Pre-eclampsia occurs in 8% of all pregnancies, and 10%15% of cases may be

complicated by hemolysis, elevated liver enzymes, and low platelet count

(HELLP) syndrome, which is a life-threatening and severe form of preeclampsia/eclampsia [1]. HELLP syndrome is associated with particularly high
maternal and perinatal morbidity/mortality rates owing to pulmonary edema,
cerebral edema and hemorrhage, disseminated intravascular coagulopathy,
acute renal failure, hepatorenal failure, subcapsular hematoma and hepatic
rupture, placental abruption, adult respiratory distress syndrome, sepsis,
stroke, and retinal detachment [1,2]. Spontaneous hepatic rupture is an
infrequent and life-threatening condition of pregnancy that is virtually
exclusively associated with severe pre-eclampsia or HELLP syndrome. The
incidence of this condition is approximately 1 per 67 000 births or 1 per 2000
patients with preeclampsia/eclampsia/HELLP syndrome [2]. There is a wide
variation in the clinical presentation and severity of the symptoms and signs of
hepatic hemorrhage/rupture. Some patients present with very mild symptoms
prior to sudden and massive circulatory collapse. However, the clinical
manifestations of hepatic hematoma include right upper quadrant or epigastric
pain, shoulder pain, and vomiting. Interestingly, these symptoms are often
present in the absence of laboratory tests [3]. The exact pathophysiology of
hepatic rupture is not completely understood. Liver histology findings show
periportal hemorrhage and intravascular fibrin deposition. This pathologic
condition can lead to hepatic sinusoidal obstruction, intrahepatic vascular
congestion, and hepatic ischemia/infarction. In some cases, intraparenchymal
and subcapsular hemorrhages develop, and more severe cases may result in
capsular rupture [2]. A recent literature review of hepatic rupture revealed a
maternal mortality rate of 39% [4] and a perinatal mortality rate of 42% [5].
These fatality rates are high despite successes in hepatic surgery and criticalcare unit assistance [5]. The aim of the present review was to analyze case
reports of pre-eclampsia/eclampsia-associated hepatic hemorrhage or rupture
published during the past 2 decades.

4. Discussion Spontaneous hepatic rupture in pregnancy is an infrequent but

life-threatening condition that is strongly associated with signifi- cant maternal
and perinatal morbidity/mortality. Furthermore, it is predominantly associated
with HELLP syndrome [610], with only a few cases linked to preeclampsia/eclampsia without HELLP syndrome [6,10]. In the present review,

hepatic rupture in preeclampsia/eclampsia was associated with HELLP

syndrome in 92.8% of cases. The incidence of hepatic hematoma with or
without rupture is estimated to be approximately 1 case per 53259
pregnancies complicated by HELLP syndrome [2,9,10]. Accurate and timely
diagnosis followed by immediate management of pre-eclampsia/eclampsia and
HELLP syndrome contributed to a decreased rate of complications such as
hepatic hematoma. The incidence of spontaneous hepatic rupture associated
with HELLP syndrome can vary between highand low-income countries. In the
present review, the majority of cases of hepatic rupture involved multiparous
women (57.4%) over 25 years of age (86.3%); 52.1% of all cases involved
women who were 2835 years of age. These findings are consistent with those
from other studies [4,6]. The maternal demographic characteristics in the
present and other studies [4,6] were similar to those reported by Isler et al. [8]
in their study of maternal death as a result of HELLP syndrome. Although preeclampsia occurs more often in primigravidae, spontaneous liver
rupture usually occurs in multigravidae. HELLP syndrome has classically been
defined as a complication of hypertensive disorders of pregnancy that occurs
more often among older multigravidae [8,9], consistent with the present
findings. Eclampsia occurs 65% of the time in primigravidae with a median age
of 19 years [1113]. In the present study, only 12 (6.7%) cases of hepatic
hemorrhage were associated with HEEH. Furthermore, only 1 case of eclampsia
without HELLP syndrome was found from the past 21 years [14]; however,
before HELLP syndrome had been defined, reports of eclampsia and hepatic
rupture were more common [15]. We believe that eclampsia is not an
important risk factor for hepatic hemorrhage/rupture. HELLP syndrome is a true
risk and was present in 92.8% of the cases of hepatic rupture associated with
hypertensive disorders of pregnancy during the past 2 decades. This is an
important point, because the presence of eclampsia did not seem to change
the risk of hepatic hematoma with or without capsule rupture in women with
HELLP syndrome. Spontaneous hepatic hemorrhage/rupture has been reported
to occur most commonly in the right lobe of the liver [2,16]. This is consistent
with findings from the present review, in which the most frequently affected
lobule was the right (77.0%), followed by both lobules (21.0%); the left lobule
was affected in only a small number of cases (2.0%). Before 1970, the maternal
mortality rate associated with hepatic hemorrhage was up to 100% in cases in
which surgical treatment was not provided [17]. It had decreased to 77% by
the early 1980s [18], and to 39% by the end of the 1990s [4] in cases of
surgical management. In the present review, the maternal mortality rate in
cases of hepatic hemorrhage/rupture during the period 19902000 was 28.9%,
decreasing to 16.4% during the period 20012010. This reduction probably
reflects advances in resuscitation, intensive-care medicine, hepatic surgery,
liver transplantation, and arterial embolization especially in high-income
countries. Rinehart et al. [7] reported that the perinatal mortality rate in cases

