Improving survival with liver rupture complicating pregnancy

Improving survival with liver rup$me complicating pregnancy WILLIAM

N.

WILLIAM

E. BRENNER,

Dalln.\,

P. HERBERT,

Tuxns, clnd Chapel Hill,

M.D. M.D.

‘Vorth Carolina

The reported maternal mortality of 59% that results from rupture of the liver in pregnancy is probably excessive if modem diagnostic and treatment te&tniqu~ are fully t&&z&. The farity and variable presentation should not lead to an incorrect diagn@s and possible f&al outcome Pregnant patients or patients who recently have compiain of epigastric and/or dtscomfo considered to be’candidates for rupture o adequate diagnostic technique in most patients. are helpful tools. Ligation of spec/fic bleeding ~~, cmemf pedicles, topical agents, ligation of the hepatic btery, h&p& artery embo@on, and other techniques should be used prior to performance of t-&my. Drainage is recommended. Replacement of blood, correction of coagulation defects, monitoring of respiratory function, and attention to known postoperative complications should improve the outcome of patieirts with this serious complication. (AM. J. OBSTET. GYNECOL. 142:53fl, 1982.3

FIFTY-SISE PERCENT of mothers and 62% of fetuses are reported to die when rupture of the liver complicates pregnancy.’ Delay in diagnosis often results in an extremely compromised patient before surgical treatment is initiated. Increased awareness and recent diagnostic and therapeutic advances should promote earliel diagnosis and more effective management of patients with this complication. This report discusses the clinical presentation and available diagnostic and therapeutic modalities in the context of four patients who surG\.ecl rupt tire of- the liver associated with pregnancy.

Case reports The details of four cases are presented in Table I. Maternal ages ranged from 22 to 30 years; parity, from

From the Department of Vbstrtrics und Gynecology, The C’nizv):+ of TPMS Health Scirnre Center, Southwestern Medical School, and the Department of Ob.~tetricsand Gynecology, The Unirfersity of North Carolina School of Mrdicnv. Keceil& for publicution July 10, 1981. Rnkd

Sepember 24, 1981.

.4ccrptrd October 1, 1981. Reprint rcquesty: William IV. P. Herbert, M.D., DiznSion of Maternal and Fetal Medicine, Department of’Obst&ics and ~~mxology, University of North Carolina School of Medxme, 214 MacNider Bldg., 202-H. Chapel Hill, North Carolina 27514.

530

0 to 5; and duration of pregnancy, from 24 weeks to 1 day post partum. Three of the four patients were hyperter&v?; fetal bradycardia prompted surgical intervention in two of the three cases in which the fetus was viable at the time of presentatiun. All patients reco\.ered, and three of four infants survived. Cum-t Cl+ticd presemtation. The cause of rupture of the liver during pregnancy is usually unknown. Trauma, uterine contractions, vomiting, convulsions, and delivery have been associated events.’ The periportal necrosis associated with preeclampsia may predispose the live; to hemorrhage. Once bleeding occurs, a s&capsular hematoma usually develops, most frequently on the anterior and superior aspects of the liver. Several days may lapse before the hematoma ruptures, resulting in intraabdominal hemorrhage and shock. Both the clinical findings and the reliability of diagnostic tests wilI depend upon the point in the course of the condition when the examination or tests are performed. The rarity of ruptured liver and the variable clinical presentation probably account for the fact that diagnosis prior to surgical intervention is unutual. Preoperative diagnosis was correct in only six af 60 case-s reviewed by Bis and Waxman.’ Confusion with more common clinical entities is freooO2-9378/82/050530+05$00.50/0

