Hepatic hemorrhage

Although occurring in only 2 per cent of patients, intrahepatic hemorrhage can be catastrophic and fatal ( Sibai.ef a/ 1993). Liver histopathology does not correlate with either biological data or liver enzymes. Patients with HELLP syndrome, in particular those with epigastric and right upper quadrant pain, should be evaluated by ultrasound to exclude an intrahepatic hematoma. CT may complete the diagnostic picture and help to differentiate an intact hematoma from a rupture of Glisson's capsule with secondary hemoperitoneum. A liver hematoma should be treated conservatively but does indicate expeditious delivery. Vaginal delivery is not the preferred method because of the fear of hepatic rupture. Cesarean section should be performed by a midline incision to allow good intra-abdominal hemostasis and eventual evacuation of the subcapsular liver hematoma if it is excessively large with a major risk of rupture. Evacuation can lead to bleeding and oozing. Supportive therapy includes platelet and blood product transfusions in combination with good hypertension control. If bleeding control cannot be achieved by vessel suture and ligation, packing of the liver is indicated; packs can be removed 24 to 48 h later.

Laparotomy is indicated for an acute abdomen with shock secondary to hepatic rupture, and liver rupture should be treated as for traumatic rupture. When shock can easily be controlled by massive transfusion, arteriography with a view to embolization should precede surgery.

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