in cases where the mother can be stabilised and there is no evidence of foetal compromise. The maternal mortality rate for HELLP syndrome in developed countries is approximately 1%, while the rate for AFL is 1.8 – 18%. Perinatal mortality rates are 7 – 20% and 15 – 20%, respectively. While data on the long-term impact of AFL on the health of mother and child is still insufficient, HELLP syndrome is associated with an increased risk of developing cardiovascular, metabolic and neurological diseases in later life.

Liver Transplantation for Hemolysis, Elevated Liver Enzymes, and Low Platelet Count Syndrome: A Propensity-score Matched Long-term Survival of the Scientific Registry of Transplant Recipients Dataset

BACKGROUND

Hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome is a life-threatening form of pre-eclampsia/eclampsia, with liver transplantation being the life-saving option for treatment for those who develop severe hepatic complications.

METHODS

We retrospectively analyzed data from the Scientific Registry of Transplant Recipients (SRTR) through October 1, 1987, to December 31, 2014. Forty patients were listed for liver transplantation, with 18 patients finally receiving their transplant. These 18 patients were matched with 1:10 patients using a propensity-score matched approach.

RESULTS

Baseline demographics were comparable between HELLP syndrome patients who received a transplant and those who did not. The 10-year intent-to-treat survival was 63.6% for non-transplanted HELLP patients, 64.2% for transplanted HELLP patients, and 61.8% for matched patients (P = .369). Overall survival was also similar between HELLP patients and matched patients, with 10-year survival at 64.2% and 61.8% respectively (P = .985). However, death-censored graft survival was inferior in HELLP patients, with 10-year survival at 63.4% compared with 75.4% in the matched patients (P = .044).

CONCLUSIONS

Patients with HELLP syndrome who did not receive a transplant achieved similar intent-to-treat survival with those transplanted patients, while the death-censored graft survival of transplanted patients was inferior to matched patients. This might guide improved liver donor allocation in clinical practice.

A rare case of spontaneous hepatic rupture in a pregnant woman

Background

Spontaneous hepatic rupture in pregnancy is a rare and life-threatening event during the perinatal period.

Case presentation

We report a case of a 33-year-old woman with 36 + 6 weeks’ gestation that present with elevated blood pressure before delivery, who was admitted to our hospital due to irregular abdominal pain. Diagnosed with abdominal paracentesis, the emergent caesarean section and laparotomy were performed. Postoperatively, the patient experienced 22-day intensive therapy in ICU and was transferred to the General Surgery Department in good physical condition without post-operative complications.

Conclusions

This case indicates that making an accurate and timely diagnosis and taking multidisciplinary approach contribute to a successful clinical outcome.

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.

Diagnosis and Management of HELLP Syndrome Complicated by Liver Hematoma

Subcapsular liver hematoma is a rare but potentially life-threatening complication of preeclampsia and hemolysis, elevated liver enzymes, and low platelets syndrome. It may present with nonspecific signs and symptoms, none of which are diagnostic, and can mimic pulmonary embolism of cholecystitis. There is no consensus on the management of subcapsular liver hematoma. Unruptured liver hematoma can be conservatively managed. When rupture occurs, surgical, endovascular approaches and, rarely, liver transplantation, may be required. Actual literature is scant and retrospective in nature. Data on follow-up, time to resolution and outcome of subsequent pregnancies are very limited. We here review the diagnosis and management of liver hematoma.

Acute liver failure in pregnancy: Challenges and management

Acute liver failure (ALF) in pregnancy negatively affects both maternal and foetal outcome. The spectrum of liver disease in pregnancy may range from mild asymptomatic transaminitis to fatal and irreversible deterioration in liver functions leading to significant morbidity and even mortality. In this comprehensive review, we searched articles published as review articles, clinical trials, and case series in the Medline from 1970 to 2012. The overall outcome of ALF in pregnancy depends on the aetiology, timely diagnosis, prompt management, and early referral to a centre equipped in managing medical or obstetric complication. The foetal outcome is affected by the stage of pregnancy in which the mother has a deterioration of the liver function, with a worst prognosis associated with first or second-trimester liver failure. When ALF complicates pregnancy, liver transplantation is the one of the viable options. Management protocols need to be individualised for each case keeping in mind the risk versus benefit to both the mother and the foetus.

Hepatic capsular avulsion after video-assisted thoracic biopsy of the lung

We report a life-threatening subcapsular hepatic hemorrhage after VATS, successfully treated with Gelfoam embolization of the right hepatic artery. The postprocedure course was complicated by infarction of the right hepatic lobe.

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.

Spontaneous liver rupture: A report of two cases

Spontaneous bleeding due to a non traumatic liver rupture is a rare occurrence. However, it is associated with high morbidity and mortality. Usually the predisposing factors are like Hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome in pregnant women and other liver diseases. It is generally diagnosed by imaging studies such as ultra sonogram or computerized tomogram (CT). Due to its rarity no standard treatment has been described. Here, we report two cases of spontaneous rupture of normal liver in two young males. They presented with severe shock and hemoperitoneum. The diagnosis was confirmed by CT. They were managed surgically. In case of hemoperitoneum, spontaneous liver rupture should be considered. An early aggressive resuscitation and appropriate intervention gives better outcome.

