Saudi Journal of Gastroenterology
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CASE REPORT Table of Contents   
Year : 1998  |  Volume : 4  |  Issue : 3  |  Page : 176-178
Post-partum spontaneous liver rupture: A case report


Department of Medicine, Gezira University, Wad-Medani, Sudan

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Date of Submission11-May-1996
Date of Acceptance27-Apr-1998
 

How to cite this article:
Hamour OA, Hafiz AA. Post-partum spontaneous liver rupture: A case report. Saudi J Gastroenterol 1998;4:176-8

How to cite this URL:
Hamour OA, Hafiz AA. Post-partum spontaneous liver rupture: A case report. Saudi J Gastroenterol [serial online] 1998 [cited 2019 Nov 22];4:176-8. Available from: http://www.saudijgastro.com/text.asp?1998/4/3/176/33915


Spontaneous liver rupture is a rare but serious complication of pregnancy, which may be associated with preeclampsia[1]. High maternal and fetal mortality rates have been reported[2]. In this report we describe a patient with spontaneous hepatic rupture diagnosed in the post-partum period. The presentation, diagnosis and treatment of this condition are discussed. The related literature is reviewed.


   Case report Top


A 30-year-old Sudanese woman gravida 5, para 4+0 was admitted to Wad-Medani teaching hospital in Sudan, with a diagnosis of preeclampsia. The patient was at 38 weeks gestation when she presented to the emergency room with swelling of both lower limbs and a mild frontal headache for 10 days. She had four full term normal spontaneous vaginal deliveries at home. All children were alive and well. The past medical history was not contributory.

The patient did not attend any ante-natal clinic visits during this pregnancy. On examination she looked ill, her pulse rate was 100 per minute and the blood pressure was 180/110. On physical examination she was not anemic, jaundiced or cyanosed. Examination of the chest and the abdomen was negative. The fundal height was at term and the uterus was not tender. The presentation was cephalic and the fetal heart sounds were audible and normal. Vaginal examination showed the forewaters intact and the presentation was cephalic at 3 station above ischial spine. Lower limbs examination showed pitting edema. Hemoglobin was 12 gms/l. Coagulation profile and liver functions were normal. Urinalysis showed albuminuria of four crosses. One hour after admission induction of labor was started by forewaters amniotomy and syntonin infusion. Labor progressed satisfactorily with fairly strong uterine contractions. Six hours later a normal female infant and placenta were easily delivered per vagina. The blood pressure and pulse were closely monitored during labor and delivery. Immediately after delivery the patient was exhausted but she did not complain of any abdominal pain. The post delivery blood pressure was 150/90.

On the second post partum day the patient complained of severe epigastric and right hypochondrial pain accompanied by nausea and vomiting. The abdomen was distended, tender with guarding and rebound tenderness in the upper part of the abdomen. The bowl sounds were not heard. The blood pressure was 90/60 and the pulse rate was 100 per minute. The hemoglobin dropped to 7 gms/l. A clinical diagnosis of internal hemorrhage was made. An ultrasound scan was not readily available. Therefore a decision to do an emergency operation was made. At laparotomy about 500ccs of blood was found inside he peritoneal cavity. On the anterior surface of the right lobe of the liver there was a hematoma which caused rupture of Glison's capsule. Underneath the hematoma the liver harbored a 4 cm long by 2 cm deep linear laceration. Hemostasis was secured by the application of deep liver sutures on an omental pedicle. A sump drain was left in the right paracolic gutter. The postoperative course was uneventful. The patient was discharged in a good condition on the 12th postoperative day.


   Discussion Top


Abercrombie reported the first, case of liver rupture in pregnancy in 1844[1] Since then similiar such cases are increasingly being reported. One study reported an incidence of one per 45, 145 live birth[2]. As far as we can gather we believe that this was the first case to be reported from Sudan.

Various disease conditions can be complicated by spontaneous liver rupture. It is not uncommonly seen with hepatocellular carcinoma[3],[4], Polyarteritis nodosa and following a ruptured hydatid disease of the liver[5]. It can complicate bacterial cholangiohepatitis[6], however it is often associated with pregnancy induced hypertension[7]. Multiparous patients over the age of 30 years constitute the majority of cases. Heny et al reviewed 75 cases and reported a mean age of 31.7 and 80% were multiparous[8]. Some reports have pointed out that as opposed to the young primigravida who is at a higher risk of developing preeclampsia, the elderly multipara with preeclampsia is at a higher risk of developing both uterine and liver rupture[9]. The role of degenerative changes in the tissues is yet to be proved.

Several authors incriminated exogenous minor trauma as being a specific cause of the subcapsular hematoma, occurring during transportation of the patient, during abdominal palpation or at manual removal of the placenta[8],[15]. Endogenous sources of trauma mentioned include vigorous contraction of the muscles of the diaphragm, abdominal wall or uterus. Convulsions and excessive vomiting are mentioned as additive factors[11] What is common among these factors is the sudden increase in the intraabdominal pressure to a level high enough to cause the rupture. In our patient the symptoms and signs occurred on the second post-partum day. This does not exclude the intraabdominal pressure rise hypothesis. Since the rupture could have happened during delivery, was initially missed and detected the next day.