of hepatic hemorrhage/rupture was 78% between 1960 and 1979, decreasing

to 50% between 1980 and 1997. In the present review, the perinatal mortality
rate was 30.7%, probably owing to improvements in the care of preterm and
critically ill neonates in the past 2 decades compared with before the 1990s.
The perinatal mortality rate remained constant over the past 2 decades.
Accurate and effective management of hepatic rupture is facilitated by a
combination of surgical intervention and aggressive supportive care. Some
surgical techniques have considerably decreased the morbidity and mortality
rates associated with hepatic rupture, although there is not complete
agreement on which is the best approach [6]. Conservative management
[6,19,20], hepatic artery ligation [6,21], arterial embolization [22,23],
hepatorrhaphy [4,5], liver packing [36], collagen sponges [2], absorbable
mesh [5], fibrin glue [4], argon laser [2,23], hepatic transplantation [4,24],
recombinant factor VIIa [2,25], and combined management have all been used
[2,4,6]. Techniques used in the management of HELLP syndrome and hepatic
rupture vary, especially between high-income and low-income countries, which
can lead to different mortality rates and trends in mortality. In the present
review, liver transplantation or the use of selective arterial embolization by
interventional radiologists was associated with the lowest maternal mortality
rate (8.3%). In the last decade studied, the survival rate was 100% with arterial
embolization or liver transplantation. Surgical exploration and management
(packing of bleeding areas, drainage of the perihepatic space, hepatic
resection, supportive therapy, fibrin glue, recombinant factor VIIa, and argon
laser) comprised the most commonly used treatment modality for managing
women with hepatic rupture and pre-eclampsia/eclampsia in the period
studied. In this treatment group, the maternal mortality rate was 33.9% in the
period 19902000, decreasing to 16.6% in the period 20012010. This
reduction was probably associated with advances in resuscitation and
intensive-care medicine. If there is a clinical suspicion of hepatic
hematoma/rupture, radiologic evaluation should be performed at the discretion
of the physician. Ultrasound and computed tomography can be used to confirm
the diagnosis of hepatic subcapsular hematoma before rupture [7]. The
ultrasound imaging technique is especially useful because it can enable a
bedside diagnosis without having to mobilize the patient away from specific
obstetrics areas, operating rooms, or critical-care areas. However, when there
is clinical suspicion of hepatic rupture, laparotomy should not be delayed; these
patients must be managed in a multidisciplinary center with correct
management of liver surgeryincluding liver transplantationand experts in
arterial embolization. Primary laparotomy and tamponade of the bleeding
source should not be postponed and must be done in the primary-care hospital
if the patient is not stable enough to be transported [4]. Several hypotheses
have been proposed for explaining the development of hepatic hemorrhage.
We propose that the following sequence of events could lead to hepatic
hemorrhage and rupture: hypertension; hypovolemia; vasospasm; hemolysis;

fibrin deposition; platelet aggregation; synusoidal obstruction; ischemia;