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 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).

Outcomes of severe pregnancy-related liver disease: refining the role of transplantation

Severe liver disease in pregnancy is generally considered to have a favorable prognosis. The limited data available have not yielded disease-specific prognostic criteria or guidance on who should undergo liver transplantation (LT). We retrospectively evaluated 54 admissions with pregnancy-related liver disease to (1) evaluate if any admission parameters were associated with death and/or transplantation and (2) identify maternal complications. Eighteen had acute fatty liver of pregnancy and 32 had hypertension/eclampsia related disease. Seven patients (13%) died and four (7%) underwent LT. Survival rates were 43/48 if not listed for LT and 4/6 if listed. Of the four transplanted, three survived. Patients who died and/or underwent LT were more likely to have encephalopathy (p = 0.04) and hyperlactaemia (p = 0.03). Serum lactate was the best discriminant (ROC AUC 0.84). An admission lactate greater than 2.8mg/dL had 73% sensitivity and 75% specificity for predicting death or LT. The addition of encephalopathy to this parameter increased sensitivity and specificity to 90% and 86%, respectively. The King's College criteria were not effective in predicting outcome. This study confirms the overall favorable prognosis in pregnancy-related liver failure but indicates that elevated lactate levels in the presence of encephalopathy best identify patients at greatest risk of death or LT.

Spontaneous liver rupture associated with hydatidiform mole pregnancy

BACKGROUND

Spontaneous liver rupture is a rare occurrence during pregnancy.

CASE

A young woman presented early in her pregnancy with severe abdominal pain, tachycardia, and hypotension. She was taken emergently to the operating room with a presumed diagnosis of ruptured ectopic pregnancy. Exploration revealed that her hemoperitoneum resulted from large fractures within her liver. During her resuscitation and treatment, a transvaginal ultrasound scan revealed a hydatidiform molar pregnancy. On resolution of postoperative complications and complete recovery, the patient was discharged home.

CONCLUSION

This case illustrates that, although very unusual, hydatidiform molar pregnancies should be considered as a precipitating factor for spontaneous liver rupture.

Second trimester hepatic rupture in a 35 year old nulliparous woman with HELLP syndrome: a case report

The HELLP syndrome (haemolysis, elevated liver blood tests and low platelets) is a serious complication in pregnancy characterized by haemolysis, elevated liver enzymes and low platelet count occurring in 0.5 to 0.9% of all pregnancies and in 10–20% of cases with severe preeclampsia. Hepatic capsular rupture is a rare yet dramatic complication of HELLP syndrome. The majority of cases occur in multiparous women over the age of 30. Classically it presents with acute onset right upper quadrant pain in the presence of constitutional symptoms such as vomiting and pyrexia. However, symptoms and signs are usually non specific. Spontaneous hepatic rupture can be preceded by signs of hypovolaemic shock; yet the diagnosis is infrequently made prior to emergent laparotomy. We present the case of a 35 year old nulliparous woman with a second trimester gestational hepatic rupture associated with HELLP syndrome. We briefly discuss the aetiology, diagnostic difficulties and treatment options associated with this rare presentation.

Gastrointestinal complications of pre-eclampsia

Gastrointestinal complications of pre-eclampsia can occur and have the risk of being life-threatening for the mother and fetus. Hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome has been recognized as a complication of pre-eclampsia for decades. Pregnancies complicated by this syndrome require a well-formulated management plan, including assessing and stabilizing the maternal condition as well as evaluating fetal well-being. Patients with HELLP syndrome should receive anti-seizure prophylaxis with magnesium sulfate, treatment for severe hypertension, and correction of coagulopathy, if present. The potential benefits of expectant management of HELLP syndrome in those remote from term and the use of corticosteroids to improve maternal outcome remain experimental. Computed tomography or ultrasound of the abdomen should be performed if a subcapsular hematoma of the liver is suspected. If a ruptured hematoma is confirmed, massive transfusions and laparotomy are indicated. Ischemia associated with pre-eclampsia cannot only damage the liver but also the pancreas and gallbladder.

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

Spontaneous hepatic rupture with hemoperitoneum is an uncommon but devastating complication of hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome. Although the syndrome has been considered a variant of preeclampsia/eclampsia, its pathogenesis is not completely understood. Hepatic rupture increases the perinatal and maternal morbidity and mortality. This report describes 3 cases of extensive spontaneous hepatic rupture in pregnant women with HELLP syndrome. Early diagnosis and adequate tertiary management of this rare but life-threatening condition reduce the high maternal and newborn mortality.

Maternal deaths due to eclampsia and HELLP syndrome

OBJECTIVE

To evaluate maternal deaths associated with eclampsia, HELLP syndrome, and the concurrence of these conditions.

METHOD

A review of Medline studies reporting maternal deaths associated with eclampsia or HELLP syndrome published in English, Spanish, and Portuguese between 1995 and June 2008.

