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Porrello G, Cannella R, Bernuau J, Agman A, Brancatelli G, Dioguardi Burgio M, Vilgrain V. Liver imaging and pregnancy: what to expect when your patient is expecting. Insights Imaging 2024; 15:66. [PMID: 38411871 PMCID: PMC10899155 DOI: 10.1186/s13244-024-01622-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 01/07/2024] [Indexed: 02/28/2024] Open
Abstract
Liver diseases in pregnancy can be specific to gestation or only coincidental. In the latter case, the diagnosis can be difficult. Rapid diagnosis of maternal-fetal emergencies and situations requiring specialized interventions are crucial to preserve the maternal liver and guarantee materno-fetal survival. While detailed questioning of the patient and a clinical examination are highly important, imaging is often essential to reach a diagnosis of these liver diseases and lesions. Three groups of liver diseases may be observed during pregnancy: (1) diseases related to pregnancy: intrahepatic cholestasis of pregnancy, pre-eclampsia, eclampsia, hemolysis, elevated liver enzymes and low platelets (HELLP) syndrome, and acute fatty liver of pregnancy; (2) liver diseases that are more frequent during or exacerbated by pregnancy: acute herpes simplex hepatitis, Budd-Chiari syndrome, hemorrhagic hereditary telangiectasia, hepatocellular adenoma, portal vein thrombosis, and cholelithiasis; (3) coincidental conditions, including acute hepatitis, incidental focal liver lesions, metabolic dysfunction-associated steatotic liver disease, cirrhosis, hepatocellular carcinoma, liver abscesses and parasitosis, and liver transplantation. Specific knowledge of the main imaging findings is required to reach an early diagnosis, for adequate follow-up, and to avoid adverse consequences in both the mother and the fetus.Critical relevance statement Pregnancy-related liver diseases are the most important cause of liver dysfunction in pregnant patients and, in pregnancy, even common liver conditions can have an unexpected turn. Fear of radiations should never delay necessary imaging studies in pregnancy.Key points• Pregnancy-related liver diseases are the most frequent cause of liver dysfunction during gestation.• Fear of radiation should never delay necessary imaging studies.• Liver imaging is important to assess liver emergencies and for the diagnosis and follow-up of any other liver diseases.• Common liver conditions and lesions may take an unexpected turn during pregnancy.• Pregnancy-specific diseases such as pre-eclampsia and HELLP syndrome must be rapidly identified. However, imaging should never delay delivery when it is considered to be urgent for maternal-fetal survival.
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Affiliation(s)
- Giorgia Porrello
- Service de Radiologie, AP-HP Nord, Hôpital Beaujon, Paris, Clichy, France.
- Department of Biomedicine, Neuroscience and Advanced Diagnostics (Bi.N.D.), University Hospital "Paolo Giaccone", Palermo, Italy.
| | - Roberto Cannella
- Department of Biomedicine, Neuroscience and Advanced Diagnostics (Bi.N.D.), University Hospital "Paolo Giaccone", Palermo, Italy
| | - Jacques Bernuau
- AP-HP Nord, Hôpital Beaujon, Service d'Hépatologie, Paris, Clichy, France
| | - Antoine Agman
- Service de Gynécologie obstétrique maternité, AP-HP Nord, Hôpital Beaujon, Paris, Clichy, France
| | - Giuseppe Brancatelli
- Department of Biomedicine, Neuroscience and Advanced Diagnostics (Bi.N.D.), University Hospital "Paolo Giaccone", Palermo, Italy
| | - Marco Dioguardi Burgio
- Service de Radiologie, AP-HP Nord, Hôpital Beaujon, Paris, Clichy, France
- Université Paris Cité, Inserm, Centre de recherche sur l'inflammation, F-75018, Paris, France
| | - Valérie Vilgrain
- Service de Radiologie, AP-HP Nord, Hôpital Beaujon, Paris, Clichy, France
- Université Paris Cité, Inserm, Centre de recherche sur l'inflammation, F-75018, Paris, France
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2
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Mossayebi MH, Iyer NS, McLaren RA, Moussa HN, Sibai BM, Al-Kouatly HB. HELLP syndrome at <23 weeks' gestation: a systematic literature review. Am J Obstet Gynecol 2023; 229:502-515.e10. [PMID: 37150281 DOI: 10.1016/j.ajog.2023.04.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 04/23/2023] [Accepted: 04/26/2023] [Indexed: 05/09/2023]
Abstract
