Pre-eclampsia/eclampsia and hepatic rupture

Spontaneous Hepatic Rupture in a Pregnant Woman with Preeclampsia and HELLP Syndrome

Spontaneous hepatic rupture is a rare complication associated with preeclampsia and is characterized by hemolysis, elevated liver enzymes, and a low platelet count (HELLP syndrome), with a nonspecific clinical presentation and high mortality rate. We present the case of a 34-year-old primigravida woman in whom spontaneous hepatic rupture associated with HELLP syndrome was accidentally detected during cesarean delivery. The patient was successfully managed with liver packing and transcatheter arterial embolization, followed by plasmapheresis. Spontaneous hepatic rupture should be considered in any HELLP syndrome patient presenting with epigastric or right upper quadrant pain and early signs of hemodynamic instability. A multimodal approach can help achieve good clinical outcomes in patients with this rare presentation.

Spontaneous hepatic haemorrhage after caesarean section in a patient with uraemia and superimposed preeclampsia: a case report

Perinatal spontaneous hepatic haemorrhage is a very rare disease affecting pregnant women, particularly those on long-term dialysis, that has a high maternal and infant mortality rate. Most patients experience preeclampsia with haemolysis, elevated liver enzymes and low platelets syndrome. Here, the case of a 35-year-old multigravida patient with known chronic kidney disease and chronic hypertension with uraemia, who developed spontaneous hepatic haemorrhage after caesarean section, is described. The patient experienced sudden massive circulatory failure, but hemodynamics were temporarily stabilized after emergency surgery. Following transfer to the intensive care unit for continued treatment, her blood pressure and haemoglobin level continued to drop. Selective hepatic artery embolization was performed on day 2 after delivery, and her vital signs gradually stabilized. On day 30 after delivery, the patient was discharged in a stable condition. The newborn recovered after therapy in neonatal intensive care for 2 months. The present case suggests that, for perinatal spontaneous hepatic haemorrhage, timely and accurate diagnosis, multidisciplinary management and determining the therapeutic approach according to clinical symptoms are essential.

Spontaneous subcapsular hepatic hematoma in pregnant patients

Spontaneous subcapsular hepatic hematoma (SSHH) with or without previous history of preeclampsia and/or HELLP syndrome represents a very rare pathological condition in pregnancy and postpartum, (1/45,000-1/225,000 pregnancies). Its importance for the anesthesiologist lays in its association with high morbidity and mortality for the mother (60-86%, 39%) and newborn (42%). After a high clinical suspicion, the certainty clinical diagnosis is settled by different imaging techniques. However, in most cases the diagnosis of SSHH is a casual intraoperative finding associated to a maternal or foetal compromise. Nowadays the obstetric and anaesthetic management of a SSHH is not standardized and depends on its integrity, hemodynamic stability and the gestational period when diagnosed. The possibility of an acute critic haemorrhage with necessity of massive transfusion, makes advisable to provide updated protocols for the treatment of obstetric hemorrhage, adapting them to the clinical peculiarities of these patients. After the acute phase, close attention should be kept on thromboembolic complications.

Preeclampsia: Narrative review for clinical use

Aim

Preeclampsia is a very complex multisystem disorder characterized by mild to severe hypertension.

Methods

PubMed and the Cochrane Library were searched from January 1, 2002 to March 31, 2022, with the search terms "pre-eclampsia" and "hypertensive disorders in pregnancy". We also look for guidelines from international societies and clinical specialty colleges and we focused on publications made after 2015.

Results

The primary issue associated with this physiopathology is a reduction in utero-placental perfusion and ischemia. Preeclampsia has a multifactorial genesis, its focus in prevention consists of the identification of high and moderate-risk clinical factors. The clinical manifestations of preeclampsia vary from asymptomatic to fatal complications for both the fetus and the mother. In severe cases, the mother may present renal, neurological, hepatic, or vascular disease. The main prevention strategy is the use of aspirin at low doses, started from the beginning to the end of the second trimester and maintained until the end of pregnancy.

Conclusion

Preeclampsia is a multisystem disorder; we do not know how to predict it accurately. Acetylsalicylic acid at low doses to prevent a low percentage, especially in patients with far from term preeclampsia. There is evidence that exercising for at least 140 min per week reduces gestational hypertension and preeclampsia. Currently, the safest approach is the termination of pregnancy. It is necessary to improve the prediction and prevention of preeclampsia, in addition, better research is needed in the long-term postpartum follow-up.