0

1982 The C. V. Mosby CO.

Volume 142 Number 5

quent. Epigastric discomfort is frequently attributed to “indigestion” or to “discomforts of pregnancy.” Pain in the right upper quadrant of the abdomen or epigastric pain associated with preeclampsia may erroneously be considered to be just part of the uncomplicated preeclamptic syndrome. Chest pain, as described in two of our patients, may lead to a diagnosis of pulmonary embolus. Furthermore, in the second patient, a lung scan demonstrated a small wedge-shaped defect, whereas no infiltrate was noted on the chest radiograph. A decreasing hematocrit prompted a liver scan, which disclosed a defect. Institution of anticoagulant therapy would probably have been catastrophic. Pain in the back with tenderness at the costovertebral angle and fever may result in the misdiagnosis of pyelonephritis, as occurred in Case 3. An obtunded sensorium may be attributed to the postictal state or to diabetic coma, as occurred in Case 4. The clinical presentation is so variable that any woman who is pregnant or has recently undergone delivery and describes epigastric pain or discomfort in the right upper quadrant of the abdomen should be considered to be a candidate for a ruptured liver, especially if she has hypertension. Only with an increased awareness of this entity will early diagnosis be possible. Diagnostic tests. Serial determinations of blood pressure, heart rate, and hematocrit are useful. The decrease in blood pressure and increase in pulse rate associated with intraperitoneal bleeding occur more rapidly in hypertensive gravid women with contracted volumes of blood than in normotensive women who have normal volumes of blood. Paracentesis with lavage has a diagnostic accuracy exceeding 95% in detecting intra-abdominal hemorrhage and has only a 0.5% complication rate.’ Since the pelvis is the most dependent portion of the abdomen when the patient lies supine, culdocentesis should also be reliable in detecting significant amounts of intraabdominal blood. Immediate celiotomy should follow the discovery of free blood within the abdomen by either procedure. Plain abdominal radiography is not diagnostic, although intraperitoneal blood may produce a diffuse shadow lateral to the bladder and uterus. Lltrasonography may disclose a subcapsular hematoma, which appears as a radiolucent area near the surface of the liver. Differentiation from ascitic fluid is possible if the hematoma is intact, since ascitic Huid can be detected at other sites. This distinction is lost after the hematoma ruptures. Radionuclide scanning with the use of technetium (?nTc) sulfur colloid is a means of identifying injuries

Liver rupture complicating

pregnancy

531

to the liver. ssmTc is trapped by Kupffer cells, so that areas devoid of these cells, such as hematomas, are distinguishable from normal hepatic tissue.” Castenada and associates“ were the first to utilize liver scans to accurately diagnose hepatic hemorrhage in three preeclamptic women preoperatively; all of the women survived. Computed tomography has been found to be useful in diagnosing hepatic lesions. Computed tomography, radionuclide scanning, and uttrasonography were evaluated in 51 patients with several types of hepatic spaceoccupying lesions. All procedures were considered to be valuable, with radionuclide imaging being the simplest, and ultrasonography the most accurate.” Selective angiography can demonstrate the hepatic blood supply. This procedure was used by Sommer and associates” to correctly diagnose hepatic rupture preoperatively in a hypertensive multiparous women at 24 weeks’ gestation. Treatment. Immediate celiotomy is mandatory when the diagnosis is made or strongly suspected. Both the abdomen and chest should be prepared. A midline incision in the upper abdomen is adequate for management of most hepatic injuries, with the use of median sternotomy when exposure of all surfaces of the liver is required.’ After the bleeding site has been identified, evacuation of the hematoma is performed. Techniques to establish hemostasis include compression, simple suture, topical coagulant agents, arterial embolization, omental pedicles, ligation of the hepatic artery, and lobectomy. The procedures selected depend upon the extent of the injury. Use of a gravity suit and packing of the rupture site are temporary measures that may allow transfer of the patient to a more specialized care center. Specific bleeding points should be ligated, followed by careful suturing with 2-O chromic catgut suture on a blunt-tipped atraumatic P-inch liver needle in figureof-eight or interlocking fashion.’ Care must be taken not to place sutures too deeply into the parenchyma of the liver since they may cause devascularization and subsequent necrosis.” Lucas and Ledger-wood8 found no postoperative complications related to the use of “prophylactic” suture in areas in which bleeding had occurred. Drainage of the hepatic bed with a Penrose or sump drain through a separate stab wound is usually recommended for traumatic rupture of the liver. Drainage by cholecystotomy tube, choledochostomy tube, or “T” tube is associated with a morbidity rate higher than and a mortality rate similar to or higher than those with the use of Penrose drains.# “Venous oozing” may be controlled by the use of

March 1, 1982

532 Herbert and Brenner

.4m. 1. Obstet. Gvnecol.