OBJECTIVE We performed a systematic review to evaluate the clinical presentation and maternal and fetal outcomes in pregnancies with early-onset HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome. DATA SOURCES PubMed, Ovid MEDLINE, Scopus, CINAHL, Cochrane Library, and ClinicalTrials.gov were queried from inception through January 1, 2023 with the following terms: "HELLP syndrome," "HELLP," "hemolysis, elevated liver enzymes, low platelets," "hemolysis, elevated liver enzymes, low platelets syndrome," "pre-viable," "peri-viable," "previable," "periviable," "first trimester," "second trimester," "before 23 weeks," "<23 weeks," "<23 week gestation," and "before 23 weeks gestation." We also included an additional case from our institution. STUDY ELIGIBILITY CRITERIA Abstracts, unpublished studies, and review articles were excluded, yielding 46 studies that met our inclusion criteria. METHODS Two reviewers (N.S.I. and M.H.M.) performed the study selection and subsequent data extraction independently, after which the results were reviewed together. PRISMA guidelines were followed, and our study was registered at PROSPERO (CRD42021292692). RESULTS A total of 55 patients had 58 pregnancies complicated by early-onset HELLP syndrome, including 3 with recurrent HELLP. The most common presenting signs/symptoms were abdominal pain (35/45; 78%), hypertension (32/49; 65%), nausea/vomiting (16/45; 36%), headache (13/45; 29%), and edema (8/45; 18%). Lactate dehydrogenase ≥600 IU/L was observed in 21 of 31 (68%) cases, whereas liver enzyme abnormalities and thrombocytopenia were reported in 48 of 51 (94%) and 50 of 54 (93%) cases, respectively. Maternal complications were encountered in 25 of 56 (45%) cases. The most common complications were hepatic (13/56; 23%), central nervous system-related (11/56; 20%), and respiratory (11/56; 20%). In 36 of 57 (63%) cases, pregnancy was terminated. Of the 21 continued pregnancies, early fetal death (at <20 weeks' gestation) was reported in 10 (48%), stillbirth in 6 (28%), and neonatal demise in 2 (10%). Living neonates were reported in 3 of 21 (14%) cases, all delivered at 23 weeks. The perinatal mortality rate was 73% (8/11). One case (2%) reported maternal death. Antiphospholipid syndrome was diagnosed in 14 of 29 (48%) cases. CONCLUSION Early-onset HELLP syndrome presents with symptoms similar to those observed in later gestation. Maternal complications are life-threatening, with the most common complications being hepatic, central nervous system-related, and respiratory. Fetal outcomes are poor.
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Affiliation(s)
- Matthew H Mossayebi
- Department of Obstetrics and Gynecology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA.
| | - Neel S Iyer
- Department of Obstetrics and Gynecology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Rodney A McLaren
- Department of Obstetrics and Gynecology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Hind N Moussa
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Toledo, ProMedica Health System, Toledo, OH
| | - Baha M Sibai
- Department of Obstetrics, Gynecology and Reproductive Sciences, The University of Texas Health Science Center at Houston, Houston, TX
| | - Huda B Al-Kouatly
- Department of Obstetrics and Gynecology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
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3
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Williamson C, Nana M, Poon L, Kupcinskas L, Painter R, Taliani G, Heneghan M, Marschall HU, Beuers U. EASL Clinical Practice Guidelines on the management of liver diseases in pregnancy. J Hepatol 2023; 79:768-828. [PMID: 37394016 DOI: 10.1016/j.jhep.2023.03.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 03/10/2023] [Indexed: 07/04/2023]
Abstract
Liver diseases in pregnancy comprise both gestational liver disorders and acute and chronic hepatic disorders occurring coincidentally in pregnancy. Whether related to pregnancy or pre-existing, liver diseases in pregnancy are associated with a significant risk of maternal and fetal morbidity and mortality. Thus, the European Association for the Study of Liver Disease invited a panel of experts to develop clinical practice guidelines aimed at providing recommendations, based on the best available evidence, for the management of liver disease in pregnancy for hepatologists, gastroenterologists, obstetric physicians, general physicians, obstetricians, specialists in training and other healthcare professionals who provide care for this patient population.
