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Hepatic rupture caused by HELLP syndrome?
Letters to the Editors
www. AJOG.org
Hepatic rupture caused by HELLP syndrome? TO THE EDITORS: Reading the article on hepatic rupture caused by HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets) by Araujo et al,1 concerning 10 cases in Brazil (1990-2002), I found myself with questions in three areas. First, what was the definition of hepatic rupture in this context? How did the authors recognize the subcapsular hematoma of liver?2 What was or is the progression of hepatic rupture caused by HELLP syndrome? As case 2 death on the arrival to the hospital, it was often the case at emergency department in daily practice; however, such as case 9, only observation and monitoring, as well as supplement of albumin can “cure” the hepatic rupture caused by HELLP? Overall, there were apparently no remarkable findings for values of lactate dehydrogenase (LDH), thrombocytopenia, and alanine aminotransferase (AST), which are key lab data. In other words, clinicians may not be able to diagnose the hepatic rupture early enough to provide treatment in time. Ultrasound and chest-X ray could identify some abnormal findings, such as hepatic hematoma and pleural effusion, but these may not be useful or good indicators for rupture of liver hematoma. Moreover, how did the authors distinguish hepatic rupture from hepatic hematoma? The overestimate of hepatic subcapsular hematoma as hepatic rupture caused by HELLP syndrome is worth addressing. My next point is that the authors did not mention or discuss other medical complications concurrent with HELLP syndrome, such as disseminated intravascular coagulation (DIC),
placental abruption, acute renal failure, and acute respiratory failure or adult respiratory distress syndrome (ARDS).3 Pleural effusion may not be looked upon as a disease or as a specific complication of certain disease. Last of all, even though perhaps this was beyond the scope of the original article, it would be good to see strategies addressed for prevention, early diagnosis, and management of hepatic f rupture associated with HELLP. Ching-Ming Liu, MD, MPH Department of Obstetrics and Gynecology Chang Gung Memorial Hospital, Linkou Medical Center Chang Gung University College of Medicine No 5, Fu-Hsin St., Kweishan Taoyuan 333, Taiwan [email protected] REFERENCES 1. Araujo ACPF, Leao MD, Nobrega MH, et al. Characteristics and treatment of hepatic rupture caused by HELLP syndrome. Am J Obstet Gynecol 2006;195:129-33. 2. Wicke C, Pereira PL, Neeser E, Flesch I, Rodegerdts EA, Becker HD. Subcapsular liver hematoma in HELLP syndrome: evaluation of diagnostic and therapeutic options—a unicenter study. Am J Obstet Gynecol 2004;190:106-12. 3. Rolfes DB, Ishak KG. Liver disease in toxemia of pregnancy. Am J Gasteroenterol 1986;81:1138-44. © 2007 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2006.11.008
REPLY The definition of hepatic hematoma we used was that of Barton and Sibai,1 which describes it as an accumulation of hemorrhage between the liver capsule and underlying parenchyma. The diagnosis of hepatic lesion was made during the cesarean (4/10), by ultrasound findings (5/10), or postpartum (1/10) during laparotomy.2 The progression and the exact moment of the capsule rupture are not well defined. Microscopic examination reveals periportal necrosis and occlusion by fibrin deposit of the periportal capillaries, which could be involved in the disseminated intravascular coagulopathy in HELLP syndrome.3 Patients in our series were admitted to the hospital already presenting with hepatic rupture and hemoperitoneum. The initial hepatic lesions were not documented, except for patient 9, who had a hepatic hematoma. This case was treated clinically for the hepatic lesion, with support therapy; albumin administration was used because of hypoproteinemia, and not to treat the HELLP syndrome. This patient remained hospitalized until full remission. It is likely that control of the hypertension and the delivery, with removal of the probable causal factor, interrupted the full progression of hepatic lesions.2 She was
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American Journal of Obstetrics & Gynecology APRIL 2007
followed clinically because of the anatomic localization of the hepatic hematoma and clinical stability. All surgical procedures were performed within a few hours of admission. No complications such as kidney insufficiency or acute adult respiratory syndrome were observed in our patients. Case 2 was admitted already in severe hypovolemic shock, one day postpartum, and died during laparotomy. Clinical history, ultrasound, and laboratory markers are valuable tools to confirm a liver rupture.1 Several imaging techniques, such as MRI, CT, and ultrasound, have the sensitivity to diagnose liver rupture.1 Preventive measure to avoid liver rupture should include the careful management of the severe preeclampsia, with early diagnosis and treatment of the complications. In our opinion, patients with preeclampsia presenting with epigastric pain, without signs of extensive vaginal bleeding and with a conserved uterine tonus, should be carefully investigated to rule out hepatic lesion. f Marcos D. Leao, MD Health Graduating Program
