"Hepatic rupture in preeclampsia and HELLP syndrome: A catastrophic presentation"

Hepatic Rupture Associated With HELLP (Hemolysis, Elevated Liver Enzymes, and Low Platelets) Syndrome: A Report of Two Cases and Literature Review

Hepatic rupture is a rare complication of severe preeclampsia. A high index of suspicion is required in the presence of abdominal pain accompanied by hemodynamic decompensation in a pregnant woman. Hepatic rupture constitutes a medical emergency that demands immediate intervention, often with the support of other medical disciplines, in a highly specialized hospital setting. Unruptured hepatic hematomas can be managed conservatively. Immediate delivery and surgical repair of the liver are necessary for maternal survival. Spontaneous liver rupture in pregnancy is often unrecognized, highly lethal, and not completely understood with few cases having been reported in the literature. Therefore, we present two cases of HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome with hepatic rupture, emphasizing their clinical presentation and therapeutic approaches.

Subcapsular liver hematoma complicating HELLP syndrome: A case report and review of management strategies

Subcapsular liver hematoma is a life-threatening complication of pregnancy. It is associated with preeclampsia and HELLP syndrome. We present the case of a 36-year-old Caucasian nulliparous woman who was diagnosed at 29 weeks and 6 days of gestation with mild preeclampsia. After brief hospitalization she was discharged. During a daily follow-up, at 31 weeks and 3 days of gestation, she complained of mild abdominal pain and blood tests revealed HELLP syndrome. The cervix was unripe. A healthy baby was delivered by emergency cesarean section. The following day, the patient complained of persistent abdominal pain, and at the same time the hepatic cytolysis worsened dramatically. A computed tomography (CT) scan revealed a significant subcapsular hematoma without any active bleeding or breach of Glisson's capsule. We treated the patient conservatively and she was discharged home 10 days after the diagnosis was made. The symptoms of subcapsular liver hematoma are non-specific. They include nausea, vomiting and epigastric pain, and pain in the right upper quadrant or shoulder. Biological analyses can show hepatic cytolysis, haemolysis and coagulation disorders. Medical imaging can confirm the diagnosis. The management of subscapular liver hematoma may depends on whether there is hemodynamic stability, active bleeding or breach of Glisson capsule's. If the patient is stable and in the absence of active bleeding, management should be purely symptomatic.

Expression of insulin-like growth factor binding protein-3 in HELLP syndrome

OBJECTIVE

To investigate the expression of insulin-like growth factor binding protein-3(IGFBP-3) in HELLP syndrome and its possible role in the pathogenesis of this disease.

METHODS

1) 87 subjects were enrolled, including 29 patients with HELLP syndrome, 29 patients with pre-eclampsia (PE), and 29 healthy gravidae as control. The levels of IGFBP-3, IGF-1, TGF-β1, and VEGF in maternal and umbilical blood of them were detected using ELISA. Correlation analysis was used to observe the correlation between IGFBP-3 and IGF-1/TGF-β1/VEGF in maternal and umbilical blood, as well as that between maternal serum IGFBP-3 and clinical diagnostic indicators of HELLP syndrome. 2) Human hepatic sinusoid endothelial cells (HLSEC) and human umbilical vein endothelial cells (HUVEC) were cultured with different concentrations of IGFBP-3. After 72 h of culture, cell apoptosis and the normal living cells rate were detected and compared.

RESULTS

1) In both maternal and umbilical blood of HELLP group, levels of IGFBP-3 and TGF-β1 were higher than control and PE group, IGF-1was lower than control group, VEGF was lower than control and PE group. IGFBP-3 in maternal blood was correlated with IGF-1/TGF-β1/ VEGF, while IGFBP-3 in umbilical blood was linked to IGF-1/TGF-β1. In maternal blood, there was a negative correlation between PLT and IGFBP-3, and a positive correlation between ALT/AST/LDH and IGFBP-3. 2) After cultured with IGFBP-3, the total apoptosis rate of either HLSEC or HUVEC was considerably elevated, while the normal living rate was decreased.

CONCLUSION

The expression of IGFBP-3 is elevated in HELLP syndrome, which may subsequently promote cell apoptosis by affecting the expression and function of IGF-1, VEGF, and TGFβ1 in the IGF/PI3K/Akt, TGF-β1/Smad3, and VEGF/eNOS/NO pathways. IGFBP-3 aggravates inflammatory reactions of the vascular endothelium and liver under hypoxia, affects the normal function of cells, and plays a role in the pathogenesis of diseases.

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.

An advanced understanding of the heterogeneous clinical features of "non-criteria" obstetric antiphospholipid syndrome: Two case reports and a literature review

Antiphospholipid syndrome (APS) is an acquired autoimmune disorder characterized by recurrent venous and/or arterial thrombosis and/or pregnancy complications, in the presence of elevated antiphospholipid (aPL) antibodies. APS in pregnant women is referred to as "obstetrical" APS (OAPS). The diagnosis of definite OAPS requires the presence of one or more typical clinical criteria and persistent aPL antibodies at least 12 weeks apart. However, the classification criteria for OAPS have generated wide discussion, with a growing impression that certain patients not fully meeting these criteria might be inappropriately excluded from the classification, which is known as "non-criteria" OAPS. We present here two unique cases of potentially lethal "non-criteria" OAPS, complicating severe preeclampsia, fetal growth restriction (FGR), liver rupture, preterm birth, refractory recurrent miscarriages, or even stillbirth. We further share our diagnostic search and analysis, treatment adjustment, and prognosis for this unusual antenatal event. We will also present a short review of an advanced understanding of the pathogenetic mechanisms of this disease, heterogeneous clinical features, and potential significance.