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4
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Lam NP, Mai AT, Pham TC, Kieu HT, Nguyen HQ. Spontaneous Hepatic Rupture in a Pregnant Woman with Preeclampsia and HELLP Syndrome. Case Rep Crit Care 2023; 2023:6683645. [PMID: 37051265 PMCID: PMC10085647 DOI: 10.1155/2023/6683645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 03/13/2023] [Accepted: 03/14/2023] [Indexed: 04/05/2023] Open
Abstract
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.
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Affiliation(s)
- Nguyen Phuoc Lam
- Intensive Care Unit, Cho Ray Hospital, Ho Chi Minh City, Vietnam
- University of Medicine and Pharmacy at Ho Chi Minh City, Vietnam
| | - Anh Tuan Mai
- University of Medicine and Pharmacy at Ho Chi Minh City, Vietnam
| | - Thanh Chi Pham
- University of Medicine and Pharmacy at Ho Chi Minh City, Vietnam
| | - Hieu Trung Kieu
- Intensive Care Unit, Cho Ray Hospital, Ho Chi Minh City, Vietnam
- University of Medicine and Pharmacy at Ho Chi Minh City, Vietnam
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5
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Mcnamara G, Moirano J, May BJ. Call IR for HELLP: Postpartum Hepatic Rupture. Cardiovasc Intervent Radiol 2023; 46:522-524. [PMID: 36918427 DOI: 10.1007/s00270-023-03404-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 02/23/2023] [Indexed: 03/16/2023]
Affiliation(s)
| | - Joseph Moirano
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Benjamin J May
- Weill Cornell Medical College, Cornell University, Ithaca, New York, NY, USA.
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Liu J, Liu L, Liao G, Yao L. Conservative Treatment of Huge Hepatic Subcapsular Hematoma Complicated with Hepatic Infarction after Cesarean Section Caused by HELLP Syndrome - a Case Report and Literature Review. Z Geburtshilfe Neonatol 2023. [PMID: 36849111 DOI: 10.1055/a-1967-2451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
Hepatic subcapsular hematoma and hepatic infarction in labor are mostly secondary to HELLP syndrome and preeclampsia. There are few reported cases with a complicated diagnosis and treatment and high mortality. Here, we present a case of a huge hepatic subcapsular hematoma complicated with hepatic infarction after cesarean section that was secondary to HELLP syndrome and the patient was treated conservatively. Further, we have discussed the diagnosis and treatment of hepatic subcapsular hematoma and hepatic infarction caused by HELLP syndrome.
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Affiliation(s)
- Jun Liu
- Department of Obstetrics, Pingxiang Maternal and Child Health Hospital, Pingxiang, China
| | - Li Liu
- Department of Gynecology, Clinical Oncology School of Fujian Medical University,Fujian Cancer Hospital, Fuzhou, China
| | - Guangyuan Liao
- Department of Intensive Care Unit, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Lifeng Yao
- Department of Obstetrics, Pingxiang Maternal and Child Health Hospital, Pingxiang, China
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7
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Muacevic A, Adler JR. Management of Ruptured Subcapsular Liver Hematoma as a Result of Hemolysis, Elevated Liver Enzyme, and Low Platelet Syndrome in a Rural Facility. Cureus 2023; 15:e33852. [PMID: 36819327 PMCID: PMC9932572 DOI: 10.7759/cureus.33852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/14/2023] [Indexed: 01/18/2023] Open
Abstract
Subcapsular liver hematoma is a rare complication of hemolysis, elevated liver enzyme, and low platelet (HELLP) syndrome. This case depicts a previously healthy 27-year-old primigravida at 39 weeks' gestation who presented with severe abdominal pain and was diagnosed with HELLP syndrome based on vital signs and laboratory values. While arranging transport to a regional perinatal care facility she became acutely unstable with maternal hypotension and resultant fetal bradycardia. An emergent cesarean section was performed and a ruptured subcapsular liver hematoma was diagnosed intraoperatively. She was successfully managed with supportive care and surgical intervention and was discharged from the hospital on postoperative day 6. Here we review the indications and methods of conservative and surgical management of subcapsular liver hematoma as a result of HELLP syndrome.
