Hemorrhagic hepatic infarction in a pregnant woman with severe pre-eclampsia: a case report

Abstract

Introduction and importance:

Severe pre-eclampsia is a medical condition that affects women during the last two trimesters of pregnancy. Hemorrhagic hepatic infarction is a hepatic complication and is rarely encountered in women with severe pre-eclampsia. This case report aims to present the characteristics of hemorrhagic hepatic infarction in a pregnant woman with severe pre-eclampsia.

Case presentation:

A 27-year-old pregnant woman with a 30-week gestation of amenorrhea was admitted with a blood pressure of 160/100 millimeters of Mercury (mmHg), headaches, dizziness, and oedema in the lower limbs.

Clinical discussion:

These complaints with clinical and paraclinical examinations led to the diagnosis of severe pre-eclampsia, and she underwent an emergency cesarean section, but 6 h later, she presented with hypovolemic shock, and this led to a new surgery. A surgery that made it possible to develop or discover a diffuse hepatic infarction with hemorrhagic infiltration of the gallbladder and the falciform ligament without active bleeding in the liver. Emergency management of pre-eclampsia was adopted, and the postoperative course was simple, with a good clinical outcome when the patient was discharged.

Conclusion:

Severe pre-eclampsia and hemorrhagic hepatic infarction are complications of pregnancy, which require emergency treatment, and above all, these medical conditions require the termination of the pregnancy.

Introduction

Highlights

• Severe pre-eclampsia is a clinical condition that affects women during the pregnancy. Hemorrhagic hepatic infarction is a rare hepatic complication in women with severe pre-eclampsia.

• Severe pre-eclampsia and hemorrhagic hepatic infarction are complications of pregnancy that require emergency treatment, but the prognosis is favorable after delivery.

• The presentation of this case made it possible to identify the association between the clinic and the diagnosis of hemorrhagic hepatic infarction in a hospital in a region without modern medical equipment.

Severe pre-eclampsia is a condition that affects a certain number of women during pregnancy; it is also a major public health and maternal and child health problem due to its high prevalence of maternal and perinatal morbidity and mortality in economically weak countries¹. Hemorrhagic hepatic infarction is a rare hepatic complication of pre-eclampsia and is more often associated with HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome and usually occurs late in pregnancy². Severe pre-eclampsia is often complicated by liver damage in 2–5% of cases (retro capsular hematoma, liver rupture, hepatic infarction). The hepatic changes in pre-eclampsia range from mild elevation in liver enzymes to life-threatening complications like hepatic infarction, rupture, or hemorrhage. Hepatic infarction is much rarer than subcapsular hematomas³.

Hepatic infarction occurs due to a combination of vasospasm, endothelial dysfunction, and microthrombi formation, all of which compromise blood flow to the liver. In severe pre-eclampsia, particularly when complicated by HELLP syndrome, exacerbates the coagulopathy, contributing to the formation of infarcts⁴. Though rare, hepatic infarction in pre-eclampsia is associated with significant maternal morbidity and, in some cases, mortality. Timely diagnosis and intervention are crucial to improve outcomes⁵. This case report aims to describe the presentation of a case of hemorrhagic hepatic infarction in a pregnant woman with severe pre-eclampsia in a hospital in an under-equipped region of an economically poor country.

Case presentation

We report a case of a 27-year-old pregnant woman, a housekeeper of parity 0, gestation 2, abortion 1, carrying a pregnancy of 30 weeks of amenorrhea and 1 day. The pregnant woman was transferred with the main complaints: headache, dizziness, epigastralgia, and vomiting. Her pregnancy was single-fetal. Her last period date was 19 April 2023, and her probable due date was 24 January 2024. The pregnant woman had poorly attended her prenatal consultations and had an abortion during the first pregnancy. She had no known pathological history.

On admission, his general condition was altered by a look of pain and puffiness on the face. Her blood pressure was 160/100 millimeters of Mercury (mmHg), her uterus height was 26 centimeters (cm), the fetal presentation was cephalic, and the fetal heart sound was 150 beats per minute. During the clinical examination, we noted epigastric sensitivity without defense. She presented with significant lower limb oedema. The paraclinical assessment carried out upon admission of the patient is shown in the table (Table 1). After clinical and paraclinical examinations, we concluded that there was severe pre-eclampsia with suspicion of HELLP syndrome. Upon her emergency arrival, the pregnant woman received a dose of dexamethasone (for lung maturation), magnesium sulfate (for the prevention of eclampsia), as antihypertensives: alpha-methyl dopa (Aldomet) associated with calcium channel blocker (Adalat) were administered. An emergency cesarean section was performed without incident under spinal anesthesia and gave birth to a female newborn weighing 1300 g with Apgar of 7-8-9 but unfortunately, the child died.

Table 1.