Hypertensive disorders in pregnancy complicated by liver rupture or hematoma: a systematic review of 391 reported cases

Background

Spontaneous liver rupture in pregnancy is often unrecognized, highly lethal, and not completely understood. The goal was to summarize and define the etiology, risk factors, clinical presentation, appropriate diagnostic methods, and therapeutic options for spontaneous hepatic rupture during pregnancy/puerperium (SHRP) complicated by the hypertensive disorder.

Methods

Literature search of all full-text articles included PubMed (1946–2021), PubMed Central (1900–2021), and Google Scholar. Case reports of a spontaneous hepatic rupture or liver hematoma during pregnancy or puerperium as a complication of hypertensive disorders (preeclampsia, eclampsia, HELLP syndrome) were searched. There was no restriction of language to collect the cases. Additional cases were identified by reviewing references of retrieved studies. PRISMA guidelines for the data extraction and quality assessment were applied.

Results

Three hundred and ninety-one cases were collected. The median maternal age was 31 (range 17–48) years; 36.6% were nulliparous. Most (83.4%) occurred in the third trimester. Maternal and fetal mortality was 22.1% and 37.2%, respectively. Maternal and fetal mortality was significantly higher 1) before the year 1990, 2) with maternal hemodynamic instability, and 3) eclampsia. The most important risk factors for SHRP were preeclampsia and HELLP syndrome. Most women had right lobe affected (70.9%), followed by both lobes in 22.1% and left lobe in 6.9%. The most common surgical procedure was liver packing. Liver transplantation was performed in 4.7% with 100% survival. Maternal mortality with liver embolization was 3.0%. Higher gestational age increases fetal survival.

Conclusion

The diagnosis and treatment of SHRP are often delayed, leading to high maternal and fetal mortality. SHRP should be excluded in hemodynamically unstable patients with preeclampsia/eclampsia or HELLP syndrome and right upper abdominal pain. Liver embolization and liver transplantation contribute to maternal survival. Maternal and fetal mortality was significantly higher before the year 1990. Hemodynamic instability, preeclampsia, and eclampsia have a significant negative influence on maternal survival.

Level of evidence

Level V

Supplementary Information

The online version contains supplementary material available at 10.1186/s13017-022-00444-w.

Subcapsular hepatic hematoma as a complication of severe preeclampsia: a case report

Background

Subcapsular hepatic hematoma is a rare and life-threatening complication of pregnancy. It is most commonly associated with severe preeclampsia and hemolytic anemia, elevated liver enzymes, and low platelets syndrome. Patients with subcapsular hepatic hematoma typically present with epigastric, right upper quadrant or shoulder pain, nausea and vomiting, and/or shortness of breath. Here we describe a patient with a classic pain presentation, a large unruptured hematoma, and an unusual postpartum course.

Case

A 40-year-old gravida 1 para 0 Caucasian woman presented at 39 + 6 weeks gestational age with a 3-day history of new onset pain in an otherwise uncomplicated pregnancy. She described the pain along her right torso as severe, shooting, and sharp, but at times pleuritic in nature. She was found to have new onset preeclampsia and hemolytic anemia, elevated liver enzymes, and low platelets syndrome. Induction of labor was initiated and eventually she delivered by cesarean section. Her pain persisted in the postpartum period and abdominal computed tomography scan revealed a 16 cm subcapsular hepatic hematoma. Despite the hematoma being thin walled, conservative management was recommended by the general surgeon. She then re-presented on postpartum day 15 with tachypnea, dyspnea, and pleuritic chest pain. Secondary to the subcapsular hepatic hematoma, she then developed an infected and loculated, large pleural effusion. This required video-assisted thoracoscopic surgery before her eventual discharge home on postpartum day 21.

Conclusions

There should be high clinical suspicion of subcapsular hepatic hematoma in patients with persistent pain in the right upper quadrant of the abdomen. Urgent imaging to investigate for subcapsular hepatic hematoma is then indicated. Cesarean delivery without labor and treatment for severe preeclampsia should be undertaken if subcapsular hepatic hematoma is found. Conservative management and serial imaging are reasonable for the follow-up of a large, unruptured hematoma. Hepatic artery embolization should also be considered. Subcapsular hepatic hematoma may be complicated by infected pleural effusions and require video-assisted thoracoscopic surgery.