Spontaneous hepatic rupture during late pregnancy in a patient with solitary necrotic nodule of the liver: A case report

Background

Spontaneous hepatic rupture (SHR) during pregnancy is a rare and life-threatening event, which usually occurs together with preeclampsia, eclampsia, HELLP syndrome, or liver tumors. However, SHR resulting from solitary necrotic nodule of the liver (SNNL) is extremely rare.

Case presentation

We report the case of a 32-year-old pregnant woman who presented at 33 weeks of gestation with abdominal pain and emesis. Transabdominal ultrasound and magnetic resonance imaging revealed massive hemoperitoneum and lesions in the left lobe of the liver. An emergency cesarean section was performed and the hepatic rupture was managed surgically via left lateral lobectomy. The postprocedural course was uneventful. The premature baby successfully survived, and the patient was discharged 8 days after admission without complications. Histological examination revealed a diagnosis of SNNL, which resulted in the hepatic hematoma and SHR.

Conclusion

To our knowledge, this is the first case of SHR resulting from SNNL during late pregnancy. Multidisciplinary collaboration and surgical management are important cornerstones for improving the perinatal outcomes when SHR is suspected in a pregnant patient.

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.

Pregnancy-Associated Liver Diseases

The liver disorders unique to pregnancy include hyperemesis gravidarum, intrahepatic cholestasis of pregnancy, acute fatty liver of pregnancy, and preeclampsia-associated hepatic impairment, specifically hemolysis, elevated liver enzymes, and low platelet count syndrome (HELLP). Their importance lies in the significant maternal and fetal/neonatal morbidity and mortality. Expeditious diagnosis and clinical evaluation is critical to ensure timely, appropriate care and minimize risks to the pregnant woman and her fetus/baby. A multidisciplinary approach is essential, including midwives, maternal-fetal-medicine specialists, anesthetists, neonatologists, and hepatologists.

Conservative management of a pregnancy complicated by preeclampsia and postpartum spontaneous hepatic rupture: A case report and review of the literature

INTRODUCTION AND OBJECTIVES

Most spontaneous hepatic rupture cases are associated with a pregnancy-induced hypertensive disorder like preeclampsia and HELLP syndrome. Although it is a rare complication, it is still associated with high maternal and fetal morbidity and mortality rates. With this study, we aim to present a case report and review the available literature on hepatic rupture associated with hypertensive disorders of the pregnancy.

METHODS

We present a case report and a review of the literature of the last 20 years on hepatic rupture associated with pregnancy-induced hypertensive disorders. The selected cases were reviewed to collect information on maternal characteristics, clinical presentation, diagnostic studies, therapeutic modalities and maternal and fetal outcomes.

RESULTS

Our review has found 57 publications describing a total of 93 cases of hepatic hemorrhage with capsule rupture associated with pregnancy-induced hypertensive disorders. Most of the patients were less than 35 years old and primiparous and the first symptoms of hepatic rupture included epigastric and right upper abdominal pain. Most of the diagnoses were made during surgery without previous diagnosis and, in the majority of cases, a surgical approach was necessary to achieve hemostasis. Perihepatic packing was the most used surgical method.

DISCUSSION/CONCLUSION

Our clinical case and literature review reinforces the importance of closely monitoring all pregnancies complicated with hypertensive disorders, including in the postpartum period. Although hepatic rupture accounts for high maternal and fetal morbidity and mortality rates, it is possible to keep a conservative approach with good maternal and fetal outcomes, with a high index of suspicious, an early diagnosis and a multidisciplinary approach.

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.

Hepatic infarction, hematoma, and rupture in HELLP syndrome: support for a vasospastic hypothesis

Purpose: HELLP syndrome is a relatively uncommon pregnancy-related condition characterized by hemolysis, elevated liver function tests, and low platelets. It can be accompanied by life-threatening hepatic complications including hepatic infarction, hematoma formation, and hepatic rupture. HELLP syndrome occurs in approximately 0.2% of pregnancies. Major hepatic complications occur in less than 1% of HELLP patients suggesting an incidence of 1/50,000. The pathogenesis is incompletely understood and in particular, it is difficult to understand a disorder with both major thrombotic and bleeding manifestations.Methods: Literature review.Results: On the basis of reports in the published literature, and our own clinical experience, we suggest that vasospasm is one of the principal drivers with hepatic ischemia, infarction, and hemorrhage as secondary events. It is known that vasoactive substances are released by the failing placenta. We suggest these cause severe vasospasm, most likely affecting the small post-sinusoidal hepatic venules. This leads to patchy or confluent hepatic ischemia and/or necrosis with a resultant increase in circulating liver enzymes. Reperfusion is associated with a fall in platelet count and microvascular hemorrhage if the microvasculature is infarcted. Blood tracks to the subcapsular space causing hematoma formation. If the hematoma ruptures the patient presents with severe abdominal pain, intra-abdominal hemorrhage, and shock.Conclusions: We suggest that hepatic and other complications associated with HELLP syndrome including placental abruption, acute renal failure, and posterior reversible encephalopathy syndrome (PRES) may also be due to regional vasospasm.