Paraclinical assessments carried out upon admission of the patient

Variables	Paraclinical assessments upon arrival	Normal values
ALAT	47.79	0–41 IU/l in women
ASAT	97.05	0–37 IU/l
Hemoglobin	14.7 g/dl	11–16 g/dl
Hematocrit	44.7%	37–48% in women
Platelets	169 000	150 000–400 000/mm3
Creatine	0.5 mg/dl	0.7–1.4 mg/dl
Urea	29.6 mg/dl	15–45 mg/dl
Acid uric	6.3 mg/dl	2.6–5.7 mg/dl
Proteinuria (Dipstick)	+++	Less than 2+ compared to pre-eclampsia
Kaliemia	4.86 mmol/l	3.5–5.5 mmol/l
Natremia	134 mmol/l	135–145 mmol/l
Chlorine	109.3 mmol/l	98–108 mmol/l

ALAT, alanine aminotransferase; ASAT, aspartate aminotransferase; g/dl, gram per deciliter; L, liter; mg/dl, milligram per deciliter; mm³, cubic millimeter; mmol/l, millimole per liter; UI, international units.

Six hours later, the pregnant woman presented a hypovolemic shock with agitation, generalized abdominal tenderness, coldness of the extremities but also a weakening of consciousness with a Glasgow score of 12. Her blood pressure varied between 70 and 80 mmHg for systolic and 40–50 mmHg for diastolic, and her heart rate was between 50 and 67 beats per minute. A diagnosis of hypovolemic shock was made and the abdomen was reopened after hemodynamic stabilization under vasopressor and crystalloid filling. During surgery, we aspirated ~2 l of incoagulable blood without active bleeding from the hysterorrhaphy (Fig. 1), which will raise suspicion of liver rupture. A second median supra-umbilical incision of ~10 cm was made, which allowed us to discover a diffuse hepatic infarction with hemorrhagic infiltration of the gallbladder and the falciform ligament without active bleeding or loss of hepatic continuity (Fig. 2). Given that the patient was in a state of hypovolemic shock and we feared a resumption of bleeding, we packed with six abdominal compresses which we removed 48 h later. When the compresses were removed, the liver and gallbladder returned to a normal appearance and there was a small peritoneal collection reacting to the paralytic ileus resulting from the irritation to the compresses. She benefited from 750 ml of packed red blood cells during and after the intervention. She was taken back to intensive care for close monitoring and continued treatment. When the patient was discharged on the 12th day after her admission, the paraclinical assessments were carried out and they are also represented in the table (Table 1). The postoperative course was simple.

Figure 1.

Surgery to reopen the abdomen, which shows no active bleeding from the uterus.

Figure 2.

Increasing the incision to reveal a diffuse hepatic infarction.

Discussion

The work has been reported in line with the SCARE 2023 criteria⁶. Hypertensive disorders during pregnancy are very common and represent medical conditions that can be responsible for serious maternal and fetal complications. Hemorrhagic hepatic infarction during severe pre-eclampsia is a rare medical condition in the clinic¹, it is commonly associated with HELLP syndrome. In our case, the diagnosis of HELLP syndrome was not retained because all the diagnostic criteria were not met.

Clinical features of HELLP syndrome include right upper quadrant and epigastric pain, headache, nausea, and vomiting. Abnormalities in liver tests are found in 20–30% of patients with severe pre-eclampsia and are probably secondary to hepatic vasoconstriction. Transaminases can rise to more than 10 times the norm. Complications include hemorrhage, liver rupture, or hepatic necrosis increasing maternal and perinatal morbidity and mortality⁷. It is recommended to examine medical imaging, preferably CT and MRI, which are more precise than ultrasound, in the diagnosis of hematomas and hepatic infarction each time the patient presents. call signs. However, in our regions of economically weak countries, it is difficult to carry out imaging examinations due to the cost and the lack of these diagnostic means in many hospitals.

The biological assessments were carried out urgently and it was noted that the transaminases were two to three times higher than normal values, but other studies, such as the study carried out by El Allani et al.⁸ in 2020, also show a very significant elevation of transaminases.

The diagnosis of hepatic necrosis was made intraoperatively in a context of hemoperitoneum complicated by hypovolemic shock, which had threatened the patient’s life 6 h after the cesarean section. Monitoring under scope in the postoperative ICU made it possible to detect the progressive deterioration of hemodynamics and the onset of pallor, which allowed the team to suspect a hemorrhagic complication. We noted an ecchymosis and necrotic liver as a whole with hemorrhagic infiltration of the gallbladder and the falciform ligament without loss of hepatic continuity or hematoma. We were unable to do the imaging because of the extreme urgency, which did not allow for a delay in treatment. Packing is necessary in the event of rupture of the subcapsular hematoma when the team cannot do anything to control the bleeding⁹, but in our case, we carried it out as a precaution given that the hemodynamics were unstable at the risk of rebleeding after stabilization of blood pressure. We did not find the necessary drainage, given that we had the possibility of doing an ultrasound to exclude a hematic collection in the immediate aftermath. We proceeded with a rapid delivery given the severity of the disease and this made it possible to limit the worsening as described by the other authors^2,8,10.

