Acta Obstetricia et Gynecologica Scandinavica
ISSN: 0001-6349 (Print) 1600-0412 (Online) Journal homepage: http://www.tandfonline.com/loi/iobs20
Postpartum rupture of a subcapsular hematoma of the liver Richard H. Wilson & Barry M. S. Marshall To cite this article: Richard H. Wilson & Barry M. S. Marshall (1992) Postpartum rupture of a subcapsular hematoma of the liver, Acta Obstetricia et Gynecologica Scandinavica, 71:5, 394-397 To link to this article: http://dx.doi.org/10.3109/00016349209021081
Published online: 03 Aug 2009.
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Date: 17 December 2015, At: 17:44
CASE REPORT
Postpartum rupture of a subcapsular hematoma of the liver RICHARDH. WILSONAND BARRYM. S. MARSHALL
Downloaded by [Monash University Library] at 17:44 17 December 2015
From the Departments of Surgery and Obstetrics and Gynaecology, Mater lnfirmorum Hospital, Crumlin Road, Belfast BT14 6AB, N. Ireland
Acta Obstet Gynecol Scand 1992; 71: 394-391
We report a case of postpartum rupture of a subcapsular hematoma of the liver. The etiology, pathology, diagnosis and treatment of this condition are discussed. We emphasize the modern concepts in treatment of hepatic hemorrhage. This knowledge and an awareness of the possible diagnosis will help to decrease the high morbidity and mortality rates associated with this disorder. Key words: hepatic rupture; subcapsular hematoma; pregnancy Received April 12, IYYI Accepted February 18, I992
Spontaneous hepatic rupture in pregnancy was first reported by Abercrombie in 1844 (1). The incidence was calculated to be 1 in 45000 live births in a recent report (2). It is most commonly associated with preeclampsia (3). The diagnosis is rarely made prior to rupture and emergency surgery. There has been improved survival in recent years. This has been due to better diagnostic techniques and advances in the treatment of hepatic bleeding. We report a case in which there was considerable morbidity but a successful outcome following conservative surgery.
Case report A 24 year old single para 2 booked late at 30 weeks gestation. Her blood pressure then was 125/70 mm Hg. There were no problems in her past medical or obstetric histories. She did not attend for any subsequent antenatal clinic appointments. Eight weeks later she was admitted in spontaneous labor and progressed to a normal delivery of a healthy female infant weighing 2550 g. Labor lasted two hours, the estimated blood loss was 200 ml and her condition after delivery was satisfactory. Nineteen hours later, she developed epigastric pain radiating to her back Acta Obstet Gynecol Scund 71 (1992)
and vomiting. Epigastric tenderness was present with a soft abdomen and her blood pressure was elevated for the first time at 190/100 mm Hg. Two hours later she collapsed with a pulse rate of 104 and a blood pressure of 70/0 mm Hg. Her abdomen was distended with a well-contracted uterus and there were no neurological abnormalities. A n abdominal ultrasound scan revealed free intraperitoneal blood. Her hemoglobin had dropped to 6.1 g/dl and platelets to 104,000 per mm’. A coagulation screen revealed a prothrombin time of 28.2 seconds (control 14.9), partial thromboplastin kinase time of 53.5 seconds (32.6), thrombin clotting time of 26.4 seconds (15.0), fibrinogen 1.1 g (2.0-3.5) and fibrin degradation products > 40. Liver enzymes were mildly disturbed but there was no evidence of hemolysis or the HELLP syndrome (hemolysis, elevated liver enzymes and low platelets). Following resuscitation with intravenous colloids and concentrated red cells, a laparotomy was performed jointly by the obstetricians and surgeons. The operative findings were a ruptured subcapsular hepatic hematoma with 2 litres of blood in the peritoneal cavity. The liver parenchyma contained multiple hemorrhages. The raw area on the diaphragmatic surface of her liver was packed with Surgicel and large abdominal
Downloaded by [Monash University Library] at 17:44 17 December 2015
Hepatic rupture in pregnancy packs, thorough lavage performed, wide-bore drains inserted and a Tru-cut liver biopsy taken. This revealed necrosis with fibrin deposition in keeping with pre-eclampsia. A repeat laparotomy and change of packs was performed the following day and the packs removed at a third laparotomy 72 hours later. A t this stage she was very ill with acute renal failure, respiratory failure, hepatic failure and disseminated intravascular coagulation. Two weeks later she developed a right-sided hemothorax requiring intercostal drainage. She needed a further laparotomy and 1.5 liters of blood was removed and tube drains reinserted. Subsequently, she made gradual progress and her respiratory, renal and hepatic function improved. She was fit for discharge four months post-delivery, remains under review and is well.