Table I. Details of patients with ruptured

Case 1

2X-year-old woman, gravida 1. eclamptic in labor at term: persistent severe fetal bradycardia - immediate cesarean delivery. Hemoperitoneum secondary to a ruptured subcapsular hematoma noted Procedure No. 2 performed for persistent bleeding Procedure No. 3 performed for recurrent bleeding

liver associated with pregnancy

(Iesarean delivex-!; drainage ot he-

Whole blood: 17 units Packed RB<:: 48 units

matoma: direct

Fresh frozen plasma:

pressure

32 uuits

Pleural effusion, pulmonary infection, reactive psychosis

Fresh plasma: 4 units Platelets: tii packs

Patient recovered: infant 3,200 gm; Apgar ,518

‘Topical collagen. gelatin sponge Drainage of second hematoma, hepatic artery liga-

Procedure No. 4 performed for recurrent bleeding

Case 2

Procedure No. 5 performed for persistent bleeding, cholecystitis 22-year-old woman, gravida 1. at 24 weeks with severe hypertension, proteinuria, int rauterine fetal death Magnesium sulfate, oxytocin induction of labor - 700, g-m

tion, omental graft Hepatic arterv emhohzdtion $ith gelatin sponge Partial hepatic lobectomy, cholecystectomy Whole blood: 2 units

None

Recovered

grossly normal stillborn mfant Right pleuritic chest pain with splinting on second postpartum day; arterial PO, 76 torr; chest radiograph -* elevation of hemldiaphragm, pleural effusion, no infiltrates; lung scan - wedge-

shaped defect; hematocrit decline (33% to 25%‘); liver scan - compression of lateral margin of right heparic

lobe, inferior filling defect: celiotomy performed + subcapsular hematoma

Drainage of hematoma; sutures; direct pressure

topical agents. Purified animal gelatin (Gelfoam, The Upjohn Co., Kalamazoo, Michigan) absorbs man! times its weight in blood. and forms a framework in which a clot can develop. It may be applied dry or saturated with sodium chloride or thrombin. Excess material shordd not be removed after hemostasis is achieved. It is absorbed in 4 to 6 weeks. Topical bovine thrombin (Parke, Davis 8c Co., Morris Plains, New Jersey), when sprinkled on the bleeding surface, promotes clotting of’ the blood fibrinogen. It can be applied in dry form, be reconstituted and topically applied in a concentration of 1,000 to 2,000 units/ml, or be used to saturate purified gelatin as described above. Purilied bovine microfibrillar collagen (Avitene, Avicon, Inc., Fort Worth, Texas) adheres firmly to bleeding surfaces. Platelets become enmeshed in its fibrils, and the

f‘ormation of thrombus follows. Excess material should be teased away with forceps and gentle irrigation with saline solution. Oxidized regenerated cellulose (Surgicel. Surgikos, New Brunswick, New .Jersey) is a knitted fabric which promotes hemostasis. lt may be sutured or cut without tiaying. When saturated with blood, it forms a gelatinous mass which aids in the formation of clot. Arterial emholization with clot, fat, muscle, silicone, gelatin sponge (Gelfoam), and a variety of other substances has been used to control henorrhage.” ln our first patient, cut strips of Gelfoam were injected into selected hepatic arteries through a c&et&r intro&c&d percutaneously into the femoral artery. &lee&q decreased significantly after the procedure. Stone and Lamb”’ have reported the successful use

