Recurrent spontaneous hepatic rupture in pregnancy

Abstract

Rationale:Spontaneous and repeated hepatic ruptures caused by hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome are uncommon but life-threatening conditions that rarely occur early in the second trimester of pregnancy.Patient concerns:We describe a patient who experienced spontaneous hepatic ruptures in the absence of hypertension during the early second trimesters of both her first and second pregnancies.Diagnoses:A 34-year-old multiparous woman without hypertension was admitted at 21 weeks’ gestation because of a spontaneous hepatic rupture with hemoperitoneum. Four years previously, the patient had undergone an exploratory laparotomy during her first pregnancy that involved the ligation of bleeders, because a hepatic capsule rupture had caused hemoperitoneum development.Interventions:Unlike the first pregnancy, she was managed nonsurgically and conservatively during the second pregnancy, and she underwent frequent laboratory analyses and magnetic resonance imaging follow-up. On day 11 of the patient's hospital admission, we decided to deliver the baby at 23 weeks’ gestation, because her condition had deteriorated.Outcomes:Non-surgical management improved the patient's outcome, and the baby was born alive, even though the pregnancy was in the early second trimester and the maternal condition was deteriorating rapidly.Lessons:HELLP syndrome without hypertension and the recurrence of an intrahepatic rupture at an extremely premature gestational age are rare. This patient's findings suggested HELLP syndrome, which was subsequently diagnosed. This patient's clinical course highlights the difficult decisions made by clinicians for mothers and fetuses.

Liver haematoma in pregnancy: A rare complication of HELLP syndrome

“…About 0.39% to 1.6% of cases of HELLP syndrome are complicated by liver haematoma. 2 The incidence of liver haematoma is 1 in 40,000 to 2,50000 deliveries. 2 It is rather considered as disease of older and multiparous women.…”

“…2 The incidence of liver haematoma is 1 in 40,000 to 2,50000 deliveries. 2 It is rather considered as disease of older and multiparous women. 4 The exact cause is not completely known however the proposed cause mentioned in different literature is basically fibrin deposition in periportal area leading to hepatocytes necrosis and parenchymal haematoma and haemorrhage if there is break in Glisson's capsule.…”

“…The exact aetiology of HELLP syndrome is not known. 2 Spontaneous liver haematoma is very rare but life-threatening complication of preeclampsia and HELLP syndrome. 1 Until now only one case has been reported in Nepal.…”

Ruptura hepática espontánea en el síndrome de HELLP. Una revisión de la literatura

“…proteínas a través de la orina) (12). La mayoría de las pacientes con síndrome de HELLP presentará hipertensión pero, puede manifestarse sin hipertensión ni proteinuria, la hipertensión puede estar ausente hasta en el 18% de los casos (21,22).…”

“…La ruptura hepática espontánea generalmente ocurre asociada a preclamsia y al síndrome de HELLP (1-4). Pero, puede ocurrir, con menos frecuencia, por una patología subyacente, como el hígado graso agudo, adenomas, neoplasias malignas, hemangiomas hepáticos (21), carcinoma hepatocelular asociado al embarazo, metástasis, traumatismos, infecciones, aneurismas; granulomas, uso de cocaína durante el embarazo, terapia con esteroides anabólicos y amiloidosis sistémica e idiopáticas (27).…”