Discussion Pre-eclampsia is the predisposing condition to hepatic hematoma and rupture in pregnancy in 80% of cases, as here (3). Other causes include trauma, biliary tract disease, hepatic neoplasms especially hemangiomas, viral infections, malaria, syphilis, and vascular anomalies including visceral artery aneurysms (4). The liver is not primarily involved in pre-eclampsia but may be damaged as the disease progresses. Liver biopsy, as in this case, reveals periportal fibrin deposition and/or hemorrhage and hepatocellular necrosis in severe cases (5). HELLP syndrome with its combination of hemolysis, elevated liver enzymes and low platelets occurs in 4 1 2 % of patients with pre-eclampsia and is associated with a poor maternal and perinatal outcome (6). This may occur coincidentally with hepatic rupture. Subcapsular hematoma and rupture tend to occur in multiparous patients (as in our case) as opposed to the usual association of pregnancy-induced hypertension with primigravidae (7). The age range is reported to be 21 to 43 years with a mean of 30 years (4). The subcapsular hematoma is usually on the anterior and superior surfaces and affects the right heand both patic lobe in 75% of cases, left lobe in llo/~ in 14% (8). Rupture is preceded by a parenchymal hematoma which detaches, elevates and eventually tears Glisson’s capsule at its inferior margin causing exsanguinating hemorrhage. The clinical presentation is of sudden onset with epigastric or right hypochondria1 pain radiating to the back, nausea and vomiting. Hepatic rupture may be heralded by hypotension, peritonism and antenatally by absent fetal heart sounds. Hemoperitoneum may be discovered at laparotomy for suspected pla-
395
cental abruption, ruptured uterus o r perforated viscus. Fourteen percent of cases occur postpartum, usually within 24 hours of delivery (4). The exact diagnosis was only made preoperatively in 7% of cases in the literature. However, hepatic rupture was suspected preoperatively in 6 of 7 cases recently reported (2). Four of these patients had preoperative evaluation with ultrasound scan, computerised axial tomography (CAT scan) or peritoneal lavage. A CAT scan will reveal subcapsular and intrahepatic hematoma and intraperitoneal blood and is particularly suitable for postpartum patients (9). Peritoneal lavage may be utilized to exclude hemoperitoneum if interpretation of the CAT scan is difficult. The successful management of hepatic hemorrhage in pregnancy requires prompt recognition. Any patient with clinical evidence of pre-eclampsia and right hypochondrial pain should be considered at risk. Evidence of thrombocytopaenia and elevated liver enzymes should further raise suspicion. Methods of treatment of non-ruptured subcapsular hematomas include: a. b. c. d.
observation. evacuation and drainage. oversewing of the damaged liver bed. application of topical hemostatic agents. e. hepatic artery ligation. f. hepatic artery embolization, and g. hepatic lobectomy (2).
In pregnancy, cesarean section may be performed to prevent rupture of the hematoma which could be caused by labor and vaginal delivery, to treat preeclampsia and t o save the fetus depending upon the gestational age (8). A ruptured hematoma requires immediate laparotomy. Manas et al. in 1985 demonstrated in 7 cases that intact subcapsular hematoma diagnosed by CAT scanning could be managed conservatively by observation alone (10). Delayed rupture has been reported up to six weeks after diagnosis of subcapsular hematoma when conservative management was used. Ultrasound or CAT scan follow-up should continue until resolution has taken place (11). Hepatic angiography and transcatheter embolization should be considered particularly when the patient is very unstable and the risks of surgery high (12). Selective catheterization and embolization of the bleeding branch of the hepatic artery may abruptly halt the hemorrhage. However, this may be only temporary and laparotomy is then required. Complications such as hepatic abscess, sepsis and ischaemia of the gallbladder may all occur with embolotherapy. Actu Obstet Gynecol Scand 71 (1992)
396
R. H. Wilson and B. M . S. Marshall
The indications for laparotomy during observation include:
Downloaded by [Monash University Library] at 17:44 17 December 2015
a. hemodynamic instability or ongoing blood loss. b. increasing pain or peritonism. c. progressive expansion of the hematoma on serial scans, and d. secondary infection of the hematoma. The management of hepatic bleeding has evolved in the last decade, mainly as a result of advances in trauma surgery (13). Changes in the management of hepatic rupture in pregnancy have paralleled these advances. A non-operative approach is safe in carefully selected patients managed in an Intensive Care Unit by experienced surgeons with good radiological backup. Patients must stay in hospital for at least a fortnight with scans to check for hematoma resolution. However, the majority of patients with hepatic bleeding will require surgery. The general principles are: a. b. c. d. e.
