Right hepatectomy after spontaneous hepatic rupture in a patient with preeclampsia: A case report.

INTRODUCTION: Spontaneous hepatic rupture associated with preecalmpsia or HELLP syndrome is a rare and life threatining event, only 200 cases have been reported in the literature. PRESENTATION OF CASE: We present a case of a 31 year old female with 28 weeks of gestation that presented with acute abdominal pain, elevated blood pressure and altered liver enzymes an abdominal ultrasound that showed a subcapsular hematoma occupying the whole right lobe and free abdominal fluid, she required emergent laparotomy, C-section, hepatic packing, followed by angioembolization and finally right hepatectomy. DISCUSSION AND CONSLUSION: Spontaneous hepatic rupture due to preeclampsia or HELLP syndrome is a medical emergency, it requires a prompt and decisive treatment. Multiple treatment modalities are available, from simple hepatic packing to endovascular embolization, but in extreme situations a formal hepatectomy might be required.

Introduction

Spontaneous hepatic rupture associated with preeclampsia or HELLP syndrome is a rare event, the incidence is 1 in 40.000–1 in 250.000 pregnancies [1]. It carries a high mortality reaching up to 28% [2]. Treatment depends on the clinical presentation from a conservative management to emergent laparotomy perihepatic packing and second look operation. Other treatment modalities like endovascular embolization and even liver transplantation can be used succesfully [3], [4]. Formal hepatectomy is an option to be considered when less invasive measures fail to stop the bleeding or when there is extensive liver necrosis due to the risk of infection. Only a few cases of cases of hepatectomy after spontaneous hepatic rupture have been described in the literature [5]. This case report follows the SCARE criteria [6].

Presentation of case

A 31 year old hispanic female G1P1A0 with 28 weeks gestation and irregular prenatal control, a body max index of 30, arrived to the emergency room at our private university hospital in Bogota, Colombia with one day history of right upper quadrant pain, emesis and diahrrea. Past medical history was uneventful. Her previous pregnancy was an uncomplicated vaginal delivery.Physical examination revealed a blood pressure of 145/90 mm/Hg, a heart rate of 97 beats per minute, tenderness in the right upper quadrant, a uterine height of 28 cm, and a normal fetocardia. Laboratory tests revealed a WBC of 14500 m/L, Hgb of 12 mg/dl, Platelet count of 220.000 m/L, liver enzymes with an ALT of 97 mg/dl, AST of 87 mg/dl, INR of 1.4, LDH 1100 UI/L, normal bilirrubin and renal function tests, proteinuria of 500 mg/dl in a random urine sample.

Abdominal US showed a subcapsular hematoma comprising segments V,VI,VII,VIII and free abdominal fluid. A diagnosis of ruptured subcapsular hematoma associated with preeclampsia was made and emergent laparotomy was indicated. Informed consent was obtained from the patient and family, prophylactic antibiotic was initiated and hemoderivative reserve was requested. In less than 4 h of admission she was in the operating room accompanied by acute care surgery, obstetrics and neonatology. The operation revealed the following findings: 3000cc of hemoperitoneum a ruptured subcapsular hematoma involving the whole right lobe with acute bleeding. She underwent C-section and perihepatic packing. The newborn was transfered to the neonatal intensive care unit had an adequate adaptation and after a week was discharged. During surgery she required 4 units of packed red blood cells (PRBC) and 4 units of plasma. She was transfered to the ICU (Intensive Care Unit) after surgery to continue ressucitation with intravenous fluids, vasoactive support: noradrenaline titrated up to 1 mcg/kg/min and vasopressin up to 6 u/h, all under hemodynamic monitoring with FLOTRAC ™, during the course of the second postoperative day there was evidence of persistent hypovolemia, requiring additional 2 units of PRBC, so it was decided to take her to selective angioembolization of the right hepatic artery by vascular surgery. She was scheduled for a second look operation 24 h later by hepatobiliary surgery, finding a devitilized and a necrotic right lobe so cultures were taken and a formal right hepatectomy was done (Fig. 1). Total operating time was 4 h, blood loss was 100cc. After the procedure she slowly recovered but developed a fluid colection in the liver bed that required percutaneous drainage and 21 days of antibiotic treatment, cultures grew Klebsiella Pneumonie and Citrobacter Freuni. The total hospital stay was 33 days.