Liver pathology in pregnancy

Liver dysfunction occurs in up to 3% of pregnancies and can be due to pregnancy-associated liver injury, exacerbation of pre-existing liver disease, or co-incident with pregnancy. The most common form of pregnancy-associated liver injury is intrahepatic cholestasis of pregnancy (ICP). This condition is typically benign and self-limited, but is associated with fetal morbidity and mortality with high levels of serum bile acids. Acute fatty liver of pregnancy (AFLP) and the hypertensive disorders of pregnancy (including pre-eclampsia, eclampsia, and hemolysis, elevated liver enzymes, and low platelets [HELLP] syndrome) are more commonly associated with maternal and fetal complications and may necessitate expedient delivery. Histologically, ICP shows nonspecific features of cholestasis, while AFLP and the hypertensive disorders have more characteristic histologic findings. While not a true liver disease, hyperemesis gravidarum can cause elevated liver enzymes. Pregnant patients are at increased risk of developing severe hepatitis E and herpesvirus infections, Budd-Chiari syndrome, and gallstones, and they may also experience worsening of known chronic liver disease. Mass lesions in pregnancy including hemangiomas, focal nodular hyperplasia, and hepatocellular adenomas and carcinomas can present unique challenges for diagnosis and management. This review will explore the pathophysiology, presentation, histologic features, and management of these conditions.

Transcatheter Arterial Embolization for Spontaneous Hepatic Rupture Associated with HELLP Syndrome: A Case Report

Background: Spontaneous hepatic rupture associated with the syndrome characterized by hemolysis, elevated liver enzymes, and a low platelet count (HELLP syndrome) is a rare and life-threatening condition, and only a few cases regarding the management of this condition through transcatheter arterial embolization (TAE) have been previously reported. Case summary: Herein, we report a case involving a 35-year-old pregnant woman who presented at 28 weeks of gestation with right upper quadrant pain, hypotension, and elevated levels of liver enzymes. Transabdominal ultrasound revealed fetal death. She required an emergency cesarean section, and hepatic rupture was identified after the fetus had been delivered. Hepatic packing and TAE were performed. The postprocedural course was uneventful, and the patient was discharged 14 days after she had been admitted to our hospital. Conclusions: Spontaneous hepatic rupture associated with HELLP syndrome is a very serious condition that requires prompt and decisive management. The high maternal and fetal mortality rates associated with this condition can be reduced through early accurate diagnosis and adequate management. The findings in the reported case indicate that TAE may be an attractive alternative to surgery for the management of spontaneous hepatic rupture associated with HELLP syndrome.

Manejo de la ruptura hepática espontánea en el síndrome de HELLP

Introducción. El síndrome de HELLP es una variante grave de la preeclampsia, con una baja incidencia, entre el 0,5-0,9 % de todos los embarazos. La ruptura hepática espontánea en el embarazo es infrecuente, presenta una alta mortalidad, y se ha relacionado con hemangiomas hepáticos, coriocarcinoma y síndrome de HELLP. Caso clínico. Mujer de 29 años con embarazo de 34,3 semanas, con actividad uterina progresiva, sufrimiento fetal agudo y hallazgos compatibles con síndrome de HELLP. Se practicó cesárea de urgencia encontrando hemoperitoneo y ruptura hepática del lóbulo derecho, por lo que se realizó empaquetamiento abdominal y posterior reintervención quirúrgica. Discusión. La ruptura hepática espontánea en el embarazo es una entidad infrecuente y potencialmente mortal. Es esencial un alto nivel de sospecha para realizar el diagnóstico y la rápida intervención. Requiere un manejo multidisciplinario para un resultado exitoso. Se han descrito múltiples tratamientos que dependen de las manifestaciones clínicas y extensión de la lesión, pero es claro que la laparotomía primaria y el taponamiento constituyen la mejor elección ante el hallazgo intraoperatorio

Managing a rare complication of HELLP syndrome in Australia: Spontaneous liver haematoma in pregnancy