aggressive resuscitation. rapid control of bleeding. debridement of devitalized tissues. adequate drainage of blood and bile, and supportive postoperative care.
Once the liver is exposed and mobilized, the hematoma should be evacuated to allow visualization of bleeding points. In most cases, simple operative techniques such as diathermy, application of topical hemostatic agents (e.g. Gelfoam or Surgicel) or hepatorrhaphy with absorbable atraumatic sutures will suffice. Bleeding can be controlled with Pringle’s manoeuvre. This involves clamping the free edge of the lesser omentum occluding inflow from the portal vein and hepatic artery. This allows accurate localisation and ligation of vessels without ischaemic hepatic injury. Perihepatic packing involves placing abdominal packs around the liver, compressing it and controlling bleeding. Widebore tube drains should be inserted and broad spectrum antibiotics administered. If packing is insufficient, hepatotomy and selective vascular ligation is the best option. The only indications for hepatic resection are total segmental or lobar disruption and inability to control life threatening bleeding. It must be remembered that the underlying cause of hepatic rupture in preeclampsia is reversible after delivery. Postoperative management in an Intensive Care Unit is vital in order to detect early rebleeding, progression of coagulopathy, sepsis o r cardiorespiratory insufficiency. Disseminated Intravascular Coagulation should be treated with antithrombin 111, Acta Obstet Gynecol Scand 71 (1992)
fresh frozen plasma, low dose heparin, cryoprecipitates and platelet transfusions (8). Improved survival can be achieved through a high index of suspicion, accurate diagnosis and a multidisciplinary approach (8). The survival rate with packing and drainage is 82% compared with 25% amongst patients undergoing hepatic lobectomy (2). The mortality rate with hepatic rupture in pregnancy is 59% for mothers and 62% for the fetus (4). Maternal mortality rates may differ with modes of treatment: a. cesarean section plus operation on the liver has a 30% mortality. b. antepartum operation o n the liver alone has a 50% rnortality,and c. operation on the liver postpartum has a 25% mortality (8). The average hospital stay is 31 days (4). As well as the hepatic, renal and respiratory failure seen in our case, postoperative complications include fever, sepsis, pleural effusion, secondary hemorrhage and pulmonary embolism. Subsequent, uneventful pregnancy has been reported in patients who survived hepatic rupture in pregnancy 1-3 years previously
(14).
Acknowledgments We would like to thank Mr J Verzin, Mr J Moorehead and Mr C Harvey for their permission to report this case.
References 1. Abercrombie J. Haemorrhage of the liver. London Medical Gazette 1844; 34: 7924. 2. Smith LG, Moise KJ, Dildy GA, Carpenter RJ. Spontaneous rupture of the liver during pregnancy: current therapy. Obstet Gynecol 1991; 77: 171-5. 3. Rolfes DB, Ishak KG. Liver disease in toxaemia of pregnancy. Am J Gastroenterol 1986; 81: 113844. 4. Bis KA, Waxman B. Rupture of the liver associated with pregnancy: a review of the literature and report of 2 cases. Obstet Gynecol Surv 1976; 31: 763-73. 5. Schorr-Lesnick B, Lebovics E, Dworkin B, Rosenthal WS. Liver diseases unique to pregnancy. Am J Gastroenterol 1991; 86: 6.59-70. 6. Sibai BM, Taslim MM, El-Nazer A, Amon E, Mabie BC, Ryan GM. Maternal-perinatal outcome associated with the syndrome of haemolysis, elevated liver enzymes and low platelets in severe pre-eclampsia eclampsia. Am J Obstet Gynecol 1986; 155: 501-9. 7. Lavery DWP, Bowes RM. Subcapsular haematoma of the liver in pregnancy; report on 4 cases. S Afr Med J 1971; 45: 603-5.
