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Death from peripartum liver rupture despite early diagnosis and agressive management
Abstract Number: T 59
Abstract Type: Case Report/Case Series
Introduction: Spontaneous liver rupture is a rare and potentially devastating complication of HELLP syndrome. Here, we describe the diagnosis and management of a case of peripartum liver rupture which included early suspicion and diagnosis of the event as well as Herculean efforts at resuscitation and surgical intervention that ultimately proved to be unsuccessful.
Case: XX was a 42 year old woman G9P3 at 35 weeks gestation who presented with the chief complaint of right upper quadrant pain. Her exam included findings of a blood pressure of 228/132, a tender right upper quadrant and right flank, and a urinalysis with 2+ protein. Due to the concern for both mother and fetus, the patient was rushed to the OR for an emergency C-Section. The surgery was completed without incident under general anesthesia with delivery of an 1885g infant with Apgars of 7 and 9. During the procedure the liver was inspected and no abnormalities were detected; there was no oozing and hemostasis was good. The patient was extubated and brought to the recovery room awake with systolic blood pressures in the 120-140s range. Preoperative labs became available at arrival to the PACU with the following notable results: INR 3.28, aPTT 99.2s, platelets 51 x 109/L, ALT 1643 U/L, AST 1779 U/L. A diagnosis of HELLP syndrome was made. About an hour later, the patient became somewhat hypotensive to 90s/60s with heart rate in the 60s to 70s. There were no signs of bleeding either at the incision site or vaginally and the patient’s blood pressure responded appropriately to ephedrine. Approximately 20 minutes later the patient again became hypotensive and again responded to ephedrine. As we began the process of placing an arterial line, the patient again became hypotensive, but this time was not responsive to increasing does of ephedrine and phenylephrine. At that time the patient’s abdomen was noted to be somewhat distended. An ultrasound of the abdomen was done which revealed a large amount of free fluid. The patient was rushed to the OR, general anesthesia was induced, central access was achieved and significant pressor therapy was started. Once the patient’s abdomen was opened, the patient was diagnosed as having a ruptured liver capsule extending over segments 7 and 8 and extensive subcapsular hematomas on segments 6, 4b, 2 and 3. Despite aggressive treatment with pressors, more than 200 units of blood transfusions, two doses of recombinant factor VIIa, initiation of CVVH and more than 7 hours of surgical attempts to repair the liver, our efforts were ultimately unsuccessful and the patient succumbed to her disease.
Discussion: The incidence of liver rupture during pregnancy is thought to be <1/45,000 with the mortality of mother and child around 15% and 42% respectively. Certain aspects of this case, such as the severe pre-operative coagulopathy and the extent of microscopic and gross liver damage likely made resuscitation that much more difficult.