infarction; necrosis; neovascularization; microhemorrhage; hematoma; and
rupture of hepatic capsule [27,9,10,1719,23] (Table 3). Clinicians have 4
clinical conditions for diagnosis and management: pre-eclampsia; preeclampsia with HELLP syndrome; HELLP syndrome with hepatic hemorrhage or
hematoma; and HELLP syndrome with hepatic rupture. The time between preeclampsia and hepatic hematoma/rupture may be hours [2,6,24,25], days
[3,20,25], or weeks [5,22]. However, timely diagnosis of pre-eclampsia/HELLP
syndrome and pregnancy termination can probably prevent progression to
hepatic hemorrhage in some cases. The clinical presentation of pre-eclampsia
or HELLP syndrome may be atypical; therefore, it could be underrecognized.
Furthermore, sudden and massive hepatic rupture can occur without warning or
with symptoms of pre-eclampsia/HELLP syndrome that are not recognized by
women or their families before arrival at hospital. There were limitations to the
present review. First, some cases may not have been found. Second, only
studies published in 4 languages were considered; however, few cases are
published in other languages. A third limitation was the short study period.
However, before 1990, papers reporting hepatic rupture associated with preeclampsia/ eclampsia without mention of HELLP syndrome were common. A
strength of the present review was that the search methodology was extensive,
comprehensive, and reproducible. In conclusion, hepatic rupture in pregnancy
is strongly associated with HELLP syndrome; it should be suspected in women
who display a worsening of clinical conditions before, during, or after delivery.
Hepatic hemorrhage complicating cases of pre-eclampsia/eclampsia plus HELLP
syndrome was associated with a maternal mortality rate of 16.4% and a
perinatal mortality rate of 31.3% during 20012010. Thus, close monitoring is
necessary for patients with HELLP syndrome and those with preeclampsia/HELLP syndrome and strong epigastric pain.

4. Discusin ruptura heptica espontnea durante el embarazo es una condicin poco

frecuente pero potencialmente mortal que est fuertemente asociada con la materna
significativa y morbilidad / mortalidad perinatal. Por otra parte, se asocia
predominantemente con el sndrome de HELLP [6-10], con slo unos pocos casos
vinculados a la preeclampsia / eclampsia sin sndrome HELLP [6,10]. En la presente
revisin, ruptura heptica en la preeclampsia / eclampsia se asocia con el sndrome de
HELLP en el 92,8% de los casos. La incidencia de hematoma heptica con o sin rotura se
estima que es de aproximadamente 1 caso por cada 53-259 embarazos complicados por
el sndrome de HELLP [2,9,10]. El diagnstico preciso y oportuno seguido por la
administracin inmediata del sndrome de preeclampsia / eclampsia y sndrome HELLP
contribuy a una disminucin de la tasa de complicaciones como hematoma heptico.. En
el presente estudio, slo 12 (6,7%) casos de hemorragia heptica se asociaron con Heeh.
Adems, slo 1 caso de eclampsia sin sndrome HELLP se encuentra desde los ltimos