Hepatic rupture in pregnancy
Downloaded by [Monash University Library] at 17:44 17 December 2015
3. Henny CP, Lim AE, Brummelkamp WH, Buller HR,
Ten Cate JW. A review of the importance of acute multidisciplinary treatment following spontaneous rupture of the liver capsule during pregnancy. Surg Gynecol Obstet 1983; 156: 593-8. 4, Winer-Muram HT, Muram D, Salazan J , Massie JJ. Hepatic rupture in pre-eclampsia: the role of diagnostic imaging. Journal of Canadian Association of Radiology 1985; 36: 34-6. ). Manas KJ. Welsh JD, Rankin RA, Miller DD. Hepatic haemorrhage without rupture in pre-eclampsia. N Engl J Med 1985; 312: 4 2 4 5 . 1. Lavery JP. Berg J. Subcapsular haematoma of the liver during pregnancy. South Med J 1989; 82: 1568-70. 1. Loevinger EH, Ivutic I, Lee NM, Anderson MC. Hepatic rupture associated with pregnancy: treatment with transcatheter embolotherapy. Obstet Gynecol 1985; 65: 281-4.
397
13. Wilson RH, Moorehead RJ. Hepatic trauma and its management. Injury 1991; 22: 439-45. 14. De Swiet M. Disorders of the liver. In: Medical Disorders in Obstetric Practice. London: Blackwell Scientific Publications, 1989: 431-3. Address for correspondence:
Mr R. H. Wilson, F.R.C.S. The Queen’s University of Belfast Department of Surgery Institute of Clinical Science Grosvenor Road Belfast BT12 6BJ N . Ireland
Acta Obsret Cynecol Scund 71 (1992)
ISSN: 0001-6349 (Print) 1600-0412 (Online) Journal homepage: http://www.tandfonline.com/loi/iobs20
Postpartum rupture of a subcapsular hematoma of the liver Richard H. Wilson & Barry M. S. Marshall To cite this article: Richard H. Wilson & Barry M. S. Marshall (1992) Postpartum rupture of a subcapsular hematoma of the liver, Acta Obstetricia et Gynecologica Scandinavica, 71:5, 394-397 To link to this article: http://dx.doi.org/10.3109/00016349209021081
Published online: 03 Aug 2009.
Submit your article to this journal
Article views: 3
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=iobs20 Download by: [Monash University Library]
Date: 17 December 2015, At: 17:44
CASE REPORT
Postpartum rupture of a subcapsular hematoma of the liver RICHARDH. WILSONAND BARRYM. S. MARSHALL
Downloaded by [Monash University Library] at 17:44 17 December 2015
From the Departments of Surgery and Obstetrics and Gynaecology, Mater lnfirmorum Hospital, Crumlin Road, Belfast BT14 6AB, N. Ireland
Acta Obstet Gynecol Scand 1992; 71: 394-391
We report a case of postpartum rupture of a subcapsular hematoma of the liver. The etiology, pathology, diagnosis and treatment of this condition are discussed. We emphasize the modern concepts in treatment of hepatic hemorrhage. This knowledge and an awareness of the possible diagnosis will help to decrease the high morbidity and mortality rates associated with this disorder. Key words: hepatic rupture; subcapsular hematoma; pregnancy Received April 12, IYYI Accepted February 18, I992
Spontaneous hepatic rupture in pregnancy was first reported by Abercrombie in 1844 (1). The incidence was calculated to be 1 in 45000 live births in a recent report (2). It is most commonly associated with preeclampsia (3). The diagnosis is rarely made prior to rupture and emergency surgery. There has been improved survival in recent years. This has been due to better diagnostic techniques and advances in the treatment of hepatic bleeding. We report a case in which there was considerable morbidity but a successful outcome following conservative surgery.