Spontaneous subcapsular haematoma of the liver is a rare but life-threatening complication of pregnancy. Prevention of maternal and fetal death requires early identification and specialised management. We report three cases of spontaneous liver haematoma in pregnancy from our institution between 2011 and 2018. We conducted a systematic search of online databases using search terms, ('liver' AND 'pregnancy') AND ('haematoma' OR 'rupture') in order to present a narrative review of the literature and a systematic management framework. Our series is the first Australian report of spontaneous subcapsular haematoma in pregnancy with one fetal death in utero but no maternal deaths. Our systematic search of online databases revealed 45 similar reports in the last ten years. Individual patient data were available for 73 cases. The overwhelming majority of these reports were single cases or small case series. We estimate the mean maternal mortality rate to be 15% but fetal mortality was substantially greater than 15% (although data for neonatal outcomes was incomplete). There was one case report of liver transplantation with excellent maternal and fetal outcome. In the last five years, modern diagnostic techniques and therapeutic options have significantly reduced maternal and fetal mortality. Hepatic artery embolisation is a minimally invasive approach under guidance of imaging and is likely to achieve the best maternal and fetal outcomes. Based on our literature review, we have provided a systematic management framework for spontaneous liver haematoma in pregnancy.

Comparing levels of vitamin D, calcium and phosphorus in normotensive pregnant women and pregnant women with preeclampsia

Vitamin D and calcium deficiency have been reported as one of the causes of preeclampsia. In this study, levels of vitamin D, calcium and phosphorus were evaluated in 51 normotensive pregnant women and 52 women with preeclampsia at the gestational age between 28 and 36 weeks in Tabriz. Logistic regression and general linear models were used for comparing levels and means of vitamin D, calcium and phosphorus between the two groups adjusting for education and Body Mass Index (BMI). The results showed that mean serum vitamin D (p = .73), calcium (p = .12) and phosphorus (p = .60) levels were not significantly different between the groups after adjusting for education and BMI. Based on this study, no relationship was observed between vitamin D deficiency and preeclampsia; however, it was seen that the hypocalcaemia could increase the risk of preeclampsia up to 8.5 times. Based on our results and the literature, it seems that further studies need to be done to provide more insights into this area.Impact statementWhat is already known on this subject? Preeclampsia is one of the three leading causes of maternal morbidity and mortality worldwide. Despite the importance of preeclampsia, the causes and methods of prevention of this disease are still unknown. Deficiency of vitamin D affects the calcium balance of mothers and fetuses and has also been reported as one of the causes of preeclampsia disease. Reducing serum calcium can lead to increased blood pressure in preeclamptic women. Changes in calcium metabolism during pregnancy could be one of the potential causes of preeclampsia. Although the association of vitamin D, calcium and phosphorus with preeclampsia have been discussed previously, the results are not consistent.What do the results of this study add? The results showed that mean serum vitamin D, calcium and phosphorus levels were not significantly different between the groups.What are the implications of these findings for clinical practice and/or future research? Based on this study, no relationship was observed between vitamin D deficiency and preeclampsia; however, it was seen that the hypocalcaemia could increase the risk of preeclampsia by up to 8.5 times. Based on our results and the literature, it seems that further studies need to be done to provide more insights into this area.

Expression of S100 calcium-binding protein A8 in peripheral blood of patients with preeclampsia during pregnancy

A total of 30 late onset severe preeclampsia (LS-PE) patients and 30 early onset severe preeclampsia (ES-PE) patients were selected as Experimental group, and 30 normal pregnant were selected as Control group. Expression of S100 calcium-binding protein A8 (S100A8) mRNA was detected by reverse transcription polymerase chain reaction (RT-PCR). Enzyme-linked immunosorbent assay (ELISA) was used to detect expression of S100A8 protein and inflammatory factors. Levels of uric acid (UA) and creatinine (CRE) were measured using an automatic biochemical analyzer. Urinary protein (UPRO) content was measured using biuret colorimetry. S100A8 levels were significantly higher in experimental groups than in control groups at mRNA and protein levels ( P < 0.05). Significantly increased contents of tumor necrosis factor (TNF)-α, interleukin (IL)-6, IL-12, UA, CRE, and UPRO, and decreased level of IL-10 were found in experimental groups than in control groups ( P < 0.05). Compared with patients with ES-PE, significantly higher levels of TNF-α, IL-12, IL-6, UA, CRE, and UPRO, and lower level of IL-10 were found in patients with LS-PE. S100A8 plays pivotal roles in the development of preeclampsia through the interactions with other inflammatory factors.