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8
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Obstetric Disorders and Critical Illness. Clin Chest Med 2022; 43:471-488. [PMID: 36116815 DOI: 10.1016/j.ccm.2022.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
In this article, we discuss some of the more common obstetric-related conditions that can lead to critical illness and require management in an ICU. These include the hypertensive disorders of pregnancy, postpartum hemorrhage, hemolysis, elevated liver enzymes, and low platelet syndrome, acute fatty liver of pregnancy, amniotic fluid embolism, and peripartum cardiomyopathy. We also discuss pulmonary embolism and Covid-19. Despite not being specific to obstetric patients, pulmonary embolism is a common, life-threatening diagnosis in pregnancy with particular risks and management aspects. Covid-19 does not seem to occur with higher frequency in pregnant women, but it leads to higher rates of ICU admissions and mechanical ventilation in pregnant women than in their nonpregnant peers. Its prevalence during our current global pandemic makes it important to discuss in this article. We provide a basis for critical care physicians to be engaged in informed conversations and management in a multidisciplinary manner with other relevant providers in the care of critically ill pregnant and postpartum women.
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9
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Terrault NA, Williamson C. Pregnancy-Associated Liver Diseases. Gastroenterology 2022; 163:97-117.e1. [PMID: 35276220 DOI: 10.1053/j.gastro.2022.01.060] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 01/21/2022] [Accepted: 01/26/2022] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Norah A Terrault
- Gastrointestinal and Liver Disease Division, University of Southern California, Los Angeles, California, USA.
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10
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Morrison MA, Chung Y, Heneghan MA. Managing hepatic complications of pregnancy: practical strategies for clinicians. BMJ Open Gastroenterol 2022; 9:bmjgast-2021-000624. [PMID: 35292523 PMCID: PMC8928321 DOI: 10.1136/bmjgast-2021-000624] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 01/12/2022] [Indexed: 12/17/2022] Open
Abstract
Liver disorders specific to pregnancy are rare but can have potentially serious consequences for mother and fetus. Pregnancy-related liver disorders are the most common cause of liver disease in otherwise healthy pregnant women and pose a challenge to physicians because of the need to take into account both maternal and fetal health. A good knowledge of these disorders is necessary as prompt diagnosis and appropriate management results in improved maternal and fetal outcomes. This review will focus on pregnancy-specific disorders and will aim to serve as a guide for physicians in their diagnosis, management and subsequent monitoring.
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Affiliation(s)
| | - Yooyun Chung
- Institute of Liver Studies, King's College Hospital, London, UK
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11
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Messina V, Dondossola D, Paleari MC, Fornoni G, Tubiolo D, Vergani P, Rona R, Rossi G. Liver Bleeding Due to HELLP Syndrome Treated With Embolization and Liver Transplantation: A Case Report and Review of the Literature. Front Surg 2021; 8:774702. [PMID: 34881288 PMCID: PMC8646087 DOI: 10.3389/fsurg.2021.774702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 10/14/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Liver bleeding secondary to haemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome is uncommon, but a life-threatening peripartum condition that needs a prompt multidisciplinary approach. Case Presentation: In this study, we presented a case of 28-year-old pregnant woman, who was presented to the obstetrics department with signs of preeclampsia and foetal growth restriction. An emergency caesarean section was performed, and the patient developed a HELLP syndrome complicated by spontaneous liver rupture. After radiological and surgical procedures, liver failure became evident and liver transplantation was successfully performed. The patient and her daughter are now alive. Conclusions: Despite the rarity of this disease, liver complications due to HELLP syndrome must be properly diagnosed and treated given the gravity of the possible evolution in young women. After diagnosis, the patients must be treated in specialised centres with gynaecological, liver surgery, and transplant skills.
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Affiliation(s)
- Valentina Messina
- Department of General and Liver Transplant Surgery Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Daniele Dondossola
- Department of General and Liver Transplant Surgery Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, Università Degli Studi di Milano, Milan, Italy
| | - Maria Chiara Paleari
- Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Gianluca Fornoni
- Department of General and Liver Transplant Surgery Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Daniela Tubiolo
- Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Patrizia Vergani
- Department of Maternal Fetal Medicine, Fondazione MBBM, San Gerardo Hospital, Monza, Italy
| | - Roberto Rona
- Department of Emergency and Intensive Care, University Hospital San Gerardo, Monza, Italy
| | - Giorgio Rossi
- Department of General and Liver Transplant Surgery Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, Università Degli Studi di Milano, Milan, Italy
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12
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Brito M, Gamito M, Neves AR, Caeiro F, Martins A, Dias E, Veríssimo C. Conservative management of a pregnancy complicated by preeclampsia and postpartum spontaneous hepatic rupture: A case report and review of the literature. Eur J Obstet Gynecol Reprod Biol 2021; 267:79-89. [PMID: 34731641 DOI: 10.1016/j.ejogrb.2021.10.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 09/12/2021] [Accepted: 10/13/2021] [Indexed: 10/20/2022]
Abstract
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.