Case report A 24 year old single para 2 booked late at 30 weeks gestation. Her blood pressure then was 125/70 mm Hg. There were no problems in her past medical or obstetric histories. She did not attend for any subsequent antenatal clinic appointments. Eight weeks later she was admitted in spontaneous labor and progressed to a normal delivery of a healthy female infant weighing 2550 g. Labor lasted two hours, the estimated blood loss was 200 ml and her condition after delivery was satisfactory. Nineteen hours later, she developed epigastric pain radiating to her back Acta Obstet Gynecol Scund 71 (1992)
and vomiting. Epigastric tenderness was present with a soft abdomen and her blood pressure was elevated for the first time at 190/100 mm Hg. Two hours later she collapsed with a pulse rate of 104 and a blood pressure of 70/0 mm Hg. Her abdomen was distended with a well-contracted uterus and there were no neurological abnormalities. A n abdominal ultrasound scan revealed free intraperitoneal blood. Her hemoglobin had dropped to 6.1 g/dl and platelets to 104,000 per mm’. A coagulation screen revealed a prothrombin time of 28.2 seconds (control 14.9), partial thromboplastin kinase time of 53.5 seconds (32.6), thrombin clotting time of 26.4 seconds (15.0), fibrinogen 1.1 g (2.0-3.5) and fibrin degradation products > 40. Liver enzymes were mildly disturbed but there was no evidence of hemolysis or the HELLP syndrome (hemolysis, elevated liver enzymes and low platelets). Following resuscitation with intravenous colloids and concentrated red cells, a laparotomy was performed jointly by the obstetricians and surgeons. The operative findings were a ruptured subcapsular hepatic hematoma with 2 litres of blood in the peritoneal cavity. The liver parenchyma contained multiple hemorrhages. The raw area on the diaphragmatic surface of her liver was packed with Surgicel and large abdominal
Downloaded by [Monash University Library] at 17:44 17 December 2015
Hepatic rupture in pregnancy packs, thorough lavage performed, wide-bore drains inserted and a Tru-cut liver biopsy taken. This revealed necrosis with fibrin deposition in keeping with pre-eclampsia. A repeat laparotomy and change of packs was performed the following day and the packs removed at a third laparotomy 72 hours later. A t this stage she was very ill with acute renal failure, respiratory failure, hepatic failure and disseminated intravascular coagulation. Two weeks later she developed a right-sided hemothorax requiring intercostal drainage. She needed a further laparotomy and 1.5 liters of blood was removed and tube drains reinserted. Subsequently, she made gradual progress and her respiratory, renal and hepatic function improved. She was fit for discharge four months post-delivery, remains under review and is well.
Discussion Pre-eclampsia is the predisposing condition to hepatic hematoma and rupture in pregnancy in 80% of cases, as here (3). Other causes include trauma, biliary tract disease, hepatic neoplasms especially hemangiomas, viral infections, malaria, syphilis, and vascular anomalies including visceral artery aneurysms (4). The liver is not primarily involved in pre-eclampsia but may be damaged as the disease progresses. Liver biopsy, as in this case, reveals periportal fibrin deposition and/or hemorrhage and hepatocellular necrosis in severe cases (5). HELLP syndrome with its combination of hemolysis, elevated liver enzymes and low platelets occurs in 4 1 2 % of patients with pre-eclampsia and is associated with a poor maternal and perinatal outcome (6). This may occur coincidentally with hepatic rupture. Subcapsular hematoma and rupture tend to occur in multiparous patients (as in our case) as opposed to the usual association of pregnancy-induced hypertension with primigravidae (7). The age range is reported to be 21 to 43 years with a mean of 30 years (4). The subcapsular hematoma is usually on the anterior and superior surfaces and affects the right heand both patic lobe in 75% of cases, left lobe in llo/~ in 14% (8). Rupture is preceded by a parenchymal hematoma which detaches, elevates and eventually tears Glisson’s capsule at its inferior margin causing exsanguinating hemorrhage. The clinical presentation is of sudden onset with epigastric or right hypochondria1 pain radiating to the back, nausea and vomiting. Hepatic rupture may be heralded by hypotension, peritonism and antenatally by absent fetal heart sounds. Hemoperitoneum may be discovered at laparotomy for suspected pla-
395
cental abruption, ruptured uterus o r perforated viscus. Fourteen percent of cases occur postpartum, usually within 24 hours of delivery (4). The exact diagnosis was only made preoperatively in 7% of cases in the literature. However, hepatic rupture was suspected preoperatively in 6 of 7 cases recently reported (2). Four of these patients had preoperative evaluation with ultrasound scan, computerised axial tomography (CAT scan) or peritoneal lavage. A CAT scan will reveal subcapsular and intrahepatic hematoma and intraperitoneal blood and is particularly suitable for postpartum patients (9). Peritoneal lavage may be utilized to exclude hemoperitoneum if interpretation of the CAT scan is difficult. The successful management of hepatic hemorrhage in pregnancy requires prompt recognition. Any patient with clinical evidence of pre-eclampsia and right hypochondrial pain should be considered at risk. Evidence of thrombocytopaenia and elevated liver enzymes should further raise suspicion. Methods of treatment of non-ruptured subcapsular hematomas include: a. b. c. d.
