Surgical management of spontaneous hepatic rupture associated with HELLP syndrome. Case presentation and literature review

Abstract

Background: HELLP syndrome is a serious complication in pregnancy characterized by hemolysis, elevated liver enzymes and low platelet count occurring in 0.2 to 0.6% of all pregnancies and in 10–20% of cases with severe preeclampsia. Spontaneous hepatic capsular rupture is a rare (0,015% of all pregnancies), but a life-threatening complication of HELLP syndrome with a mortality rate of up 50% for both mother and infant. Methods: We present the case of a 34-year-old nulliparous woman with a second trimester gestational hepatic rupture associated with HELLP syndrome. A systematic literature search was conducted on database of PubMed, Scopus, Medline and Embase. Results: Spontaneous hepatic rupture is an infrequent but life-threatening condition of pregnancy associated with severe pre-eclampsia and HELLP syndrome. Diagnosis is based on clinical suspicion. Abdominal CT with intravenous contrast is considered to be the best diagnostic method. The management of this pathology requires a multidisciplinary approach between gynecologists, general surgeons and intensive care physicians. The main therapeutic objectives are: eliminate the causal factor, end the pregnancy and control hemorrhage. If there is not hepatic rupture and the patient is hemodynamically stable, conservative nonoperative management for selected patients has been recommended. However, if the patient presents hemodynamic instability despite adequate resuscitation or hemoperitoneum, it has been seen that surgery significantly reduces the mortality associated with this pathology. Conclusions: Hepatic subcapsular hematoma and hepatic rupture are infrequent but life-threatening complications that can occur during pregnancy and are fundamentally related to pathologies such as preeclampsia and HELLP syndrome. The first step is to end the pregnancy and subsequently control the acute liver problem. Different surgical techniques have been described that should be individualized for each patient according to damage control principles. A high index of suspicion and prompt recognition allows a multidisciplinary approach and mortality can be reduced. Study type: Therapeutic/care management.