Liver rupture complicating pregnancy 533

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Table I-Cont’d Surgical treatment

Clinical course Case 3

Case 4

30-year-old woman, gravida 6, para 5, at 39 weeks delivered of 3,530 gm infant in ambulance en route to hospital 15 hours post partum-nausea, epigastric and back pain relieved with sitting; examination normal; antacid prescribed, with some relief Third postpartum day-right upper quadrant pain, dysuria; exquisite costovertebral angle tenderness; temperature 100.4” F. Diagnosis: pyelonephritis. Treatment: intravenous ampicillin 12 hr later-right shoulder pain, dizziness on standing. Abdomen distended, tender: hematocrit 18%. Paracentesis - free-flowing blood. Celiotomy performed-ruptured subcapsular hematoma 28-year-old woman, gravida 1, with diabetes mellitus, Class B, in good control At 37 weeks, found in semicomatose state by husband midafternoon; had not taken morning insulin, which he administered before taking her to hospital. Plasma glucose 40 mgilO0 ml on admission; obtunded; blood pressure 1401100 torr, pulse 92/min; proteinuria (2 +), fetal heart rate 150/min; no localizing signs Remained obtunded despite intravenous glucose to euglycemic state: pulse increased to 140/min; 6 hr after admission, hematocrit decreased from 37% to 26%: persistent fetal bradycardia to 50 to 60 beats/min prompted immediate cesarean delivery, where hemoperitoneum secondary to ruptured subcapsular hematoma encountered

Total blood replacement

Other complications

Whole blood: 8 units

Pulmonary infection; pleural effusion

Recovered

Whole blood: 20 units

None

Patient recovered; infant 2,925

Drainage of hematoma; sutures

gm; Apgar WI0

Multiple sutures, oxidized cellulose topically

of omental pedicles to control hemorrhage from severe injuries to the liver. After separation of the omentum

Ligation considered

from the transverse colon, the omental pedicle is wedged into the site of’ laceration. A running suture is used to pull the edges of the surface of the liver together under mild tension. This procedure was also

suturing

helpful

in controlling

hemorrhage

Outcome

in our first patient.

branch clamp,

of the hepatic artery or one of its branches is by some to be more effective than mass in controlling

hemorrhage.”

The appropriate

of’ the hepatic artery is occluded with a vascular and, if bleeding ceases, the artery is ligated. If

bleeding persists, angiography arterial anatomy of the liver,

is required to detail the since the hepatic artery

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534 Herbert and Brenner

may arise from the celiac, left gastric, or superior mesenteric artery. If ligation of the common hepatic or right hepatic artery is required, a cholecystectomy is recommended by some, since cystic artery flow may be compromised. In Case 1, a cholecystectomy was required subsequent to ligation of the right hepatic arterv. Lobectomy is performed only when other measures have failed, since the procedure is difficult and the outcome is often poor. 3 7. ” The basic procedure is ligation of the appropriate branches of the hepatic artery, portal vein, and bile duct. Survival is possible after resection of practically the entire hepatic mass. Temporary measures to control hemorrhage are sometimes required to allow for transfer of the patient. The application of a gravity suit (“G-Suit”) has been used successfully for temporary control of intraabdominal bleeding. I3 The suit surrounds the patient from the level of the ankles to the xyphoid process and is inflated to a pressure of 20 to 40 cm of water. This reduces the How of blood in the intra-abdominal vascular bed by diverting the blood to the upper body and head. The gravity suit was used in the only two survivors of eight patients with spontaneous rupture of the liver in pregnancy reported by Hibbard.‘” The use of packing at the site of rupture may also prove to be lifesaving.’

Am. ,I. Obstet. Gynecol.

Supportive care. After hemorrhage has been controlled, many patients recover quickly. However, multiple procedures may be necessary and postoperative intensive care is f’requently necessary. Since resection of major segments of the liver and ligation of‘ the hepatic artery frequently result in hypoglycemia
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