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PowerPoint Discussion of the Diagnoses and Management of Subcapsular Liver Hematoma
It is estimated that 10% to 20% of patients with severe preeclampsia/eclampsia will have hepatic involvement. This liver pathology has been described in association with a constellation of signs, symptoms (nausea, vomiting, upper gastric pain and mucosal bleeding), and laboratory abnormalities called HELLP ( h emolysis, e levated l iver enzymes and l ow p latelet count) syndrome. The laboratory criteria for HELLP syndrome are summarized in Table 11-1 . Because of low platelets and abnormal platelet function, patients could have petechiae or ecchymosis ( Fig. 11-1 ) or they can have bleeding from the gums ( Fig. 11-2 ). In addition, because of hemolysis, the urine appears tea colored ( Fig. 11-3 ).
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Subcapsular liver hematoma is a rare but life-threatening complication of HELLP syndrome. In most instances rupture involves the right lobe of the liver and is preceded by the development of a parenchymal hematoma. Most patients with a subcapsular hematoma of the liver are seen in the late second or third trimester of pregnancy, although the diagnosis might not be made until the immediate postpartum period. Frequent signs and symptoms of hepatic rupture and hepatic hemorrhage include epigastric pain, hypotension, shock, nausea and vomiting, shoulder pain, evidence of massive ascites, respiratory difficulty, or pleural effusions and often with a dead fetus ( Table 11-2 ). The degree of hypertension and proteinuria may not mirror the degree of liver involvement. Further, there is a wide variation in presentation and severity of the symptoms of hepatic rupture particularly in their time course in relation to hepatic distention and hepatic rupture. The diagnosis of liver hematoma can be confirmed by one or more of radiologic modalities described in Table 11-3 . An ultrasound or computed axial tomography of the liver should be performed to rule out the presence of subcapsular hematoma of the liver and assess for the presence of intraperitoneal bleeding ( Fig. 11-4 ). Chest x-ray findings will reveal the presence of plural effusions and elevation of the diaphragm on the right side ( Fig. 11-5 ). The diagnosis can also be made either by computed tomography (CT) scan ( Fig. 11-6 ) or magnetic resonance imaging (MRI) ( Fig. 11-7 ). Clearly, once rupture of the Glisson’s capsule occurs, hypotension and hypovolemic shock are the rule. Rupture of an intact hematoma can occur spontaneously or may be associated with exogenous forces of trauma including abdominal palpation, convulsions, or vomiting.
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The differential diagnosis for patients with physical examination findings consistent with peritoneal irritation, hepatomegaly, hemolysis and low platelet count should also include acute fatty liver of pregnancy, abruptio placentae with disseminated intravascular coagulopathy (DIC), ruptured uterus, thrombotic thrombocytopenic purpura, and a ruptured splenic artery aneurysm.
Pregnancies complicated by subcapsular hematoma are associated with extremely high rates of maternal and perinatal mortality and morbidity ( Table 11-4 ). The rate of these morbidities depends on whether the hematoma is ruptured, the availability of blood and blood products, the administration of massive transfusions of blood and blood products, and the surgical management used. The risks for the fetus are usually related to prematurity and hypoxia.