The clinical presentation of such patients is one of vague epigastric pain and / or right upper quadrant pain associated with nausea with or without vomiting. Such symptoms can easily be attributed to the original disease of preeclampsia. However, when such symptoms are accompanied with abdominal signs of peritonism, this should prompt immediate laboratory evaluation (complete blood count, liver enzymes, coagulation profile). An immediate ultrasonic examination may verify the tentative diagnosis[12]. Once the diagnosis is established the usual treatment is close monitoring, with active resuscitation with fluids and blood followed by laparotomy to effect surgical control of hemorrhage[12]. The hematoma usually involves the anterior superior aspect of the right lobe[8]. This is in contradistinction to traumatic liver injury where the damage usually involves the posterior superior segmental area of the right lobe, this is attributed to the compression of the liver between the sternum and the vertebral column[13]. The spectrum of surgical control of hemorrhage varied in different series from evacuation of the hematoma, packing and drainage to hepatic lobectomy and ligation of the right hepatic artery.

The last two options being reserved to refractory cases[2]. Ligation of the hepatic artery was reported in one case of triplet pregnancy as been life saving to four lives[14]. Non-surgical conservative treatment was reported as successful in one series, however, the authors stressed the need for long-term follow up using liver scan[15]

Our patient had a liver laceration underneath the hematoma which was evacuated and the laceration was sutured and packed with an omental pedicle flap. This is an old effective technique been described in the literature long ago[16].

We conclude that spontaneous liver rupture with pregnancy although rare but is attended by a high maternal and fetal mortality. An early diagnosis is mandatory for a favorable outcome[2],[7],[12]. The diagnosis of liver rupture must be included in the differential diagnosis of acute abdomen both antepartum and post-partum, especially in patients with severe preeclampsia.

We believe that in a setup where ICU monitoring facilities and sophisticated imaging equipment are available one would consider active conservative management of the nonruptured subcapsular liver hematoma. However, once such a hematoma ruptures here comes the danger of an underlying parenchymal liver damage with continued bleeding when surgical intervention becomes mandatory[12].

On the other hand, in a set-up like ours where there are minimal diagnostic and monitoring facilities, a high index of suspicion must be entertained, a good clinical judgment is paramount and a very low threshold for surgical exploration is probably the safety key for reducing the high incidence of maternal and fetal mortality associated with this condition.

 
   References Top

1.Abercrombie J. Hemorrhage of the liver. Lon Med Gaz. 1844;34:792-4.  Back to cited text no. 1    
2.Smith LG Jr, Moise KJ Jr, Dildy GA, Carpenter RJ Jr. Spontaneous rupture of liver during pregnancy: current therapy. Obstet Gynecol. 1991;77:171-5.  Back to cited text no. 2    
3.Cherqui D, Paris Y, Rotman N, Faniez PL. Emergency liver resection for spontaneous rupture of hepatocellular carcinoma complicating cirrhosis. Br J Surg 1993;80:747-9.  Back to cited text no. 3    
4.Dewar GA, Griffin SM, Ku KW, Lau WY, Li AK. Management of bleeding liver tumors in Hong Kong. Br J Surg 1991Apr;78:463-6.  Back to cited text no. 4    
5.Stey C, Jost R, Ammann R. Recurrent life-threatening anaphylaxis as initial manifestation of cystic echinococcosis (granulosus) of the liver. Schweiz Med Wochenschr. 1993;123:1445-7.  Back to cited text no. 5    
6.Celoria G, Coe NP, Falco E, Nardini A. Spontaneous rupture of the liver. G Chir 1993;14:349-50.  Back to cited text no. 6  [PUBMED]  
7.Mantymaa ML, Elblad U. Spontaneous rupture of the liver during pregnancy. Ann Chir Gynecol Suppl. 1994;208:91-3.  Back to cited text no. 7    
8.Heny CP, Lim AE, Brummelkamp WH. A review of the importance of acute multidisciplinary treatment following spontaneous rupture of the liver capsule during pregnancy. Surg Gynecol Obstet. 1983;156:593-6.  Back to cited text no. 8    
9.Speert H, Tillman AJB. Rupture of the liver in pregnancy. Am J Obstet Gynecol 1952;63:1127-9.  Back to cited text no. 9    
10.Palvic RS, Townsend DE. Spontaneous rupture of the liver associated with pregnancy. Am J Obstet Gynecol 1962;83:1373-6.  Back to cited text no. 10    
11.Radmaker L. Spontaneous rupture of the liver complicating pregnancy. Ann Surg 1943;188:396-9.  Back to cited text no. 11    
12.Volz J, Volz E, Stoz F, Kechstein J. Spontaneous rupture of the liver in HELLP syndrome. Geburtshilfe-Frauenheilkd 1992;52:152-6.  Back to cited text no. 12    
13.Hardy KJ. Hepatic injuries. Surg Gyncol Obstet 1972;134:39-42.  Back to cited text no. 13    
14.Virengue V, Hedon B, Chinchole JM, Boulot P, Marchal J, et al. Spontaneous rupture of the liver during triplet pregnancy following in vitro fertilization. J Gynecol Obstet Biol Reprod Paris. 1991;20:249-52.  Back to cited text no. 14    
15.Le-Bouedec G, Raymond F, Fondrinier E, Chipponi J, Bruhat MA. Spontaneous hematoma of the liver in pregnancy: Non­surgical treatment favorable outcome apropos of a case. Rev Fr Gynecol Obstet 1990;85:407-11.  Back to cited text no. 15    
16.Fabian TC, Stone HH. Arrest of severe liver hemorrhage by an omental pack. South Med J 1980;73:1490-3.  Back to cited text no. 16    

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Correspondence Address:
Osman A Hamour
Department of Surgery, Northwest Armed Forces Hospital Program, P.O. Box 100, Tabuk, Saudi Arabia

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Source of Support: None, Conflict of Interest: None


PMID: 19864769

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