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

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.

Spontaneous Hepatic Rupture Complicating Preeclampsia and HELLP Syndrome: A Case Report

Introduction: Spontaneous hepatic rupture is a rare complication that occurs in pregnant mothers with HELLP syndrome, or preeclampsia with severe features, or eclampsia. The most common symptom of hepatic rupture/hematoma is right upper quadrant pain or epigastric pain, which is similar to the presentation of preeclampsia with severe features. Therefore, the absence of specific signs and symptoms leads to a diagnostic dilemma and a delay in management. The objective of this index study is to report available evidence on incidence, clinical presentation, pathophysiology, diagnosis, maternal and perinatal outcome, challenges, and best experiences in the management of hepatic rupture. Case History: A 38-year-old G3P1A1 kaffa mother whose gestational age was 30 weeks plus 4 days from reliable last normal menstrual period had three ANCs. She presented with right upper quadrant pain of 3 days duration and severe global headache and blurring of vision of 5 days duration. Abdominal ultrasound showed a well-defined hyperechoic mass measuring 6 cm by 8 cm on the subcapsular area of the left lobe of the liver, as well as free intra-abdominal fluid. A diagnosis of ruptured hepatic subcapsular hematoma associated with preeclampsia with severe features was made, and an emergency laparotomy was done. Intraoperatively, 2500 mL of hemoperitoneum, a large hematoma (9 × 10 cm) on the left lobe of the liver, and active bleeding from the right lobe of the liver were found. Surgicell was applied to the actively bleeding site, and the right hepatic artery was ligated, along with perihepatic packing and a subhepatic drainage tube. Cesarean delivery was made to effect a delivery of a freshly dead male fetus weighing 1.4 kg. Despite this management, after 6 h of admission to the ICU, she passed away with a possible cause of death of multiorgan failure (liver, kidney, respiratory, and heart) secondary to underlying illness. Conclusion: A high index of suspicion, multidisciplinary approach, and urgent laparotomy to secure hemostasis could prevent maternal death and perinatal loss due to hepatic rupture in preeclamptic mothers. The absence of specific signs and symptoms and a high case fatality rate mandate standardized protocols of management for hepatic rupture during pregnancy.

Atypical Presentation of Subcapsular Liver Hematoma With a Delayed Onset of Hemolysis, Elevated Liver Enzymes, Low Platelet Count (HELLP) Syndrome

Subcapsular liver haematoma in pregnancy, a rare and life-threatening condition, is more commonly associated with severe preeclampsia and haemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome. The common presenting symptom of subcapsular haematoma is acute-onset upper abdominal pain in patients suffering from preeclampsia; shock is the presenting feature in severe cases of rupture. Here we have discussed a case of subcapsular haematoma associated with HELLP syndrome in a patient who responded to conservative management. The diagnosis of subcapsular haematoma was delayed as the clinical presentation was atypical. A 30-year-old primigravida with an apparently uncomplicated pregnancy attended with sudden onset acute abdominal pain in Croydon University Hospital, London, UK. Due to associated cardiotocography (CTG) concerns, the initial diagnosis was placental abruption. An urgent caesarean section was performed, and a spontaneous hemoperitoneum of 500 ml was found during the surgery. Following the caesarean section, the blood pressure started to rise. Subsequently, the blood picture deteriorated to full-blown HELLP syndrome, and the pain worsened. Further imaging revealed a large subcapsular haematoma of the liver. The patient was managed conservatively in the intensive therapy unit (ITU) by a multidisciplinary team including intensivists, an upper gastrointestinal surgeon, and an obstetric team. She responded to conservative management and had an uneventful recovery. A high index of suspicion in cases of severe pain in the abdomen during pregnancy can help in early diagnosis. Moreover, further exploration in the case of spontaneous hemoperitoneum during caesarean section should be considered to avoid delay in diagnosis. Prompt intervention by the pertinent teams is the key to successful treatment.

