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A fatal case of complicated HELLP Syndrome and
Antepartum Eclamptic Fit with ruptured
Subcapsular Liver Hematoma
a p o l l o m e d i c i n e x x x ( 2 0 1 3 ) 1 e3

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Case report

A 25-year-old primigravida female at 28 weeks of g...
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Discussion

In spite of improvement in antenatal care maternal mor...
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A fatal case of complicated HELLP Syndrome and Antepartum Eclamptic Fit with ruptured Subcapsular Liver Hematoma

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Subcapsular hematoma and hepatic rupture are very unusual catastrophic complication of preeclampsia/eclampsia and HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome. The reported incidence of this condition varies from 1 in 40,000 to 1 in 2,50,000 deliveries.There is no agreement on the best approach to treat this severe complication of pregnancy and optimal management is still evolving.


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Transcript of "A fatal case of complicated HELLP Syndrome and Antepartum Eclamptic Fit with ruptured Subcapsular Liver Hematoma"

  1. 1. A fatal case of complicated HELLP Syndrome and Antepartum Eclamptic Fit with ruptured Subcapsular Liver Hematoma
  2. 2. a p o l l o m e d i c i n e x x x ( 2 0 1 3 ) 1 e3 Available online at www.sciencedirect.com ScienceDirect journal homepage: www.elsevier.com/locate/apme Case Report A fatal case of complicated HELLP syndrome and antepartum eclamptic fit with ruptured subcapsular liver hematoma Ahmed Samy Elagwany*, Islam Koreim, Ziad Samy Abouzaid Department of Obstetrics and Gynecology, Alexandria University, Egypt article info abstract Article history: Objective: To describe a fatal case of ruptured subcapsular liver hematoma as regards Received 30 July 2013 diagnoses and management. Accepted 4 October 2013 Design: Case report. Available online xxx Setting: Department of Obstetrics and Gynecology. Patient: A 25-year-old woman developed HELLP syndrome and antepartum eclamptic fit Keywords: complicated with ruptured subcapsular liver hematoma during the 28th week of Mortality pregnancy. HELLP syndrome Intervention: Midline abdominal exploratory laparotomy, with delivery by caesarean sec- Antepartum eclamptic fit tion. Tight abdominal packing for the hematoma and Pringle maneuver were done. Partial Ruptured subcapsular liver hema- couvelaire uterus was managed by prostaglandins and B-Lynch brace sutures to minimize toma uterine bleeding and atony. The patient developed postoperative hepatic, renal failure, Abdominal packing and B-lunch coagulopathy, deterioration and finally death. suture Conclusion(s): Ruptured subcapsular liver hematoma is a life-threatening condition that should be considered in pregnant women with HELLP syndrome and severe preeclampsia presenting with symptoms and signs of hemorrhagic shock, hemoperitoneum and the liver should be evaluated with ultrasound before delivery. In these patients delivery of the fetus is the first step and the best approach is a midline abdominal incision. Also, regular antenatal care is very important through all trimesters. Copyright ª 2013, Indraprastha Medical Corporation Ltd. All rights reserved. 1. Introduction Subcapsular hematoma and hepatic rupture are very unusual catastrophic complication of preeclampsia/eclampsia and HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome.1 The reported incidence of this condition varies from 1 in 40,000 to 1 in 2,50,000 deliveries.2 There is no agreement on the best approach to treat this severe complication of pregnancy and optimal management is still evolving. A multidisciplinary approach to the management of these patients can lead to remarkable decrease in the usual high mortality rate. We present a fatal case of severe preeclampsia, which rapidly progressed to HELLP syndrome, liver rupture, disseminated intravascular coagulation (DIC) and renal failure. * Corresponding author. El-Shatby Maternity Hospital, Alexandria University, Alexandria, Egypt. Tel.: þ20 1228254247. E-mail address: ahmedsamyagwany@gmail.com (A.S. Elagwany). 0976-0016/$ e see front matter Copyright ª 2013, Indraprastha Medical Corporation Ltd. All rights reserved. http://dx.doi.org/10.1016/j.apme.2013.10.001 Please cite this article in press as: Elagwany AS, et al., A fatal case of complicated HELLP syndrome and antepartum eclamptic fit with ruptured subcapsular liver hematoma, Apollo Medicine (2013), http://dx.doi.org/10.1016/j.apme.2013.10.001
