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

Abstract

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.

Keywords: HELLP syndrome; hemoperitoneum; pregnancy; ultrasound.

Figure 1

(a) Large hematoma is visible on the left lobe of the liver (straight arrow). (b) Perihepatic packing with sterile towel on the actively bleeding right lobe of the liver (curved arrow).