Acute abdomen after the termination of pregnancy

Abstract

A 30-year-old woman presented with severe abdominal pain and mild fever. There was a history of termination of pregnancy at 16 weeks. There was no history of trauma. Physical examination showed tenderness and guarding rigidity of the abdomen. Laboratory results showed elevated liver enzyme levels and a low platelet count of 6000 cells/cumm. Emergency ultrasonography revealed a large lesion with a heterogeneous echotexture that could not be further characterized. Therefore a CT scan of the abdomen was performed. What is the diagnosis? A large irregularly shaped area of low attenuation with interspersed hyperdense areas of attenuation (80 HU) in the right hepatic lobe was suggestive of rupture of the right lobe with large hyperattenuating subcapsular haematoma. Ascites was also present. Aspiration from the liver lesion revealed blood. Despite aggressive management the patient died 7 days after admission. The diagnosis was HELLP syndrome. HELLP - a syndrome characterized by haemolysis elevated liver enzyme levels and a low platelet count-is a serious obstetric complication. HELLP syndrome was described by Weinstein in 1982. It generally presents in the third trimester of pregnancy but can also present in the post-partum period. With post-partum presentation the onset typically occurs within the first 48 h after delivery; however the signs and symptoms may not become apparent until as long as 7 days after delivery. The condition can progress rapidly with complications such as disseminated intravascular coagulation hepatic necrosis and haemorrhagic infarction. On histological analysis the portal areas of the liver are surrounded by a combination of deposited fibrin haemorrhage and hepatocellular necrosis. CT is the image modality of choice in HELLP syndrome because it can demonstrate subcapsular haematoma and hepatic rupture with intraperitoneal bleeding. Hepatic infarction can be seen on CT as low-attenuation wedge-shaped areas in the periphery of the liver without mass effect. In the majority of patients with HELLP syndrome the management is supportive. Delivery accomplished by whatever route is deemed safest and most expeditious is the cornerstone of therapy. Patients who experience hepatic rupture with intraperitoneal bleeding require immediate surgery or selective embolisation of the hepatic arteries. (excerpt)