RESULTS

A total of 304 deaths were identified: 100 due to eclampsia, 117 due to eclampsia/HELLP, and 87 associated with HELLP syndrome. Of the total deaths, 71.3% of women had seizures and 67.1% developed HELLP syndrome. In high-income countries 3.9% of deaths were due to eclampsia without HELLP syndrome, while in low-income countries this figure was 42.5% (P<0.0001). The presence of HELLP syndrome in the women who died of eclampsia was 90.6% (29/32) in high-income countries compared with 47.6% (88/185) in low-income countries (P<0.001).

CONCLUSION

Concurrent eclampsia and HELLP syndrome was diagnosed in 5-6 out of 10 deaths associated with eclampsia or HELLP syndrome in this review.

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

BACKGROUND

Spontaneous hepatic rupture in pregnancy is rare and carries a high maternal and perinatal mortality.

CASE REPORT

We describe a case of hepatic rupture that occurred after emergency caesarean section performed in a pregnant woman at 38 weeks of gestation with Hemolysis, Elevated Liver enzymes and Low Platelet count (HELLP) syndrome. The patient was discharged after 30 days of intensive therapy and four explorative laparotomies. Today, 2 years after delivery, the patient and her baby are doing well.

CONCLUSION

Hepatic rupture in pregnancy is a rare event that may complicate HELLP syndrome. In this case, we were able to achieve an excellent clinical outcome by the performance of an immediately explorative laparotomy.

Surgical gastrointestinal disorders during pregnancy

All gastrointestinal (GI) disorders can present during pregnancy, and in fact 0.2% to 1.0% of all pregnant women require non-obstetrical general surgery. All of the clinical decision-making skills of the experienced surgeon must come into play in order to make the correct therapeutic decisions when evaluating the pregnant patient with a GI disorder that potentially requires surgery. While in general the principles of diagnosing and treating a pregnant woman with an acute surgical abdominal problem remain the same as those governing the treatment of the non-pregnant patient, some important differences are present and can pose problems. As a general rule the condition of the mother should always take priority because proper treatment of surgical diseases in the mother will usually benefit the fetus as well as the mother.

Understanding and managing HELLP syndrome: the integral role of aggressive glucocorticoids for mother and child

Antepartum or postpartum HELLP syndrome constitutes an obstetric emergency that requires expert knowledge and management skills. The insidious and variable nature of disease presentation and progression challenges the clinician and complicates consensus on universally accepted diagnostic and classification criteria. A critical review of published research about this variant form of severe preeclampsia, focused primarily on what is known about the pathogenesis of this disorder as it relates to patient experience with corticosteroids for its management, leads to the conclusion that there is maternal-fetal benefit realized when potent glucocorticoids are aggressively used for its treatment. Although acknowledging the need for definitive multicenter trials to better define the limits of benefit and the presence of any maternal or fetal risk, and given an understanding of the nature of the disorder with its potential to cause considerable maternal morbidity and mortality, we recommend for the present that aggressively used potent glucocorticoids constitute the cornerstone of management for patients considered to have HELLP syndrome.

Characteristics and treatment of hepatic rupture caused by HELLP syndrome

OBJECTIVE

The purpose of this study was to review the management of hepatic rupture caused by HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome and to assess maternal and perinatal outcomes of these cases.

STUDY DESIGN

A retrospective study of HELLP syndrome cases that were complicated by hepatic rupture was conducted.

RESULTS

Ten cases of hepatic rupture were identified. The median maternal age was 42.5 +/- 5.9 years (median +/- SD), and the median gestational age at delivery was 35.5 +/- 4.9 weeks. The most frequent signs and symptoms of hepatic rupture were the sudden onset of abdominal pain, acute anemia, and hypotension. Laboratory findings included low platelet count and increased hepatic enzymes. Surgery was performed in 9 cases. One case was treated nonsurgically. The maternal mortality rate was 10%, and the perinatal mortality rate was 80%.

CONCLUSION

A combination of surgical treatment with hepatic artery ligation and omental patching with supportive measures was effective in decreasing the mortality rate in hepatic rupture caused by HELLP syndrome.

Argon Beam Coagulator for Treatment of Hepatic Rupture With Hemolysis, Elevated Liver Enzymes, Low Platelets (HELLP) Syndrome

BACKGROUND

We present a case of hepatic rupture secondary to hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome and the novel use of the argon beam coagulator in achieving hemostasis.

CASE

The patient presented at 33 5/7 weeks of gestation with elevated liver transaminases, thrombocytopenia, and ultrasonographic findings consistent with hepatic rupture. She underwent an emergent cesarean delivery followed by exploration of her abdomen by hepatobiliary surgeons. An expanding hematoma with rupture of the right lobe of the liver was identified. The hematoma was unroofed, and hemostasis was obtained using the argon beam coagulator. The patient was discharged home in good condition 9 days after surgery.

CONCLUSION

With a multidisciplinary approach and the argon beam coagulator, we were able to achieve an excellent clinical outcome in a patient with hepatic rupture from HELLP syndrome.