Liver rupture in pregnant women with preeclampsia or HELLP leads to maternal and fetal mortality: Study
Croatia: Hypertensive disorders in pregnancy complicated by liver rupture or hematoma are often diagnosed and treated late resulting in high fetal and maternal mortality, according to a systematic review of 391 reported cases. The study was published in the World Journal of Emergency Surgery on 08 July 2022.
In hemodynamically unstable patients with preeclampsia/eclampsia or HELLP syndrome and right upper abdominal pain, spontaneous hepatic rupture during pregnancy/puerperium (SHRP) should be excluded. Liver transplantation and liver embolization contribute to maternal survival. The researchers further report that maternal and fetal mortality was significantly higher before the year 1990. Hemodynamic instability, eclampsia, and preeclampsia have a significant negative influence on maternal survival.
Spontaneous liver rupture in pregnancy is highly lethal, often unrecognized, and not completely understood. The study was conducted by Goran Augustin, School of Medicine, University of Zagreb, Zagreb, Croatia, and colleagues aimed to summarize and define the etiology, clinical presentation, risk factors, appropriate diagnostic methods, and therapeutic options for spontaneous hepatic rupture during SHRP complicated by the hypertensive disorder.
For this purpose, the researchers conducted a literature search of online databases. Case reports of a spontaneous hepatic rupture or liver hematoma during pregnancy or puerperium as a complication of hypertensive disorders (preeclampsia, eclampsia, HELLP syndrome) were searched. There was no language restriction. Additional cases were determined by reviewing references from retrieved studies. PRISMA guidelines were applied for the data extraction and quality assessment.
Key findings of the study include:
· Three hundred and ninety-one cases were collected. The median maternal age was 31 years; 36.6% were nulliparous.
· Most (83.4%) occurred in the third trimester.
· Maternal and fetal mortality was 22.1% and 37.2%, respectively.
· Maternal and fetal mortality were significantly higher 1) before the year 1990, 2) with maternal hemodynamic instability, and 3) eclampsia.
· The most important risk factors for SHRP were preeclampsia and HELLP syndrome.
· Most women had the right lobe affected (70.9%), followed by both lobes in 22.1% and the left lobe in 6.9%.
· The most common surgical procedure was liver packing.
· Liver transplantation was performed in 4.7% with 100% survival.
· Maternal mortality with liver embolization was 3.0%.
· Higher gestational age increases fetal survival.
The authors conclude, that in cases with SHRP, a multidisciplinary approach provides the best outcome. Protocols should be determined for treating patients with hepatic involvement in pregnancy to prevent catastrophic complications.
Reference:
Augustin, G., Hadzic, M., Juras, J. et al. Hypertensive disorders in pregnancy complicated by liver rupture or hematoma: a systematic review of 391 reported cases. World J Emerg Surg 17, 40 (2022). https://doi.org/10.1186/s13017-022-00444-w
