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Masselli G, Bonito G, Gigli S, Ricci P. Imaging of Acute Abdominopelvic Pain in Pregnancy and Puerperium-Part II: Non-Obstetric Complications. Diagnostics (Basel) 2023; 13:2909. [PMID: 37761275 PMCID: PMC10528125 DOI: 10.3390/diagnostics13182909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 08/28/2023] [Accepted: 09/08/2023] [Indexed: 09/29/2023] Open
Abstract
Emergency imaging in pregnancy and puerperium poses unique challenges both for clinicians and radiologists, requiring timely and accurate diagnosis. Delay in treatment may result in poor outcomes for both the patient and the foetus. Pregnant and puerperal patients may present in the emergency setting with acute abdominopelvic pain for various complications that can be broadly classified into obstetric and non-obstetric related diseases. Ultrasonography (US) is the primary diagnostic imaging test; however, it may be limited due to the patient's body habitus and the overlapping of bowel loops. Computed tomography (CT) carries exposure to ionising radiation to the foetus, but may be necessary in selected cases. Magnetic resonance imaging (MRI) is a valuable complement to US in the determination of the etiology of acute abdominal pain and can be used in most settings, allowing for the identification of a broad spectrum of pathologies with a limited protocol of sequences. In this second section, we review the common non-obstetric causes for acute abdominopelvic pain in pregnancy and post partum, offering a practical approach for diagnosis and pointing out the role of imaging methods (US, MRI, CT) with the respective imaging findings.
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Affiliation(s)
- Gabriele Masselli
- Department of Emergency Radiology-Policlinico Umberto I Hospital, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy; (G.M.); (P.R.)
| | - Giacomo Bonito
- Department of Emergency Radiology-Policlinico Umberto I Hospital, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy; (G.M.); (P.R.)
| | - Silvia Gigli
- Department of Diagnostic Imaging, Sandro Pertini Hospital, Via dei Monti Tiburtini 385, 00157 Rome, Italy;
| | - Paolo Ricci
- Department of Emergency Radiology-Policlinico Umberto I Hospital, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy; (G.M.); (P.R.)
- Department of Radiological, Oncological and Pathological Sciences, Policlinico Umberto I, Sapienza University of Rome, Viale Regina Elena 324, 00161 Rome, Italy
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Abstract
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.
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Affiliation(s)
- Norah A Terrault
- Gastrointestinal and Liver Disease Division, University of Southern California, Los Angeles, California, USA.
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Morrison MA, Chung Y, Heneghan MA. Managing hepatic complications of pregnancy: practical strategies for clinicians. BMJ Open Gastroenterol 2022; 9:bmjgast-2021-000624. [PMID: 35292523 PMCID: PMC8928321 DOI: 10.1136/bmjgast-2021-000624] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 01/12/2022] [Indexed: 12/17/2022] Open
Abstract
Liver disorders specific to pregnancy are rare but can have potentially serious consequences for mother and fetus. Pregnancy-related liver disorders are the most common cause of liver disease in otherwise healthy pregnant women and pose a challenge to physicians because of the need to take into account both maternal and fetal health. A good knowledge of these disorders is necessary as prompt diagnosis and appropriate management results in improved maternal and fetal outcomes. This review will focus on pregnancy-specific disorders and will aim to serve as a guide for physicians in their diagnosis, management and subsequent monitoring.
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Affiliation(s)
| | - Yooyun Chung
- Institute of Liver Studies, King's College Hospital, London, UK
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Morgan J, Della Torre M, Whelan AR, Rodriguez SM, DiGiovanni LM. A Case of Massive Hepatic Infarction in a Patient with HELLP Syndrome. AJP Rep 2019; 9:e84-e87. [PMID: 31041116 PMCID: PMC6424812 DOI: 10.1055/s-0039-1681028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 01/21/2019] [Indexed: 11/23/2022] Open
Abstract
Background Hepatic infarction is an exceedingly rare complication of hemolysis, elevated liver enzymes, and low platelets syndrome. Few cases have been described in the medical literature and the true incidence remains unknown. It can lead to fulminant liver failure, liver transplant, or death if not promptly addressed. Case Report A 22-year-old primigravida presented with right upper quadrant and epigastric pain at 28 weeks' gestation. She had severely elevated blood pressures requiring intravenous antihypertensives as well as proteinuria, thrombocytopenia, and mild transaminitis. Within 6 hours of admission, her rapidly rising liver function tests (LFTs) necessitated urgent delivery by primary cesarean section. Her liver enzymes continued to rapidly worsen postoperatively and immediate postpartum computed tomography of the abdomen and pelvis revealed massive hepatic infarction, 11 × 10 × 15 cm, of the right lobe of the liver. Her transaminases peaked at alanine transferase of 2,863 IU/L and aspartate transferase of 2,732 IU/L. She received supportive multidisciplinary intensive care, and LFTs returned to normal by postoperative day 20. Conclusion Hepatic infarction is an extraordinarily rare complication of pre-eclampsia. Early recognition and prompt multidisciplinary management are vital to prevent catastrophic bleeding, hepatic failure, and death.