Fig. 1

Intraoperative photo showing the necrotic right lobe.

Discussion

Spontaneous hepatic rupture associated with preeclampsia and HELLP syndrome is a rare event, it still carries a high maternal and neonatal mortality. In this particular case the patient didnt have all the diagnostic criteria for HELLP syndrome but did have elevated liver enzymes, evidence of hemolysis; and fullfiled the diagnostic criteria for preeclampsia [6]. In the initial evaluation the obstetrics and surgery department decided that the best course of action would be to perform an emergent laparotomy to peform the emergency C-section and in the same time evaluate the liver. At this point there could be several courses of action; to perform dedicated hemostasis with hepatorraphy, perform perihepatic packing, or finally perform a right hepatectomy. Due to the amount of blood loss, the difficulty in attaining hemostasis, summed to the necessity to perform another urgent procedure (the c-section), adding even more time to the procedure, it was evident that appropiate action would be a dammage control surgery with only perihepatic packing. Unfortunatly the packing alone didnt stop the bleeding. It could be said that in this scenario the second look operation could be expedited, but we decided that an additional procedure besides a second look operation might be needed so in a complementary aproach the embolization was done. It did stop the bleeding but in retrospect it might have contributed to the necrosis of the right lobe. Thats why the second look operation is crucial not only to remove the packing but to evaluate the liver parenchyma. Formal right hepatectomy was not planned for the second look operation it was decided intraoperatively due to the extensive devitilized tissue necrosis of the right lobe. The most important teaching points that can be taken from this case report are that when faced with this kind of patients the diagnosis should be made quickly, and the surgical treatment shoudnt be delayed, if laparotomy is considered, perihepatic packing should be tried first but always keeping in mind that complications or treatment failure can occur, and if they do, a lobectomy or even a liver transplant should be considered. Reviewing the literature most of the subcapsular hematomas can be managed by perihepatic packing or angioembolization [7], it is very unusual to end up in a formal lobectomy but it is important to have the availability of a liver surgeon in case its needed. Some old series report hepatectomies or lobectomies, but only as one of the various treatment available, reporting a survival after lobectomy of only 25% [8]. But many advances in anhestesia, perioperative management and ICU care make knowadays liver resection a safer procedure with better outcomes. It is interesting to see that in the series reported by Wilson et al. a small proportion of patients required elective lobectomy, for cholangitis associated with hematoma and lobe atrophy so outpatient followup is important in this patients [9]. This case reports adds to the scarce literature about subcapsular hematoma associated with preeclampsia and validates the role of lobectomy in this era of minimally invasive treatments.

Conclusion

For the successful management of spontaneous hepatic rupture secondary to preeclampsia a swift and coordinated effort by a multidisciplinary team is vital for a good outcome. When other options fail, a formal lobectomy can be done with low morbidity and no mortality.

Conflict of interest

The author declared that there was no conflict of interest.

Funding

This research did not recieve any specific grant from funding agiencies in the public, commercial, or not-from-profit sectors.

The authors do not declare some type of external financing for the presentation of the case report.

Ethical approval

This is a case report involving one patient and thus does not require IRB aproval.

Consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is availabel for review by the Editor-in-Chief of this journal on request.

Author contribution

Carlos Millan: writing paper

Juan Forero: data collection

Carlos Millan: study design

Carlos Millan: data analysis

Carlos Millan: study concept

Registration of research studies

In concordance with the Helsinki declaration this case report does not require registration in the database, in this case there is no experimentation with humans

Guarantor

Carlos Alberto Millan