Do Case Reports and Case Series Generate Clinical Discoveries About Preeclampsia? A Systematic Review

Background

Preeclampsia is a leading cause of maternal and perinatal mortality and morbidity. The management of preeclampsia has not changed much in more than two decades, and its aetiology is still not fully understood. Case reports and case series have traditionally been used to communicate new knowledge about existing conditions. Whether this is true for preeclampsia is not known.

Objective

To determine whether recent case reports or case series have generated new knowledge and clinical discoveries about preeclampsia.

Methods

A detailed search strategy was developed in consultation with a medical librarian. Two bibliographic databases were searched through Ovid: Embase and MEDLINE. We selected case reports or case series published between 2015 and 2020, comprising pregnant persons diagnosed with hypertensive disorders of pregnancy, including preeclampsia. Two reviewers independently screened all publications. One reviewer extracted data from included studies, while another conducted a quality check of extracted data. We developed a codebook to guide our data extraction and outcomes assessment. The quality of each report was determined based on Joanna Briggs Institute (JBI) critical appraisal checklist for case reports and case series.

Results

We included 104 case reports and three case series, together comprising 118 pregnancies. A severe presentation or complication of preeclampsia was reported in 81% of pregnancies, and 84% had a positive maternal outcome, free of death or persistent complications. Only 8% of the case reports were deemed to be of high quality, and 53.8% of moderate quality; none of the case series were of high quality. A total of 26 of the 107 publications (24.3%) included a novel clinical discovery as a central theme.

Conclusion

Over two-thirds of recent case reports and case series about preeclampsia do not appear to present new knowledge or discoveries about preeclampsia, and most are of low quality.

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

Grade III subcapsular liver hematoma secondary to HELLP syndrome: A case report of conservative management

Subcapsular liver hematoma (SLH) is a rare condition that is associated with preeclampsia and HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome. A high level of suspicion, early diagnosis, and coordinated, intensive multidisciplinary management are necessary to monitor for serious complications and prevent death. Options include conservative management, hepatic resection, hepatic artery ligation and liver transplantation. This paper describes a 34-year-old woman with HELLP syndrome who developed a large grade III SLH that was managed conservatively.

Conservative Management of Postpartum HELLP Syndrome and Intraparenchymal Liver Hematoma; A Case Report

The HELLP syndrome is an important variant of pre-eclampsia which is known by triad of hemolysis (H), elevated liver enzymes (EL) and low platelet count (LP). Intraparenchymal liver hematoma is a rare and important complication of HELLP syndrome which is a life threatening condition. The incidence of intraparenchymal hematoma of the liver has been reported to vary from 1 in each 40,000 to 250,000 deliveries worldwide. Herein we report a case of intraparenchymal liver hematoma following HELLP syndrome. An 18 year- old woman with moderate to severe preeclampsia after delivery, presented with Right upper quadrant (RUQ) pain and tachycardia and significant drop in hemoglobin level. Ultrasonography revealed intraparenchymal liver hematoma. This finding was also confirmed by computerized tomography (CT)-scan. Conservative treatment was applied and the patient improved without need of any surgical intervention. Spontaneous hepatic hematoma should always be considered as a life threatening and important complication of HELLP syndrome during pregnancy and it can be managed conservatively in a hemodynamically stable patient.

Postpartum Spontaneous Subcapsular Hepatic Hematoma (SSHH)- Conservative Management. Case Report and Review of Literature

Spontaneous subcapsular hematoma of the liver, with no history of preeclampsia and HELLP syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelet count.), represents an exceptionally rare clinical condition in pregnancy and postpartum. The complications can be devastating in terms of fetal and maternal mortality. We hereby present a case of a 33-year-old female that underwent an emergency Cesarean section (C-section) at term with the extraction of a live foetus. Few hours after delivery, she complained of intense epigastric and abdominal pain. The diagnostic work-up suggested a SSHH. The condition was managed conservatively in a multidisciplinary team.