  3. 3. 2 2. a p o l l o m e d i c i n e x x x ( 2 0 1 3 ) 1 e3 Case report A 25-year-old primigravida female at 28 weeks of gestation was admitted to the emergency department of the maternity department of El-Shatby University Hospitals with hemorrhagic shock and history of antepartum fit 4 h before admission. Prenatal care had not been provided since the second trimester and the pregnancy was uneventful until two days before admission where the patient complained of severe headache, epigastric pain and blurred vision with hypertension and proteinuria. Oral antihypertensive drugs were given by family doctor as alleged by relatives, for follow up. But the condition deteriorated and antepartum convulsions occurred. On admission, clinical examination revealed a pale and dull patient with disturbed level of consciousness. Multiple tongue bites were evident. The patient’s parameters were as follows HR 140 beat/min, ABP 90/30 mmHg. Local examination revealed the following, painful abdominal distention, fundal level nearly 34 weeks, and the cervix was closed with severe vaginal bleeding with clots. Laboratory parameters were as follows: hemoglobin 3 gm/dl, platelets 60,000/mm3, peripheral blood film showing hemolytic smear, INR 4, aspartate aminotransferase 500 IU/L, alanine aminotransferase 500 IU/ L, proteinuria of 3þ. Antenatal sonography revealed a living fetus nearly 28 weeks and massive abdominal collection, abdominal tapping with spinal needle revealed bloody nonclotted fluid. Resuscitation was started with colloids, a new blood sample was taken, eight units of whole blood were cross matched and the patient was urgently transferred to the operating theatre, it was decided to perform an immediate abdominal exploratory laparotomy with delivery by caesarean section. General anesthesia and endotracheal intubation was given and abdominal exploratory laparotomy through lower midline incision was done revealing massive hemoperitoneum, cesarean section was done and a living male baby weighing 1.2 kg was delivered. The uterine incision was closed. But, she developed atonic postpartum hemorrhage from partial couvelaire uterus which was managed by using prostaglandins and B-Lynch brace sutures to minimize uterine bleeding and atony was corrected. There was massive hemoperitoneum and about 3 L of blood with clots were removed. Also, a continuous accumulation of blood in the pelvis from the upper abdomen so, exploration of the abdomen by manual palpation of the upper abdominal organs revealed enlarged liver with blood clots covering it and active bleeding from surface of the liver and so, a ruptured subcapsular hepatic hematoma was suspected. Extension of the abdominal incision upwards for exploration confirming the initial diagnoses (Fig. 1a and b) so, intervention through tight abdominal packing with 22 laparotomy pads sized 30Â30 cm, sutured together and Pringle’s maneuver were done for controlling the bleeding from the liver surface and compressing the hematoma preventing its expanding in size and the bleeding was controlled. The patient received eight units of whole blood, eight units of fresh frozen plasma, and two units of platelets during the operation which extended for 3 h. Her vital parameters were Fig. 1 e Showing subcapsular liver hematoma. as follows at the end of the operation, HR 120 beats/min, ABP 100/70 mmHg, CVP 6 cm H20, urine output nearly 100 cc. Closure of the abdomen, leaving the packs to be removed after stabilization of the condition of the patient. Two drains were left intraperitoneal. The baby was transferred for NICU but the baby died after six days because of respiratory distress syndrome and sepsis. The patient was transferred to the intensive care unit on mechanical ventilation. The patient continued blood, plasma and platelet transfusions. There was no urine output even with furosemide and dopamine infusions. Her laboratory parameters were as follows: hemoglobin 6 gm/dl, platelets 60,000/mm3, INR 2, aspartate aminotransferase 2000 IU/L, alanine aminotransferase 1500 IU/L, serum blood urea was 120 mg/dl and serum creatinine 8 mg/dl over the next days with the drains revealed 500 cc/24 h with altered blood clots. CT brain revealed brain hypoxia and edema. The patient remained haemodynamically unstable requiring further transfusion of fresh frozen plasma, platelets and blood. She developed acute kidney failure, respiratory insufficiency, liver failure and major coagulopathy. The condition deteriorated and eventually, the patient died after 48 h following cardiac arrest from which she could not be resuscitated. Please cite this article in press as: Elagwany AS, et al., A fatal case of complicated HELLP syndrome and antepartum eclamptic fit with ruptured subcapsular liver hematoma, Apollo Medicine (2013), http://dx.doi.org/10.1016/j.apme.2013.10.001
