Spontaneous Subcapsular Liver Hematoma Associated With Pregnancy

Abstract

A gravida 3, para 2 woman in her mid-30s with a history of preeclampsia presented at 23 weeks' gestation with severe right upper quadrant pain. On arrival, she suffered seizures and cardiac arrest and was successfully resuscitated. A computed tomographic scan revealed a 16.8-cm, heterogeneous attenuation involving the medial and inferior portion of the liver, consistent with a subcapsular liver hematoma (arrow, Figure 1). Exploratory laparotomy revealed a ruptured subcapsular hematoma of the liver and lacerations predominantly involving the right lobe. Approximately 2.5 L of clotted blood was evacuated from the hematoma. The hepatic artery was clamped for 20 minutes, and the liver was packed to achieve hemostasis. During surgery and in the immediate postoperative period, the patient received 16 units of packed red cells, 18 units of platelets, 10 units of cryoprecipitate, and 14 units of fresh frozen plasma. However, the patient developed anuric renal failure. Despite continued hemodynamic and ventilatory support, her condition did not improve. It was determined that the patient had suffered severe anoxic brain damage as a result of the cardiac arrest. Ventilatory support was withdrawn by family request on the fourth day after admission.Autopsy revealed a large subcapsular liver hematoma dissecting the Glisson capsule from the surface of the entire right lobe, with laceration of the hepatic parenchyma and capsule rupture (arrows indicate subcapsular hematoma, Figure 2). Microscopic examination of the liver showed microvesicular steatosis and periportal hepatocellular coagulative necrosis, features consistent with toxemia of pregnancy (Figure 3, hematoxylin-eosin, original magnification ×200).Spontaneous subcapsular liver hematoma is an extremely rare but potentially life-threatening complication of pregnancy, with a quoted incidence of approximately 1 per 45 000 live births.1 There is an almost exclusive association with severe preeclampsia or with HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets), as more than 80% of cases occur in patients with preeclampsia/eclampsia and/or HELLP syndrome.2 Conversely, spontaneous hematoma occurs in approximately 1% to 2% of patients with preeclampsia.2 The clinical presentation of subcapsular hematoma is not characteristic; most patients present with right upper quadrant pain.1 However, due to the rarity of this entity and its variable presentation, most cases are missed and diagnosed only at laparotomy.The pathogenesis of subcapsular liver hematoma and subsequent rupture is unclear. Fibrin deposition in the hepatic sinusoids is speculated to be the initiating event.3 Fibrin deposition may lead to platelet activation, thrombus formation, occlusion of capillaries, and subsequent hepatic hemorrhage and necrosis. Coalescence of these hemorrhagic areas leads to dissection of the Glisson capsule from the liver surface. Concurrent consumptive coagulopathy occurring in preeclamptic patients often aggravates the condition. It is therefore reasonable to conclude that achieving adequate hemostasis would not only control blood loss in the event of a rupture, but may prevent the formation or expansion of the subcapsular hematoma. A tense subcapsular hematoma may rupture spontaneously or secondary to trivial trauma during labor or convulsions, leading to catastrophic life-threatening hemorrhage. Awareness of this entity and its early recognition is important in reducing the morbidity and mortality associated with a ruptured liver hematoma.