Indian National Association for the Study of the Liver-Federation of Obstetric and Gynaecological Societies of India Position Statement on Management of Liver Diseases in Pregnancy

Liver diseases occurring during pregnancy can be serious and can progress rapidly, affecting outcomes for both the mother and fetus. They are a common cause of concern to an obstetrician and an important reason for referral to a hepatologist, gastroenterologist, or physician. Liver diseases during pregnancy can be divided into disorders unique to pregnancy, those coincidental with pregnancy, and preexisting liver diseases exacerbated by pregnancy. A rapid differential diagnosis between liver diseases related or unrelated to pregnancy is required so that specialist and urgent management of these conditions can be carried out. Specific Indian guidelines for the management of these patients are lacking. The Indian National Association for the Study of the Liver (INASL) in association with the Federation of Obstetric and Gynaecological Societies of India (FOGSI) had set up a taskforce for development of consensus guidelines for management of patients with liver diseases during pregnancy, relevant to India. For development of these guidelines, a two-day roundtable meeting was held on 26-27 May 2018 in New Delhi, to discuss, debate, and finalize the consensus statements. Only those statements that were unanimously approved by most members of the taskforce were accepted. The primary objective of this review is to present the consensus statements approved jointly by the INASL and FOGSI for diagnosing and managing pregnant women with liver diseases. This article provides an overview of liver diseases occurring in pregnancy, an update on the key mechanisms involved in its pathogenesis, and the recommended treatment options.

Liver Diseases During Pregnancy

Liver diseases during pregnancy pose a unique clinical challenge because they can affect the lives of both the mother and unborn child. Although severe liver disease is rare, pregnancy-related liver disease affects approximately 3% of pregnancies and can be fatal. Timely recognition and diagnosis are essential in order to institute appropriate management strategies. This article provides an overview of liver diseases during pregnancy and is divided into 2 sections: (1) liver diseases specific to pregnancy, and (2) preexisting or coincident liver diseases during pregnancy.

Liver rupture in a 28-year-old primigravida with superimposed pre-eclampsia and hemolysis, elevated liver enzyme levels, and low platelet count syndrome

Serious hepatic complications, although rare, are one of the leading causes of maternofetal morbidity and mortality in hypertensive pregnancy disorders. A 28-year-old primigravida was transferred to our hospital complaining of refractory epigastric pain in the 29th week of pregnancy and was subsequently admitted due to superimposed pre-eclampsia and hemolysis, elevated liver enzyme levels, and low platelet count syndrome. Following a pathological cardiotocogram, a cesarean section was performed. The intra-abdominal situs presented with 1000 mL of blood and a bleeding rupture of the left lobe of the liver. The trauma to the liver was surgically repaired with a suture and the patient's state was stabilized. Following the surgical procedures and neonatal intensive care, mother and newborn both recovered without residues. In order to avoid unnecessary maternal morbidity, we therefore recommend an abdominal ultrasound, beyond an obstetric focus, as an additional and sensible means of diagnostic imaging in cases of hemolysis, elevated liver enzyme levels, and low platelet count syndrome.

Management of acute abdomen in pregnancy: current perspectives

Acute abdomen in pregnancy represents a unique diagnostic and therapeutic challenge. Acute abdominal pain in pregnancy can occur due to obstetric factors as well for reasons that are unrelated to pregnancy. The diagnostic approach of acute abdomen during pregnancy can be tricky owing to the altered clinical presentations brought about by the anatomical and physiological changes of gestation along with the reluctance to use certain radiological investigations for fear of harming the fetus. Delay in diagnosis and treatment can lead to adverse outcomes for both the mother and fetus. In this article, we attempt to review and discuss the various etiologies, the current concepts of diagnosis, and treatment, with a view to developing a strategy for timely diagnosis and management of pregnant women presenting with acute abdominal pain.