  4. 4. a p o l l o m e d i c i n e x x x ( 2 0 1 3 ) 1 e3 3. Discussion In spite of improvement in antenatal care maternal mortality in developing countries is high. Hypertensive disorders, including HELLP syndrome are one of the main causes of maternal mortality.3 HELLP syndrome is a disease of variable presentation with high mortality and morbidity.4 Liver rupture and hemorrhage is the most unusual and serious complication of HELLP syndrome.5 The cause of subcapsular and intraparenchymal hepatic hematoma in HELLP syndrome is not definitely known. Ultrasound scan is the quickest means of diagnosis although computerized tomography is more sensitive. Hepatic rupture generally occurs during the last trimester of pregnancy or, less commonly, in the first 24 h after delivery.6 The clinical presentation of acute persistent right upper quadrant or epigastric pain associated with hypotension and elevated hepatic enzymes should prompt the clinician to consider hepatic rupture, particularly if there is a history of hypertension during pregnancy.6,7 However, elevated hepatic enzymes may not be present, and although liver transaminases normally fall during a healthy pregnancy, the alkaline phosphatase level can rise up to 500 by the end of the third trimester.6e8 The right lobe of the liver is affected more often than the left.9 Hepatic rupture occurs in 1:45,000 live births,6 and the mortality is high. If it occurs before delivery the fetal mortality rate is approximately 60%.6 The prognosis depends on early recognition of the possible diagnosis, prompt investigation and surgical intervention. Radiological imaging is helpful in establishing the diagnosis. Ultrasound scanning is quick and simple and often used as a first line test, but contrast enhanced CT scanning is more useful.6,7 Magnetic resonance imaging is appropriate in the more stable patient.6,7 Serial MRI and CT scanning can be used to monitor the recovery of the liver in the patients who survive the initial hemorrhagic episode.10 Intra-arterial digital subtraction hepatic angiography is probably the gold standard as it can be used not only to diagnose but also selectively to embolise the bleeding area.6e8 If there is only a subcapsular hematoma and the patient is stable, close observation of the patient may be all that is needed.7 In cases where the patient becomes haemodynamically unstable, prompt surgical intervention is recommended.6 A Pringle maneuver (i.e. occlusion of the hepatic artery and portal vein) is useful to initially control the hemorrhage from the liver and assess the areas of damage. Local liver hemorrhage can then be controlled by a combination of direct pressure and hematoma evacuation with packing, Argon coagulator or diathermy hemostasis, hemostatic wrapping, and over sewing of lacerations. In the presence of severe liver damage, a limited liver resection or even liver transplantation has been successfully performed.6e10 Early involvement of a surgeon with experience of liver surgery is 3 essential to optimize the chance of successful control of hemorrhage. 4. Conclusion This case report shows that ruptured subcapsular liver hematoma is a serious, life-threatening condition. Therefore, a high index of suspicion is necessary. It should be considered in pregnant women with HELLP syndrome and severe preeclampsia presenting with symptoms and signs of hemorrhagic shock, hemoperitoneum and the liver should be evaluated with ultrasound before delivery. Regular antenatal care is very important through all the trimesters. Treatment is comparable with treatment of traumatic lesions of the liver with special attention for the pregnant patient. In these patients delivery of the fetus is the first step and the best approach is a midline abdominal incision. Conflicts of interest All authors have none to declare. references 1. Sheikh RA, Yasmeen S, Pauly MP. Spontaneous intrahepatic hemorrhage and hepatic rupture in HELLP syndrome: four cases and a review. J Clin Gastroenterol. 1999;28:323e328. 2. Corinna W, Pereira P. Subcapsular liver hematoma in HELLP syndrome: evaluation of diagnostic and intrahepatic options e a unicentric study. Am J Obstet Gynecol. 2004;190:106e112. 3. Araujo Ana CPF, Leao Marcos D. Characteristics and treatment of hepatic rupture caused by HELLP syndrome. Am J Obstet Gynecol. 2006;195:129e133. 4. Aldemir M, Bac B, Tacyldiz I. Spontaneous liver hematoma and hepatic rupture in HELLP syndrome: report of two cases. Surg Today. 2002;32:450e453. 5. Catriconi M, Aragiusto G, Ansalone M. Liver rupture in HELLP syndrome. Report of a case. Minerva Chir. 2000;55:167e171. 6. Matsuda Y, Maeda T, Hatae M. Spontaneous rupture of the liver in an uncomplicated pregnancy. J Obstet Gynaecol Res. 1997;23:449e452. 7. Moise Jr KJ, Belfort MA. Damage control for the obstetric patient. Surg Clin North Am. 1997;77:835e852. 8. Hunter SK, Martin M, Benda JA. Liver transplant after massive spontaneous hepatic rupture in pregnancy complicated by pre-eclampsia. Obstet Gynecol. 1995;85:819e822. 9. Schwartz ML, Lien JM. Spontaneous liver haematoma in pregnancy not clearly associated with pre-eclampsia: a case presentation and literature review. Am J Obstet Gynecol. 1997;176:1328e1333. 10. Saura P, Blanch L. Spontaneous rupture of the liver during pregnancy. Intensive Care Med. 1995;21:95e96. Please cite this article in press as: Elagwany AS, et al., A fatal case of complicated HELLP syndrome and antepartum eclamptic fit with ruptured subcapsular liver hematoma, Apollo Medicine (2013), http://dx.doi.org/10.1016/j.apme.2013.10.001
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