Dalhousie University, Halifax, NS, Canada.
J Med Case Rep. 2021 Dec 17;15(1):625. doi: 10.1186/s13256-021-03166-w.
Subcapsular hepatic hematoma is a rare and life-threatening complication of pregnancy. It is most commonly associated with severe preeclampsia and hemolytic anemia, elevated liver enzymes, and low platelets syndrome. Patients with subcapsular hepatic hematoma typically present with epigastric, right upper quadrant or shoulder pain, nausea and vomiting, and/or shortness of breath. Here we describe a patient with a classic pain presentation, a large unruptured hematoma, and an unusual postpartum course.
A 40-year-old gravida 1 para 0 Caucasian woman presented at 39 + 6 weeks gestational age with a 3-day history of new onset pain in an otherwise uncomplicated pregnancy. She described the pain along her right torso as severe, shooting, and sharp, but at times pleuritic in nature. She was found to have new onset preeclampsia and hemolytic anemia, elevated liver enzymes, and low platelets syndrome. Induction of labor was initiated and eventually she delivered by cesarean section. Her pain persisted in the postpartum period and abdominal computed tomography scan revealed a 16 cm subcapsular hepatic hematoma. Despite the hematoma being thin walled, conservative management was recommended by the general surgeon. She then re-presented on postpartum day 15 with tachypnea, dyspnea, and pleuritic chest pain. Secondary to the subcapsular hepatic hematoma, she then developed an infected and loculated, large pleural effusion. This required video-assisted thoracoscopic surgery before her eventual discharge home on postpartum day 21.
There should be high clinical suspicion of subcapsular hepatic hematoma in patients with persistent pain in the right upper quadrant of the abdomen. Urgent imaging to investigate for subcapsular hepatic hematoma is then indicated. Cesarean delivery without labor and treatment for severe preeclampsia should be undertaken if subcapsular hepatic hematoma is found. Conservative management and serial imaging are reasonable for the follow-up of a large, unruptured hematoma. Hepatic artery embolization should also be considered. Subcapsular hepatic hematoma may be complicated by infected pleural effusions and require video-assisted thoracoscopic surgery.
肝包膜下血肿是妊娠的一种罕见且危及生命的并发症。它最常与严重先兆子痫、溶血性贫血、肝酶升高和血小板减少综合征相关。肝包膜下血肿患者通常表现为上腹部、右上象限或肩部疼痛、恶心和呕吐以及/或呼吸急促。在此，我们描述了一位具有典型疼痛表现、大的未破裂血肿和不同寻常的产后病程的患者。
一位 40 岁的初产妇，白人，孕 39+6 周，在无并发症妊娠的基础上出现新的 3 天疼痛。她描述疼痛沿着她的右侧躯干，严重、放射状和锐痛，但有时性质为胸膜炎性。她被发现患有新发先兆子痫和溶血性贫血、肝酶升高和血小板减少综合征。开始引产，最终她行剖宫产分娩。她的疼痛在产后期间持续存在，腹部计算机断层扫描显示 16 厘米大的肝包膜下血肿。尽管血肿壁薄，但普外科医生建议保守治疗。然后，她在产后第 15 天再次出现呼吸急促、呼吸困难和胸膜炎性胸痛。由于肝包膜下血肿，她随后发展为感染性和分隔性大胸腔积液。这需要在她最终在产后第 21 天出院前进行电视辅助胸腔镜手术。
对于右上腹部持续疼痛的患者，应高度怀疑肝包膜下血肿。然后应立即进行影像学检查以确定是否存在肝包膜下血肿。如果发现肝包膜下血肿，应进行无分娩的剖宫产和严重先兆子痫的治疗。对于大的未破裂血肿，保守治疗和连续影像学检查是合理的。肝动脉栓塞也应考虑。肝包膜下血肿可能并发感染性胸腔积液，需要电视辅助胸腔镜手术。