observation. evacuation and drainage. oversewing of the damaged liver bed. application of topical hemostatic agents. e. hepatic artery ligation. f. hepatic artery embolization, and g. hepatic lobectomy (2).
In pregnancy, cesarean section may be performed to prevent rupture of the hematoma which could be caused by labor and vaginal delivery, to treat preeclampsia and t o save the fetus depending upon the gestational age (8). A ruptured hematoma requires immediate laparotomy. Manas et al. in 1985 demonstrated in 7 cases that intact subcapsular hematoma diagnosed by CAT scanning could be managed conservatively by observation alone (10). Delayed rupture has been reported up to six weeks after diagnosis of subcapsular hematoma when conservative management was used. Ultrasound or CAT scan follow-up should continue until resolution has taken place (11). Hepatic angiography and transcatheter embolization should be considered particularly when the patient is very unstable and the risks of surgery high (12). Selective catheterization and embolization of the bleeding branch of the hepatic artery may abruptly halt the hemorrhage. However, this may be only temporary and laparotomy is then required. Complications such as hepatic abscess, sepsis and ischaemia of the gallbladder may all occur with embolotherapy. Actu Obstet Gynecol Scand 71 (1992)
396
R. H. Wilson and B. M . S. Marshall
The indications for laparotomy during observation include:
Downloaded by [Monash University Library] at 17:44 17 December 2015
a. hemodynamic instability or ongoing blood loss. b. increasing pain or peritonism. c. progressive expansion of the hematoma on serial scans, and d. secondary infection of the hematoma. The management of hepatic bleeding has evolved in the last decade, mainly as a result of advances in trauma surgery (13). Changes in the management of hepatic rupture in pregnancy have paralleled these advances. A non-operative approach is safe in carefully selected patients managed in an Intensive Care Unit by experienced surgeons with good radiological backup. Patients must stay in hospital for at least a fortnight with scans to check for hematoma resolution. However, the majority of patients with hepatic bleeding will require surgery. The general principles are: a. b. c. d. e.
aggressive resuscitation. rapid control of bleeding. debridement of devitalized tissues. adequate drainage of blood and bile, and supportive postoperative care.