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Affiliation(s)
- Marta Brito
- Department of Obstetrics and Gynecology at Centro Hospitalar, Universitário Lisboa Central, Maternidade Dr. Alfredo da Costa, Rua Viriato 1 2890-495, Lisbon, Portugal.
| | - Mariana Gamito
- Department of Obstetrics and Gynecology at Hospital Beatriz Ângelo, Av. Carlos Teixeira 3, 2674-514 Loures, Portugal
| | - Ana Raquel Neves
- Department of Medicine Reproduction, Hospital Universitário Dexeus e Universidade Autónoma de Barcelona, Carrer de Sabino Arana, 5, 19, 08028 Barcelona, Spain
| | - Filipa Caeiro
- Department of Obstetrics and Gynecology at Hospital Beatriz Ângelo, Av. Carlos Teixeira 3, 2674-514 Loures, Portugal
| | - Amália Martins
- Department of Obstetrics and Gynecology at Hospital Beatriz Ângelo, Av. Carlos Teixeira 3, 2674-514 Loures, Portugal
| | - Elsa Dias
- Department of Obstetrics and Gynecology at Hospital Beatriz Ângelo, Av. Carlos Teixeira 3, 2674-514 Loures, Portugal
| | - Carlos Veríssimo
- Department of Obstetrics and Gynecology at Hospital Beatriz Ângelo, Av. Carlos Teixeira 3, 2674-514 Loures, Portugal
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13
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Gupta A, Joseph SR, Jeffries B. Managing a rare complication of HELLP syndrome in Australia: Spontaneous liver haematoma in pregnancy. Aust N Z J Obstet Gynaecol 2021; 61:188-194. [PMID: 33577103 DOI: 10.1111/ajo.13318] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 01/01/2021] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Akhil Gupta
- Department of Obstetric Medicine, Flinders Medical Centre (FMC), Adelaide, South Australia, Australia.,Macarthur Clinical School (School of Medicine - Campbelltown), Western Sydney University, Sydney, New South Wales, Australia
| | | | - Bill Jeffries
- Department of Obstetric Medicine, Flinders Medical Centre (FMC), Adelaide, South Australia, Australia.,FMC, Adelaide, South Australia, Australia
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14
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Abstract
Liver disease in pregnancy may present as a disorder that is unique to pregnancy or as an acute or chronic liver disease occurring coincidentally in pregnancy. Hepatic diseases that are unique to pregnancy include hyperemesis gravidarum; preeclampsia/eclampsia; the syndrome of hemolysis, elevated liver enzymes, and low platelets; intrahepatic cholestasis of pregnancy; and acute fatty liver of pregnancy. Acute and chronic forms of primary hepatic disorders that are seen in pregnancy include viral hepatitis, autoimmune hepatitis, nonalcoholic fatty liver disease, and cirrhosis. Because of the need to consider both maternal and fetal health, there are special considerations for the implementation of diagnostic strategies and pharmacologic therapies for liver disease that occurs in pregnancy. An understanding of the pathogenesis and expression of liver diseases in pregnancy has been evolving, and various diagnostic and prognostic tools have been studied in order to determine noninvasive approaches to identifying and staging of such diseases. Investigations have also been underway to evaluate the safety and utility of existing and new therapeutic agents that previously were thought to not be compatible with pregnancy. This review will explore updates in the epidemiology, diagnosis, and management of various liver diseases seen in pregnancy.
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Affiliation(s)
- Carla W Brady
- Division of Gastroenterology Duke University Medical Center Durham NC
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15
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Kaltofen T, Grabmeier J, Weissenbacher T, Hallfeldt K, Mahner S, Hutter S. Liver rupture in a 28-year-old primigravida with superimposed pre-eclampsia and hemolysis, elevated liver enzyme levels, and low platelet count syndrome. J Obstet Gynaecol Res 2019; 45:1066-1070. [PMID: 30854740 DOI: 10.1111/jog.13941] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 01/27/2019] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Till Kaltofen
- Department of Obstetrics and Gynecology, LMU Munich, Munich, Germany
| | - Johanna Grabmeier
- Department of Obstetrics and Gynecology, LMU Munich, Munich, Germany
| | | | - Klaus Hallfeldt
- Department of General-, Visceral- and Transplant-Surgery, LMU Munich, Munich, Germany
| | - Sven Mahner
- Department of Obstetrics and Gynecology, LMU Munich, Munich, Germany
| | - Stefan Hutter
- Department of Obstetrics and Gynecology, LMU Munich, Munich, Germany
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Abstract
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.
