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Hepatic capsule rupture presenting as interscapular pain in a patient with severe preeclampsia receiving neuraxial labor analgesia
Abstract Number: SAT-48
Abstract Type: Case Report/Case Series
Introduction: Hepatic capsule rupture has a reported incidence between 1:45,000 and 1:220,000 births (1). It is often seen in patients with severe preeclampsia or HELLP syndromes. Symptoms associated with capsule rupture include right upper quadrant abdominal pain, right shoulder pain, and nausea. Additionally, there may exist hemodynamic instability that can progress to circulatory collapse if left untreated. However, when a patient presents with interscapular pain, the initial evaluation is often focused elsewhere. As early as the 1984, there have been publications of the development of interscapular pain with the administration of epidural medication (2). The first large retrospective review describing interscapular pain cited an incidence of 0.46% in patients receiving epidural analgesia for labor (3).
Case Presentation: We present the case of a 35-year-old G2P0 being induced at 35 5/7 weeks for preeclampsia with severe features. Included in her laboratory derangements and symptomatic findings were a significantly elevated aspartate aminotransferase level and severe epigastric pain. A combined spinal-epidural was performed for labor analgesia. Later, after receiving a redose, she began to complain of interscapular pain not associated with contractions. She ultimately went for a cesarean delivery secondary to non-reassuring fetal heart tracing. Her epidural was further dosed with 3% 2-chlorprocaine to achieve a surgical anesthetic level, without complaint of interscapular pain. Immediately following incision, the surgeons noted frank blood in the abdominal cavity, and the presence of a hepatic capsule rupture. She was converted to general endotracheal anesthesia for repair of the hepatic injury. Estimated blood loss for the case was three liters.
Discussion: The maternal mortality rate associated with hepatic capsule rupture is reported between 1% and 24%, while the perinatal mortality rate is up to 70%. Multigravida status, maternal age approaching menopause, and concurrent preeclampsia/eclampsia or HELLP syndromes have been associated with hepatic capsule rupture (1). The development of interscapular pain due to epidural injection is still not well understood, however it is postulated that volume and duration of epidural medication administration may be responsible. In the patient reported, epidural infusion occurred for three hours before reporting interscapular pain, a similar timing of onset as reported in the literature (2). Considering the ultimate finding of hepatic capsule rupture, blood irritating the gastric body, which is innervated by the nerve roots of T5-T9, may have resulted in referred pain to the mid thoracic back, causing the symptoms reported by the patient.
References: 1) Palvis, T et al. (2009) J Surg Educ 66: 163-7. 2) Campbell, A (1984) Anaesthesia 39: 940-1. 3) Ross, V et al. (2007) Anesthesiology 107: A1780.