21 aos [14]; Sin embargo, antes de que se haba definido el sndrome de HELLP, los
informes de la eclampsia y la ruptura heptica fueron ms comunes [15]. Creemos que la
eclampsia no es un factor de riesgo importante de hemorragia heptica / ruptura. El
sndrome de HELLP es un verdadero riesgo y estaba presente en el 92,8% de los casos
de ruptura heptica asociados con la hipertensin trastornos del embarazo durante las
ltimas 2 dcadas. Este es un punto importante, ya que no pareca la presencia de la
eclampsia para cambiar el riesgo de hematoma heptico con o sin ruptura de la
cpsula en mujeres con sndrome de HELLP. Espontnea hemorragia heptica / ruptura
se ha reportado que ocurre con mayor frecuencia en el lbulo derecho del hgado
[2,16]. Esto es consistente con los hallazgos de la presente revisin, en la que el lbulo
ms frecuentemente afectado fue el derecho (77,0%), seguido de los dos lbulos
(21,0%); el lbulo izquierdo se vio afectada en slo un pequeo nmero de casos
(2,0%). Antes de 1970, la tasa de mortalidad materna asociada con hemorragia
heptica fue hasta el 100% en los casos en los que no se proporcion tratamiento
quirrgico [17]. Se haba disminuido a 77% en la dcada de 1980 [18], y al 39% a
finales de la dcada de 1990 [4] en los casos de tratamiento quirrgico. En la presente
revisin, la tasa de mortalidad materna en casos de hemorragia heptica / ruptura
durante el perodo 1990-2000 fue del 28,9%, que es del 16,4% durante el perodo
2001-2010. Esta reduccin probablemente refleja los avances en la reanimacin, la
medicina de cuidados intensivos, ciruga heptica, el trasplante de hgado, y
embolization- arterial, especialmente en los pases de ingresos altos. Rinehart et al. [7]
inform de que la tasa de mortalidad perinatal en casos de hemorragia heptica /
ruptura fue del 78% entre 1960 y 1979, que es del 50% entre 1980 y 1997. En la
presente revisin, la tasa de mortalidad perinatal fue de 30,7%, probablemente debido
a las mejoras en el cuidado de los recin nacidos prematuros y gravemente enfermos
en las ltimas 2 dcadas en comparacin con antes de la dcada de 1990. La tasa de
mortalidad perinatal se mantuvo constante durante las ltimas 2 dcadas. gestin
precisa y eficaz de ruptura heptica se ve facilitada por una combinacin de
intervencin quirrgica y el cuidado de apoyo agresivo. Algunas de las tcnicas
quirrgicas han disminuido considerablemente las tasas de morbilidad y mortalidad
asociadas con ruptura heptica, aunque no hay un acuerdo completo sobre cual es el
mejor enfoque [6]. El tratamiento conservador [6,19,20], ligadura de la arteria heptica
[6,21], la embolizacin arterial [22,23], hepatorrhaphy [4,5], el embalaje del hgado [36], esponjas de colgeno [2], malla absorbible [5], la cola de fibrina [4], lser de argn
[2,23], el trasplante heptico [4,24], el factor VIIa recombinante [2,25], como la gestin
conjunta se han utilizado [2,4,6]. Las tcnicas utilizadas en el tratamiento del sndrome
de HELLP y ruptura heptica varan, especialmente entre los de ingresos altos y los
pases de bajos ingresos, lo que puede dar lugar a diferentes tasas y tendencias de la
mortalidad de mortalidad. En la presente revisin,. En la ultima dcada
estudiado, la tasa de supervivencia fue del 100% con embolizacin arterial o trasplante
de hgado. La exploracin quirrgica y la gestin (embalaje de las reas de sangrado,
drenaje del espacio periheptico, la reseccin heptica, terapia de apoyo, la cola de
fibrina, el factor VIIa recombinante, y el lser de argn) comprenden la modalidad de
tratamiento ms utilizado para el manejo de mujeres con rotura heptica y la
preeclampsia / eclampsia en el perodo estudiado. En este grupo de tratamiento, la
tasa de mortalidad materna fue de 33,9% en el perodo 1990-2000, que es del 16,6%
en el perodo 2001-2010. Esta reduccin probablemente se asoci con los avances en
la reanimacin y cuidados intensivos medicina. Si hay una sospecha clnica de heptica

hematoma / ruptura, evaluacin radiolgica debe realizarse a la discrecin del mdico.

La ecografa y la tomografa computarizada se pueden utilizar para confirmar el
diagnstico de hematoma subcapsular heptica antes de la rotura [7]. La tcnica de
imagen por ultrasonido es especialmente til, ya que puede permitir un diagnstico de
noche sin tener que movilizar al paciente lejos de las reas especficas de obstetricia,
salas de operaciones, o reas de cuidados crticos. Sin embargo, cuando hay sospecha
clnica de ruptura heptica, debe laparotoma

no ser retrasado; estos pacientes deben ser administrados en un centro multidisciplinar

con una correcta gestin de hgado hgado la ciruga de trasplante, incluyendo-y expertos
en la embolizacin arterial. laparotoma primaria y taponamiento de la fuente de la
hemorragia no deben posponerse y se deben hacer en el hospital de atencin primaria si
el paciente no es lo suficientemente estable como para ser transportado [4].
Hubo limitaciones en la presente revisin. En primer lugar, pueden no haber sido
encontrado algunos casos. En segundo lugar, slo los estudios publicados en 4 idiomas
fueron considerados; Sin embargo, pocos casos se publican en otros idiomas. Una tercera
limitacin es el corto periodo de estudio. Sin embargo, antes de 1990, artculos con
informes ruptura heptica asociada con la preeclampsia / eclampsia sin mencin del
sndrome de HELLP eran comunes. Una de las ventajas de la presente revisin fue que la
metodologa de bsqueda fue amplia, completa y reproducible.
Hemorragia heptica que complica los casos de preeclampsia / eclampsia, ms Sd.
HELLP se asoci con una tasa de mortalidad materna del 16,4% y una tasa de mortalidad
perinatal de 31,3% durante 2001-2010.

http://fulltext.study/catego
ry/19

Por lo tanto, una estrecha vigilancia es necesaria para los pacientes con sndrome de
HELLP y los que tienen preeclampsia / sndrome de HELLP y fuerte dolor epigstrico.

http://espanol.babycenter.com/blog/mamas/como-se-mueven-tus-organos-internos-en-elembarazo/