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Affiliation(s)
- Russell Rosenblatt
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, 1305 York Avenue, 4th Floor, New York, NY 10021, USA
| | - Robert S Brown
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, 1305 York Avenue, 4th Floor, New York, NY 10021, USA.
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Abstract
Subcapsular liver hematoma is a rare but potentially life-threatening complication of preeclampsia and hemolysis, elevated liver enzymes, and low platelets syndrome. It may present with nonspecific signs and symptoms, none of which are diagnostic, and can mimic pulmonary embolism of cholecystitis. There is no consensus on the management of subcapsular liver hematoma. Unruptured liver hematoma can be conservatively managed. When rupture occurs, surgical, endovascular approaches and, rarely, liver transplantation, may be required. Actual literature is scant and retrospective in nature. Data on follow-up, time to resolution and outcome of subsequent pregnancies are very limited. We here review the diagnosis and management of liver hematoma.
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Hizkiyahu R, Rabinovich A, Thachil J, Sheiner E, Shaked G, Sebbag G, Maymon E, Erez O. Modified ISTH pregnancy-specific DIC score in parturients with liver rupture: population-based case series. J Matern Fetal Neonatal Med 2018; 32:2517-2523. [DOI: 10.1080/14767058.2018.1439469] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Ranit Hizkiyahu
- Department of Obstetrics and Gynecology “B”, Soroka University Medical Center, Ben-Gurion University of the Negev, Be’er Sheva, Israel
| | - Anat Rabinovich
- Thrombosis and Hemostasis Unit, Hematology Institute, Soroka University Medical Center, Be’er Sheva, Israel
| | - Jecko Thachil
- Department of Hematology, Manchester Royal Infirmary, Manchester, UK
| | - Eyal Sheiner
- Department of Obstetrics and Gynecology “B”, Soroka University Medical Center, Ben-Gurion University of the Negev, Be’er Sheva, Israel
| | - Gad Shaked
- Department of General Surgery and Trauma Unit, Soroka University Medical Center, Ben-Gurion University of the Negev, Be’er Sheva, Israel
| | - Gilbert Sebbag
- Department of General Surgery and Trauma Unit, Soroka University Medical Center, Ben-Gurion University of the Negev, Be’er Sheva, Israel
| | - Eli Maymon
- Department of Obstetrics and Gynecology “B”, Soroka University Medical Center, Ben-Gurion University of the Negev, Be’er Sheva, Israel
| | - Offer Erez
- Maternity Department “D” and Obstetrical Day Care Unit, Department of Obstetrics and Gynecology, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Be’er Sheva, Israel
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19
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Zhang L, Wan D, Zhang L, Xu S, Xie H, Lin S. Hepatic rupture: A case report of a severe complication of percutaneous catheter drainage. Medicine (Baltimore) 2018; 97:e9499. [PMID: 29480839 PMCID: PMC5943845 DOI: 10.1097/md.0000000000009499] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Currently, percutaneous catheter drainage (PCD) is regarded as the first-line treatment modality of pyogenic liver abscess. Severe complications associated with PCD were uncommon. Hepatic rupture is an uncommon but life-threatening liver trauma with high mortality. Its management is challenging because a delay in the diagnosis may lead to fatal hemorrhagic shock. To our knowledge, PCD-associated hepatic rupture has never been reported. PATIENT CONCERNS We report herein a rare case of PCD-associated hepatic rupture. Its clinical courses and our therapeutic approaches are presented. Moreover, the clinical significance, underlying causes, and current views on severe liver trauma management will be discussed briefly. DIAGNOSES A diabetic patient suffering from fever and malaise was diagnosed with a pyogenic liver abscess. PCD was performed because intravenous antibiotics were ineffective. The patient developed a liver rupture following PCD, with clinical and imaging confirmation but without further progression. INTERVENTIONS Surgical repair and vascular intervention were both inappropriate. As a result, medical treatments with supportive care were adopted and were found to be effective. OUTCOMES The patient's condition improved gradually, with stabilized imaging and laboratory performance. He recovered uneventfully during follow-ups. LESSONS Hepatic rupture should be listed as an extremely rare but severe complication of PCD. Immediate suspicion and effective intervention may avoid an unfavorable consequence.