We point out that during the cesarean section, we did not have the reflex to check the condition of the liver. In the event of a hepatic complication, mortality in 50% of cases is reported¹. An increase in transaminase concentrations, associated with fever or anemia, is frequently observed. Hepatic infarctions and unruptured hematomas usually heal without sequelae. Treatment of ruptured hematoma combines correction of hemorrhagic shock, emergency uterine evacuation (delivery), and laparotomy. Hemostasis of hepatic hemorrhage may require arterial embolization or surgery^1,11,12. In our patient, the evolution was favorable within 48 h, corroborating the literature, which goes in the same direction if the treatment is rapid by the termination of the pregnancy and close monitoring by the clinic, imaging, and biology in an environment. In the treatment of HELLP syndrome, the need for corticosteroid therapy and plasmapheresis is currently recognized because this treatment significantly reduces maternal mortality^9,13.

Specifically, in the present case, intraoperative hemorrhage from the infarcted liver posed a high risk of uncontrollable bleeding and further coagulational dysfunction. Additionally, managing the patient’s hypovolemic shock complicated anesthesia and surgical decisions. Limited preoperative imaging, such as the unavailability of CT or MRI, and the delays in getting them done at a resource poor setting further complicated the diagnosis and intraoperative planning. The fragile liver tissue in this setting was prone to tearing, which made the surgical manipulation delicate and increased the risk of further damage. The availability of blood products heightened the difficulty of performing complex procedures safely.

The case of hemorrhagic hepatic infarction in severe pre-eclampsia aligns with existing literature in several key aspects but also highlights certain deviations. Hepatic complications in pre-eclampsia, particularly when associated with HELLP syndrome, are well-documented, though hemorrhagic hepatic infarction remains exceedingly rare. Most reports in the literature describe hepatic involvement in the form of elevated liver enzymes, subcapsular hematomas, or liver rupture, with hepatic infarction being much less frequently encountered. In alignment with the literature, this case occurred in the third trimester, a period when pre-eclampsia-related hepatic complications are most commonly reported due to the progression of microvascular injury and coagulopathy^8,9,13.

The literature also supports the idea that hepatic infarction in pre-eclampsia is driven by vasospasm, endothelial dysfunction, and microthrombi formation. Similar to other documented cases, the patient presented with hypertension, epigastric pain, and elevated liver enzymes, symptoms typical of hepatic complications in pre-eclampsia. However, this case differs in the absence of classical HELLP syndrome markers—such as significant thrombocytopenia or overt hemolysis—leading to the suspicion of hemorrhagic hepatic infarction being made intraoperatively, rather than preoperatively through imaging or laboratory markers^8,9.

The challenges faced in diagnosing and managing the condition without advanced diagnostic tools, as in this case, are echoed in the literature from resource-limited settings, where imaging like CT or MRI is often unavailable. While timely surgical intervention and liver packing, as seen here, are established measures for managing hepatic complications, this case underscores the critical role of clinical acumen in regions with limited access to modern diagnostics. The favorable outcome, despite the resource constraints, reflects the importance of rapid surgical management, which aligns with literature emphasizing the significance of early intervention to prevent liver rupture, ongoing hemorrhage, and potential maternal mortality^8,9,13.

In contrast to more comprehensive cases reported in developed settings, where access to advanced diagnostics allows for early detection and treatment of hepatic complications, this case demonstrates the necessity of relying on clinical findings and emergency surgery, illustrating both the limitations and successes of managing such complex conditions in under-resourced environments¹³.

Recommendations

Early diagnosis and regular monitoring of blood pressure, liver function tests, and protein levels in urine are essential in detecting pre-eclampsia-related complications, including hepatic infarction. Imaging techniques like CT or MRI should be used when liver involvement is suspected, though access is limited in some regions. Timely delivery is crucial, particularly by emergency cesarean section, to prevent further complications. Surgical intervention, including liver packing, may be necessary for hemorrhagic infarction. Postoperative care, involving intensive monitoring and multidisciplinary management, is vital for recovery. Strengthening medical capacity and further research are needed, especially in under-resourced areas, to improve outcomes.

Conclusion

Severe pre-eclampsia, a condition affecting women in the last two trimesters of pregnancy, is rarely complicated by hemorrhagic hepatic infarction. However, when such complications occur, they demand immediate intervention, with termination of pregnancy often being essential to improve maternal outcomes. Timely diagnosis and management are critical in preventing severe complications and improving the prognosis, which is generally favorable after delivery. This case highlights the importance of early clinical recognition of hemorrhagic hepatic infarction, even in resource-limited settings where access to advanced medical equipment is scarce, underscoring the need for prompt and effective medical response to enhance survival.

Ethical approval

Not applicable.

Consent

Written informed consent was obtained from the patients for publication and any accompanying images. A copy of the consent is available for review by the Editor-in-Chief of this journal on request.

Source of funding

Not applicable.

Author contribution

All authors are contributed equally.

Conflicts of interest disclosure

The authors declare no conflict of interest.

Research registration unique identifying number (UIN)

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Guarantor

Antoine O. Onanga.

Data availability statement

Not applicable.

Provenance and peer review

Not commissioned, externally peer-reviewed.