Hepatic rupture from haematomas in patients with pre-eclampsia/eclampsia: a case series

Hepatic rupture from haematomas is a rare complication of severe preeclampsia/eclampsia especially when complicated with the haemolysis, elevated liver enzymes and low platelet count (HELLP) syndrome. It is associated with poor maternal and foetal outcomes as demonstrated by three cases we describe. The first case had eclampsia at 31 weeks gestation with features of abruptio placentae and at caesarean section we found haemoperitoneum of 1.5 litres, a 10cm liver rupture and a still birth. She subsequently died in ICU within 24 hours of surgery; the second case had eclampsia at 35 weeks and ended up as a table death during emergency caesarean section. She had 4 litres of haemoperitoneum, hepatic rupture, placental abruption and a stillbirth; the third case had pre-eclampsia at 33 weeks with markedly elevated liver enzymes. She had one litre haemoperitoneum, right lobe hepatic rupture and a stillbirth. She recovered after conservative management. Severe pre-eclampsia/eclampsia associated hepatic rupture calls for rapid and aggressive intervention with prompt multidisciplinary management to avert adverse outcomes.

Nonviral or Drug-Induced Etiologies of Acute Liver Failure

Acute liver failure (ALF) is a rare but highly fatal condition. The most common causes include drug-induced and viral hepatitis, but other less common etiologies, especially autoimmune hepatitis, Budd-Chiari syndrome, and Wilson disease, need to be considered. Because diagnosis is frequently tied to potential for reversibility of ALF and prognosis, early identification in a timely manner is crucial. Other causes of ALF are more easily recognizable based on specific circumstances, such as ALF in pregnancy or ischemic hepatitis. Ultimately, maintaining a wide differential diagnosis in patients with ALF is essential to identifying the proper treatment and prognosis.

A rare case of spontaneous hepatic rupture in a pregnant woman

Background

Spontaneous hepatic rupture in pregnancy is a rare and life-threatening event during the perinatal period.

Case presentation

We report a case of a 33-year-old woman with 36 + 6 weeks’ gestation that present with elevated blood pressure before delivery, who was admitted to our hospital due to irregular abdominal pain. Diagnosed with abdominal paracentesis, the emergent caesarean section and laparotomy were performed. Postoperatively, the patient experienced 22-day intensive therapy in ICU and was transferred to the General Surgery Department in good physical condition without post-operative complications.

Conclusions

This case indicates that making an accurate and timely diagnosis and taking multidisciplinary approach contribute to a successful clinical outcome.

Hepatic rupture associated with preeclampsia, report of three cases and literature review

BACKGROUND

Hepatic rupture is a complication during pregnancy that, although rare, accounts for high morbidity and mortality rates. It is mainly associated with severe preeclampsia and HELLP syndrome. Incidence is estimated to be at one per 67,000 births or one per 2000 patients with preeclampsia/eclampsia/HELLP, mainly in multiparous women; women in their 40s; after 32 weeks of gestation; and during the first 15 h postpartum.

CASES

This article exposes the institutional experience at Fundación Valle del Lili in Cali, Colombia, in managing and treating hepatic rupture associated with severe preeclampsia and HELLP syndrome in three patients in the 30th, the 26th, and the 27th week of gestation, not resulting in maternal death.

DISCUSSION

A search in Pubmed, Embase, and Ovid from 2000 to 2017 resulted in 35 cases reported in either pregnant or puerperal women. Hepatic rupture is a rare complication in pregnancy associated with preeclampsia and HELLP syndrome. Its pathophysiology is attributed to the presence of vasospasm due to an increase in concentration and sensitivity to circulating vasopressors during pregnancy. There is no standard management, but surgery reduces mortality significantly. It includes endovascular management, partial hepatectomy, or transplant (only one patient required a liver transplant in our search). The most used techniques have been ligation of the hepatic artery, embolization of the hepatic artery, and examination, packing, and drainage of hepatic lesion for bleeding control (27 cases were treated with laparotomy with evacuation of hematoma and hemostasis and four cases were treated with embolization of the hepatic artery). Hepatic artery occlusion both by surgery ligation and by embolization through interventional radiology has reported successful and failing results during pregnancy Conclusion: Management of pathologies as hepatic rupture associated with severe preeclampsia and HELLP syndrome has to be clearly protocolized for prompt diagnosis and early management. Furthermore, it has to be carried out through multidisciplinary teams in high-complexity obstetrics scenarios.