Once the liver is exposed and mobilized, the hematoma should be evacuated to allow visualization of bleeding points. In most cases, simple operative techniques such as diathermy, application of topical hemostatic agents (e.g. Gelfoam or Surgicel) or hepatorrhaphy with absorbable atraumatic sutures will suffice. Bleeding can be controlled with Pringle’s manoeuvre. This involves clamping the free edge of the lesser omentum occluding inflow from the portal vein and hepatic artery. This allows accurate localisation and ligation of vessels without ischaemic hepatic injury. Perihepatic packing involves placing abdominal packs around the liver, compressing it and controlling bleeding. Widebore tube drains should be inserted and broad spectrum antibiotics administered. If packing is insufficient, hepatotomy and selective vascular ligation is the best option. The only indications for hepatic resection are total segmental or lobar disruption and inability to control life threatening bleeding. It must be remembered that the underlying cause of hepatic rupture in preeclampsia is reversible after delivery. Postoperative management in an Intensive Care Unit is vital in order to detect early rebleeding, progression of coagulopathy, sepsis o r cardiorespiratory insufficiency. Disseminated Intravascular Coagulation should be treated with antithrombin 111, Acta Obstet Gynecol Scand 71 (1992)
fresh frozen plasma, low dose heparin, cryoprecipitates and platelet transfusions (8). Improved survival can be achieved through a high index of suspicion, accurate diagnosis and a multidisciplinary approach (8). The survival rate with packing and drainage is 82% compared with 25% amongst patients undergoing hepatic lobectomy (2). The mortality rate with hepatic rupture in pregnancy is 59% for mothers and 62% for the fetus (4). Maternal mortality rates may differ with modes of treatment: a. cesarean section plus operation on the liver has a 30% mortality. b. antepartum operation o n the liver alone has a 50% rnortality,and c. operation on the liver postpartum has a 25% mortality (8). The average hospital stay is 31 days (4). As well as the hepatic, renal and respiratory failure seen in our case, postoperative complications include fever, sepsis, pleural effusion, secondary hemorrhage and pulmonary embolism. Subsequent, uneventful pregnancy has been reported in patients who survived hepatic rupture in pregnancy 1-3 years previously
(14).
Acknowledgments We would like to thank Mr J Verzin, Mr J Moorehead and Mr C Harvey for their permission to report this case.
References 1. Abercrombie J. Haemorrhage of the liver. London Medical Gazette 1844; 34: 7924. 2. Smith LG, Moise KJ, Dildy GA, Carpenter RJ. Spontaneous rupture of the liver during pregnancy: current therapy. Obstet Gynecol 1991; 77: 171-5. 3. Rolfes DB, Ishak KG. Liver disease in toxaemia of pregnancy. Am J Gastroenterol 1986; 81: 113844. 4. Bis KA, Waxman B. Rupture of the liver associated with pregnancy: a review of the literature and report of 2 cases. Obstet Gynecol Surv 1976; 31: 763-73. 5. Schorr-Lesnick B, Lebovics E, Dworkin B, Rosenthal WS. Liver diseases unique to pregnancy. Am J Gastroenterol 1991; 86: 6.59-70. 6. Sibai BM, Taslim MM, El-Nazer A, Amon E, Mabie BC, Ryan GM. Maternal-perinatal outcome associated with the syndrome of haemolysis, elevated liver enzymes and low platelets in severe pre-eclampsia eclampsia. Am J Obstet Gynecol 1986; 155: 501-9. 7. Lavery DWP, Bowes RM. Subcapsular haematoma of the liver in pregnancy; report on 4 cases. S Afr Med J 1971; 45: 603-5.
Hepatic rupture in pregnancy
Downloaded by [Monash University Library] at 17:44 17 December 2015
3. Henny CP, Lim AE, Brummelkamp WH, Buller HR,
Ten Cate JW. A review of the importance of acute multidisciplinary treatment following spontaneous rupture of the liver capsule during pregnancy. Surg Gynecol Obstet 1983; 156: 593-8. 4, Winer-Muram HT, Muram D, Salazan J , Massie JJ. Hepatic rupture in pre-eclampsia: the role of diagnostic imaging. Journal of Canadian Association of Radiology 1985; 36: 34-6. ). Manas KJ. Welsh JD, Rankin RA, Miller DD. Hepatic haemorrhage without rupture in pre-eclampsia. N Engl J Med 1985; 312: 4 2 4 5 . 1. Lavery JP. Berg J. Subcapsular haematoma of the liver during pregnancy. South Med J 1989; 82: 1568-70. 1. Loevinger EH, Ivutic I, Lee NM, Anderson MC. Hepatic rupture associated with pregnancy: treatment with transcatheter embolotherapy. Obstet Gynecol 1985; 65: 281-4.
397
13. Wilson RH, Moorehead RJ. Hepatic trauma and its management. Injury 1991; 22: 439-45. 14. De Swiet M. Disorders of the liver. In: Medical Disorders in Obstetric Practice. London: Blackwell Scientific Publications, 1989: 431-3. Address for correspondence:
Mr R. H. Wilson, F.R.C.S. The Queen’s University of Belfast Department of Surgery Institute of Clinical Science Grosvenor Road Belfast BT12 6BJ N . Ireland
Acta Obsret Cynecol Scund 71 (1992)