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Affiliation(s)
- Liang Zhang
- Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou
- Key Lab of Combined Multi-Organ Transplantation, Ministry of Public Health, Key Lab of Organ Transplantation, P.R. China
| | - DaLong Wan
- Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou
- Key Lab of Combined Multi-Organ Transplantation, Ministry of Public Health, Key Lab of Organ Transplantation, P.R. China
| | - LeLe Zhang
- Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou
- Key Lab of Combined Multi-Organ Transplantation, Ministry of Public Health, Key Lab of Organ Transplantation, P.R. China
| | - ShiGuo Xu
- Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou
- Key Lab of Combined Multi-Organ Transplantation, Ministry of Public Health, Key Lab of Organ Transplantation, P.R. China
| | - HaiYang Xie
- Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou
- Key Lab of Combined Multi-Organ Transplantation, Ministry of Public Health, Key Lab of Organ Transplantation, P.R. China
| | - ShengZhang Lin
- Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou
- Key Lab of Combined Multi-Organ Transplantation, Ministry of Public Health, Key Lab of Organ Transplantation, P.R. China
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20
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Kim TH, Enkhbold T, Lim HS, Park YJ. Re: Spontaneous haemoperitoneum in pregnancy and endometriosis: a case series How can we handle a rare (but very serious) condition exhibiting only common symptoms during pregnancy? BJOG 2017; 125:392. [PMID: 29094799 DOI: 10.1111/1471-0528.14947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/08/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Tae-Hee Kim
- Department of Obstetrics and Gynaecology, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Temuulee Enkhbold
- Department of Interdisciplinary Program in Biomedical Science, Soonchunhyang University Graduate School, Asan, Korea
| | - Hee-Sook Lim
- Department of Food and Nutrition, Yeonsung University, Anyang, Korea
| | - Yoo-Jin Park
- Department of Interdisciplinary Program in Biomedical Science, Soonchunhyang University Graduate School, Asan, Korea
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21
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Hepatic Artery Embolization for Hepatic Rupture in HELLP Syndrome. J Vasc Interv Radiol 2016; 27:1931-1933. [DOI: 10.1016/j.jvir.2016.08.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 08/04/2016] [Accepted: 08/05/2016] [Indexed: 12/27/2022] Open
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22
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Yoshihara M, Mayama M, Ukai M, Tano S, Kishigami Y, Oguchi H. Fulminant liver failure resulting from massive hepatic infarction associated with hemolysis, elevated liver enzymes, and low platelets syndrome. J Obstet Gynaecol Res 2016; 42:1375-1378. [PMID: 27353746 DOI: 10.1111/jog.13042] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Revised: 03/21/2016] [Accepted: 04/10/2016] [Indexed: 12/17/2022]
Abstract
Hepatic infarction is an extremely rare and fatal complication associated with hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome. It can develop into fulminant liver failure, which increases both maternal and neonatal mortality rates. A 34-year-old woman with no remarkable past medical history developed eclampsia after delivery at 40 weeks of gestation. Imaging indicated massive hepatic infarction and rupture followed by cardiac arrest and fulminant liver failure. Despite liver replacement therapy with plasma exchange and continuous hemodiafiltration, the patient gradually deteriorated with persistent bacterial infection until death at 98 days after delivery. The management of fulminant liver failure complicated with HELLP syndrome should be multidisciplinary. Liver transplantation, the only radical treatment for fulminant liver failure, is worth attempting, if applicable.
