Ruptured subcapsular hematoma of the liver due to pre-eclampsia presenting as interstitial pregnancy and the role of intra-abdominal packing

Abstract

Ruptured subcapsular hematoma of the liver (RSHL) can mimic ruptured interstitial pregnancy because each of these conditions occasionally presents at the same gestational period and both do manifest hemodynamic instability. The similarities between the two conditions pose a diagnostic challenge, especially in an un-booked patient. We report a case of an un-booked primigravida, at 21 weeks of gestation, who arrived at a regional hospital with evidence of intra-abdominal bleeding and hypovolemic shock. She was diagnosed as potentially having a ruptured interstitial pregnancy. During the ensuing emergency laparotomy, RSHL was discovered, the area around the ruptured liver capsule was packed with large abdominal swabs, and the patient recovered. This case report illustrates the need to consider RSHL in patients presenting with features of ruptured interstitial pregnancy, as this will assist in the planning of intraoperative care. We also describe abdominal packing and highlight the need for this essential surgical intervention to be taught to doctors practising in low-resource settings.

Role of angiogenic factors in the pathogenesis and management of pre‐eclampsia

“…Irrespective, in 2014, chronic hypertension, obesity, and severe anemia were reported as the factors that impose the highest predisposing risk to pre‐eclampsia . Disappointingly, the use of maternal history, even in conjunction with pregnancy‐associated plasma protein A, can predict only 41% of women who will develop the disorder, and this finding supports the notion that the pathophysiology is not clearly understood. Many postulates, some of them listed in Table , have been advanced to elucidate the pathogenesis of pre‐eclampsia .…”

Spontaneous liver haematoma rupture associated with pre-eclampsia in a low- to middle-income country: Lessons to be learnt from maternal death assessments

“…[1] This condition develops in PE when there are fibrin deposits in the liver vasculature that obstruct the sinusoids and lead to ischaemia, and subsequently to haemorrhage, haematoma and possibly hepatic rupture. [5] The diagnosis of possible subcapsular haematoma of the liver is suspected on the basis symptoms, such as epigastric pain, right upperquadrant abdominal pain and nausea and vomiting in patients with PE and/or HELLP syndrome. [3,4] In the haemodynamically stable patient with symptoms and signs (tenderness or mass in the liver area) suspicious of a haematoma, ultrasound and/or computed tomography (CT) imaging can be used to confirm the diagnosis.…”

“…In a patient presenting with haemodynamic instability and acute abdominal pain, the diagnosis is usually made during an emergency laparotomy. [5] The current report is an analysis of cases of maternal deaths due to spontaneous rupture of the liver associated with hypertensive disorders of pregnancy in South Africa (SA). Specific issues and details of such cases are usually not included in the triennial SA Saving Mothers Report, and even when included might not be highlighted.…”

Hepatic haematoma rupture in a Warmblood: a rare complication of hepatic AA amyloidosis

“…Because of pathological changes in the liver due to amyloidosis, it is assumed that just the sinusoids had bled, causing intrahepatic and subcapsular haematoma. Initially, the strong capsule of the liver has a tamponade effect; however, if pressure increases sufficiently, then rupture can occur (Ngene et al 2015, Yu et al 2016). Furthermore, coagulopathy due to amyloidosis and/or blood loss could develop, stimulating the continuous bleeding.…”

“…There are various methods to treat liver ruptures in humans; however, the preferred method of treatment for hepatic rupture is surgical intervention (Chen et al 2002), and transcatheter hepatic artery embolization is described as being an effective procedure (Naito et al 2008). Laparotomy or laparoscopy can be chosen to perform a partial hepatectomy, and gauze packing or mesh wrapping of the rupture can stop the bleeding and stabilize the patient (Ngene et al 2015, Yu et al 2016. Theoretically, explorative laparoscopy under general anaesthesia in the left lateral or even dorsal recumbency might have given a view on the rupture side, but this was not considered based on the poor prognosis of the equine patient and the knowledge that bleeding from a ruptured liver is extremely difficult to stop, particularly in horses, in which abdominal packing with swabs or mesh is hardly possible due to the size of the abdominal cavity.…”