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

Abstract

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.

Non-obstetric complications in preeclampsia

“…Additional risk factors in this group of patients are: multiparity, age > 40 years, and gestational age > 32 weeks. The pathophysiology has been attributed to vasoconstriction due to increased levels and sensitivity to circulating vasopressors, such as endothelin and angiotensin II, leading to ischaemia, necrosis, and finally rupture [38].…”

“…Liver rupture during pregnancy may occur not only because of hypertensive disorders, but also due to coexisting hepatic pathologies – adenomas, haemangiomas, malignancies, and coagulation disorders. However, they are rather casuistic [38].…”

“…Escobar Vidarte et al in their literature review reported 35 cases of pregnancy hepatic haemorrhage: 28 (80%) of them caused by HELLP syndrome, three (8.5%) caused by preeclampsia and HELLP syndrome, and four (11.4%) by preeclampsia without HELLP syndrome [38].…”

Preeklampsja – choroba kobiet w ciąży

“…U kobiet po przebytej preeklampsji często pojawia się depresja poporodowa [7], a w późniejszym wieku zwiększa się ryzyko rozwoju chorób układu krążenia. U kobiet z preeklampsją nie poddanych leczeniu może dojść do pęknięcia wątroby, udaru mózgu i w konsekwencji do śmierci [8,9]. Choroba ta ma też poważne konsekwencje dotyczące płodu.…”

Manejo de la ruptura hepática espontánea en el síndrome de HELLP

“…Acorde a lo reportado por Escobar, la ruptura hepática se presenta generalmente en mujeres alrededor de los 40 años, multíparas, dentro de las primeras 15 horas postparto, generalmente después de las 32 semanas de gestación, asociado a congestión intravascular hepática por depósitos de fibrina, así como a vasoespasmo por la alta concentración de vasopresores durante el embarazo 3 .…”