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Affiliation(s)
- Jessica Morgan
- Department of Obstetrics and Gynecology, The University of Illinois at Chicago, Chicago, Illinois
| | - Micaela Della Torre
- Division of Maternal-Fetal Medicine, Department Obstetrics and Gynecology, The University of Illinois at Chicago, Chicago, Illinois
| | - Anna R. Whelan
- Department of Obstetrics and Gynecology, The University of Illinois at Chicago, Chicago, Illinois
| | - Sophia M. Rodriguez
- Department of Obstetrics and Gynecology, The University of Illinois at Chicago, Chicago, Illinois
| | - Laura M. DiGiovanni
- Division of Maternal-Fetal Medicine, Department Obstetrics and Gynecology, The University of Illinois at Chicago, Chicago, Illinois
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Abstract
PURPOSE OF REVIEW Significant and intricate immune adaptations are essential for the establishment and maintenance of normal pregnancy. Preeclampsia is a morbid, potentially life-threatening disease for both mother and neonate that occurs uniquely in pregnancy, at least in part, due to maternal immune maladaptation. We aim to review the literature that focuses on case reports, diagnostic approaches, and treatment strategies for disorders of the complement alternative pathway (CAP) as related to preeclampsia. RECENT FINDINGS There is evidence of complement dysregulation in preeclampsia and HELLP syndrome, similar to that observed in a few rare types of thrombotic microangiopathies. Complement dysregulation may be identified with functional laboratory testing as well as genetic testing. Increased utilization of a standardized diagnostic approach to establish whether persistent and/or severe cases of preeclampsia and HELLP syndrome are complement-mediated may lead to development of future treatment strategies, such as complement-targeted therapy.
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Yoshihara M, Mayama M, Ukai M, Tano S, Kishigami Y, Oguchi H. Fulminant liver failure resulting from massive hepatic infarction associated with hemolysis, elevated liver enzymes, and low platelets syndrome. J Obstet Gynaecol Res 2016; 42:1375-1378. [PMID: 27353746 DOI: 10.1111/jog.13042] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Revised: 03/21/2016] [Accepted: 04/10/2016] [Indexed: 12/17/2022]
Abstract
Hepatic infarction is an extremely rare and fatal complication associated with hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome. It can develop into fulminant liver failure, which increases both maternal and neonatal mortality rates. A 34-year-old woman with no remarkable past medical history developed eclampsia after delivery at 40 weeks of gestation. Imaging indicated massive hepatic infarction and rupture followed by cardiac arrest and fulminant liver failure. Despite liver replacement therapy with plasma exchange and continuous hemodiafiltration, the patient gradually deteriorated with persistent bacterial infection until death at 98 days after delivery. The management of fulminant liver failure complicated with HELLP syndrome should be multidisciplinary. Liver transplantation, the only radical treatment for fulminant liver failure, is worth attempting, if applicable.
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Affiliation(s)
- Masato Yoshihara
- Department of Gynecology and Obstetrics, Toyota Memorial Hospital, Toyota, Aichi, Japan.
| | - Michinori Mayama
- Department of Gynecology and Obstetrics, Toyota Memorial Hospital, Toyota, Aichi, Japan
| | - Mayu Ukai
- Department of Gynecology and Obstetrics, Toyota Memorial Hospital, Toyota, Aichi, Japan
| | - Sho Tano
- Department of Gynecology and Obstetrics, Toyota Memorial Hospital, Toyota, Aichi, Japan
| | - Yasuyuki Kishigami
- Department of Gynecology and Obstetrics, Toyota Memorial Hospital, Toyota, Aichi, Japan
| | - Hidenori Oguchi
- Department of Gynecology and Obstetrics, Toyota Memorial Hospital, Toyota, Aichi, Japan
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Perronne L, Dohan A, Bazeries P, Guerrache Y, Fohlen A, Rousset P, Aubé C, Laurent V, Morel O, Boudiaf M, Hoeffel C, Soyer P. Hepatic involvement in HELLP syndrome: an update with emphasis on imaging features. ACTA ACUST UNITED AC 2015; 40:2839-49. [DOI: 10.1007/s00261-015-0481-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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