www. AJOG.org
Hepatic rupture caused by HELLP syndrome? TO THE EDITORS: Reading the article on hepatic rupture caused by HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets) by Araujo et al,1 concerning 10 cases in Brazil (1990-2002), I found myself with questions in three areas. First, what was the definition of hepatic rupture in this context? How did the authors recognize the subcapsular hematoma of liver?2 What was or is the progression of hepatic rupture caused by HELLP syndrome? As case 2 death on the arrival to the hospital, it was often the case at emergency department in daily practice; however, such as case 9, only observation and monitoring, as well as supplement of albumin can “cure” the hepatic rupture caused by HELLP? Overall, there were apparently no remarkable findings for values of lactate dehydrogenase (LDH), thrombocytopenia, and alanine aminotransferase (AST), which are key lab data. In other words, clinicians may not be able to diagnose the hepatic rupture early enough to provide treatment in time. Ultrasound and chest-X ray could identify some abnormal findings, such as hepatic hematoma and pleural effusion, but these may not be useful or good indicators for rupture of liver hematoma. Moreover, how did the authors distinguish hepatic rupture from hepatic hematoma? The overestimate of hepatic subcapsular hematoma as hepatic rupture caused by HELLP syndrome is worth addressing. My next point is that the authors did not mention or discuss other medical complications concurrent with HELLP syndrome, such as disseminated intravascular coagulation (DIC),
placental abruption, acute renal failure, and acute respiratory failure or adult respiratory distress syndrome (ARDS).3 Pleural effusion may not be looked upon as a disease or as a specific complication of certain disease. Last of all, even though perhaps this was beyond the scope of the original article, it would be good to see strategies addressed for prevention, early diagnosis, and management of hepatic f rupture associated with HELLP. Ching-Ming Liu, MD, MPH Department of Obstetrics and Gynecology Chang Gung Memorial Hospital, Linkou Medical Center Chang Gung University College of Medicine No 5, Fu-Hsin St., Kweishan Taoyuan 333, Taiwan [email protected] REFERENCES 1. Araujo ACPF, Leao MD, Nobrega MH, et al. Characteristics and treatment of hepatic rupture caused by HELLP syndrome. Am J Obstet Gynecol 2006;195:129-33. 2. Wicke C, Pereira PL, Neeser E, Flesch I, Rodegerdts EA, Becker HD. Subcapsular liver hematoma in HELLP syndrome: evaluation of diagnostic and therapeutic options—a unicenter study. Am J Obstet Gynecol 2004;190:106-12. 3. Rolfes DB, Ishak KG. Liver disease in toxemia of pregnancy. Am J Gasteroenterol 1986;81:1138-44. © 2007 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2006.11.008
REPLY The definition of hepatic hematoma we used was that of Barton and Sibai,1 which describes it as an accumulation of hemorrhage between the liver capsule and underlying parenchyma. The diagnosis of hepatic lesion was made during the cesarean (4/10), by ultrasound findings (5/10), or postpartum (1/10) during laparotomy.2 The progression and the exact moment of the capsule rupture are not well defined. Microscopic examination reveals periportal necrosis and occlusion by fibrin deposit of the periportal capillaries, which could be involved in the disseminated intravascular coagulopathy in HELLP syndrome.3 Patients in our series were admitted to the hospital already presenting with hepatic rupture and hemoperitoneum. The initial hepatic lesions were not documented, except for patient 9, who had a hepatic hematoma. This case was treated clinically for the hepatic lesion, with support therapy; albumin administration was used because of hypoproteinemia, and not to treat the HELLP syndrome. This patient remained hospitalized until full remission. It is likely that control of the hypertension and the delivery, with removal of the probable causal factor, interrupted the full progression of hepatic lesions.2 She was
e16
American Journal of Obstetrics & Gynecology APRIL 2007
followed clinically because of the anatomic localization of the hepatic hematoma and clinical stability. All surgical procedures were performed within a few hours of admission. No complications such as kidney insufficiency or acute adult respiratory syndrome were observed in our patients. Case 2 was admitted already in severe hypovolemic shock, one day postpartum, and died during laparotomy. Clinical history, ultrasound, and laboratory markers are valuable tools to confirm a liver rupture.1 Several imaging techniques, such as MRI, CT, and ultrasound, have the sensitivity to diagnose liver rupture.1 Preventive measure to avoid liver rupture should include the careful management of the severe preeclampsia, with early diagnosis and treatment of the complications. In our opinion, patients with preeclampsia presenting with epigastric pain, without signs of extensive vaginal bleeding and with a conserved uterine tonus, should be carefully investigated to rule out hepatic lesion. f Marcos D. Leao, MD Health Graduating Program