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Affiliation(s)
- Masato Yoshihara
- Department of Gynecology and Obstetrics, Toyota Memorial Hospital, Toyota, Aichi, Japan.
| | - Michinori Mayama
- Department of Gynecology and Obstetrics, Toyota Memorial Hospital, Toyota, Aichi, Japan
| | - Mayu Ukai
- Department of Gynecology and Obstetrics, Toyota Memorial Hospital, Toyota, Aichi, Japan
| | - Sho Tano
- Department of Gynecology and Obstetrics, Toyota Memorial Hospital, Toyota, Aichi, Japan
| | - Yasuyuki Kishigami
- Department of Gynecology and Obstetrics, Toyota Memorial Hospital, Toyota, Aichi, Japan
| | - Hidenori Oguchi
- Department of Gynecology and Obstetrics, Toyota Memorial Hospital, Toyota, Aichi, Japan
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23
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Tran TT, Ahn J, Reau NS. ACG Clinical Guideline: Liver Disease and Pregnancy. Am J Gastroenterol 2016; 111:176-94; quiz 196. [PMID: 26832651 DOI: 10.1038/ajg.2015.430] [Citation(s) in RCA: 139] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Accepted: 12/01/2015] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Tram T Tran
- Department of Medicine, Liver Transplant, Cedars Sinai Medical Center, Los Angeles, California, USA
| | - Joseph Ahn
- Department of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Nancy S Reau
- Department of Medicine, Rush University, Chicago, Illinois, USA
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24
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Hepatic involvement in HELLP syndrome: an update with emphasis on imaging features. ACTA ACUST UNITED AC 2015; 40:2839-49. [DOI: 10.1007/s00261-015-0481-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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25
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Jungfleisch K, Fittschen M, Rapp HJ, Schäfer H, Bahlmann F. Liver rupture in HELLP syndrome. CASE REPORTS IN PERINATAL MEDICINE 2015. [DOI: 10.1515/crpm-2013-0083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abstract
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.
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Affiliation(s)
- Katrin Jungfleisch
- Department of Obstetrics and Gynecology, Bürgerhospital, Frankfurt, Germany
| | - Monica Fittschen
- Department of Obstetrics and Gynecology, Bürgerhospital, Frankfurt, Germany
| | - Hans-Jürgen Rapp
- Department of Anesthesiology, Bürgerhospital, Frankfurt, Germany
| | - Henry Schäfer
- Department of Intensive care, Bürgerhospital, Frankfurt, Germany
| | - Franz Bahlmann
- Department of Obstetrics and Gynecology, Bürgerhospital, Frankfurt, Germany
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26
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Snydal S. Major Changes in Diagnosis and Management of Preeclampsia. J Midwifery Womens Health 2014; 59:596-605. [DOI: 10.1111/jmwh.12260] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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27
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You JS, Chung YE, Chung HS, Joo Y, Chung SP, Lee HS. Spontaneous hepatic rupture caused by hemolysis, elevated liver enzymes, and low platelet count syndrome. Am J Emerg Med 2014; 32:686.e3-4. [DOI: 10.1016/j.ajem.2013.12.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2013] [Accepted: 12/02/2013] [Indexed: 11/24/2022] Open
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28
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Boulouis G, Marmin C, Lemaire S, Boury S, Sergent G, Mordon S, Ernst O. CT and MRI imaging at the acute phase of inaugural non-traumatic hepatic haemorrhages. Diagn Interv Imaging 2013; 94:292-9. [PMID: 23375427 DOI: 10.1016/j.diii.2012.09.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
PURPOSE Although rare, non-traumatic hepatic haemorrhage is a known complication of liver tumors. In cases where the haemorrhage is the first clinical event, diagnostic work-up is critical. MATERIAL AND METHODS This retrospective study was conducted between July 2001 and March 2011. Acute phase CT-scan and MRI imaging in patients diagnosed with non-traumatic liver hematomas were interpreted with particular attention to the radio-semiotic characteristics of hematomas and liver lesions. Those findings were then confronted to the patients' final diagnoses. RESULTS Twelve patients were included (mean age of 42 years). In seven of them a suspect liver lesion was discovered in the acute CT-Scan or MRI imaging. All lesions were strongly hyper vascular.The haemorrhage revealed hepatocarcinoma in four patients, liver adenoma in two and focal nodular hyperplasia in an other. CONCLUSION It is important in spontaneous liver haemorrhage to consider the high probability of hepatocarcinoma or potentially malignant lesions even when the patient has no known hepatic disorders, and especially in young patients. The results of this study show that imaging is a key issue at the acute phase of inaugural non-traumatic hepatic haemorrhages and requires a simple but complete triphasic injected protocol.
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Affiliation(s)
- G Boulouis
- Service de Radiologie Digestive et Endocrinienne, Hôpital Huriez, Centre Hospitalier Régional Universitaire de Lille, Université Lille Nord-de-France, 1, place de Verdun, 59037 Lille Cedex, France.
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