Intramural Hematoma of the Esophagus Complicating Severe Preeclampsia

Intramural hematoma of the esophagus is a rare injury causing esophageal mucosal dissection. Forceful vomiting and coagulopathy are common underlying causes in the elderly population taking antiplatelets or anticoagulation agents. Acute retrosternal pain followed by hematemesis and dysphagia differentiates the hematoma from other cardiac or thoracic emergencies, including acute myocardial infarction or aortic dissection. Direct inspection by endoscopy is useful, but chest computed tomography best assesses the degree of obliteration of the lumen and excludes other differential diagnoses. Intramural hematoma of the esophagus is generally benign and most patients recover fully with conservative treatment. Bleeding can be managed medically unless in hemodynamically unstable patients, for whom surgical or angiographic treatment may be attempted; only rarely esophageal obstruction requires endoscopic decompression. We report an unusual case of esophageal hematoma, presenting in a young preeclamptic woman after surgical delivery of a preterm twin pregnancy, with a favorable outcome following medical management.

ACG Clinical Guideline: Liver Disease and Pregnancy

Consultation for liver disease in pregnant women is a common and oftentimes vexing clinical consultation for the gastroenterologist. The challenge lies in the need to consider the safety of both the expectant mother and the unborn fetus in the clinical management decisions. This practice guideline provides an evidence-based approach to common diagnostic and treatment challenges of liver disease in pregnant women.

Pregnancy and the Immune System: General Overview and the Gastroenterological Perspective

Pregnancy represents a unique immune tolerant condition that cannot be attributed merely to generalized immunosuppression. A variety of mechanisms have been described, ranging from the non-self recognition, immunomodulation of specific inflammatory cell populations and a Th2-directed shift of the immune response, which are mediated by both localized and systemic mediators. Furthermore, an inflammatory response directed toward the conceptus is no longer considered an obligatory deleterious response; instead, it is considered an important factor that is necessary for normal growth and development. These immunomodulatory changes during pregnancy may also affect concurrent conditions and alter the course of inflammatory diseases. Herein, we review the main immunomodulatory changes that occur during pregnancy and their effect on coexisting inflammatory conditions, with a specific focus on gastrointestinal disorders.

Management of Spontaneous Hepatic Rupture on Top of HELLP Syndrome: Case Report and Review of the Literature

Introduction

We report the case of a patient with antepartum HELLP syndrome and simultaneous rupture of the right liver lobe. An emergency caesarean section was performed and the liver rupture was managed surgically via perihepatic packing. The mother and her child recovered well and were discharged 19 days after admission.

Case Report

We describe a case report and review the literature. Based on our own experience and the most common clinical presentations of such patients, we were able to establish an algorithm for managing such cases.

Conclusion

An association between liver rupture and HELLP syndrome is rare but was previously described in several case reports. In pregnant women with HELLP syndrome and acute onset abdominal pain, a potential spontaneous hepatic rupture should be taken into consideration.

Liver rupture in HELLP syndrome

We report on a 30-year-old Caucasian woman admitted to our clinic after 34 weeks of gestation because of a severe partial hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome. A cesarean section was performed when her clinical symptoms and laboratory values worsened. Intraoperatively she was diagnosed with hepatic subcapsular hematoma and liver rupture. Surgical treatment, including perihepatic packing with sterile towels removed 2 days post-surgery, resulted in an uneventful recovery. The patient was discharged 26 days after admission. Case reports such as ours may contribute to the management of pregnancies complicated by hepatic hematoma and rupture of the liver capsule associated to HELLP syndrome.

Management of hepatic rupture diagnosed after an emergency cesarean section

A careful management of hepatic capsular rupture, with massive hemoperitoneum which occurred 14 hours after an emergency cesarean section at 36 weeks of gestation, is meticulously reported. The grade of hepatic involvement varies from minor capsular laceration to extensive parenchymal rupture. Our management involved a combination of surgical interventions and aggressive supportive care. The patient was discharged after 53 days and 4 laparotomies and an unsuccessful attempt of superselective artery embolization. Ultrasound after 40 days from the last surgery showed uniform hepatic parenchyma free of focal lesions. Due to the rarity and the unpredictability nature of this devastating event we believe necessary to report our experience, reinforcing the importance of the postsurgery management.