unusual. Sheehan and Lynch (1973) described that some degree As a third presentation, hemorrhagic infarction may extend of hepatic infarction accompanied hemorrhage in almost half of to form a hepatic hematoma. This in turn can extend to form women who died with eclampsia. hese findings corresponded a subcapsular hematoma that may rupture. Computed tomogwith reports during the 1960s that described elevated serum raphy (CT) scanning or magnetic resonance (MR) imaginghepatic transaminase levels. Along with the earlier observations greatly aids diagnosis (Fig. 40-9). Unruptured hematomasby Pritchard and associates (1954), who described hemolysis are probably more common than clinically suspected and areand thrombocytopenia with eclampsia, this constellation of more likely to be found with HELLP syndrome. Althoughhemolysis, hepatocellular necrosis, and thrombocytopenia was later termed HELLP syndrome.
FIGURE 40-8 Gross liver specimen from a woman with preeclampsia who died from aspiration Periportal hemorrhagic necrosis was seen microscopically. (Reproduced with permission from Cunningham FG: Liver disease complicating pregnancy. Williams Obstetrics, 19th ed. (Suppl 1), Norwalk, Appleton & Lange, 1993.) a woman with severe HELLP syndrome and right-upper quadrant pain. A large subcapsular hematoma (asterisk) is seen confluent with intrahepatic infarction and hematoma (arrowhead). Numerous flameshaped hemorrhages are seen at the hematoma interface (arrows).
FIGURE 40-11 Composite illustration showing location of cerebral hemorrhages and petechiae in women with eclampsia. Insert shows the level of the brain from which the main image was constructed. (Data from Sheehan, 1973.) once considered a surgical condition, current management of a hepatic hematoma usually consists of observation unless bleeding is ongoing. In some cases, however, prompt surgical intervention or angiographic embolization may be lifesaving. In one review of 180 cases of hepatic hematoma or rupture, 94 percent of afected gravidas had HELLP syndrome, and in 90 percent of the total, the capsule had ruptured (Vigil-De Gracia, 2012). The maternal mortality rate was 22 percent, and the perinatal mortality rate was 31 percent. In rare cases, liver transplantation is necessary (Hunter, 1995; Wicke, 2004).
Acute fatty liver of pregnancy is sometimes confused with preeclampsia (Nelson, 2013; Sibai, 2007a). It too has an onset in late pregnancy, and often there is accompanying hypertension, elevated serum transaminase and creatinine levels, and thrombocytopenia. However, the hallmark of acute fatty liver is significant liver dysfunction, and Table 55-1 (p. 1059) highlights these clinical diferences.
Last, no convincing data link pancreatic involvement with preeclampsia syndrome (Sheehan, 1973). Thus, the occasional case of concurrent hemorrhagic pancreatitis is likely unrelated (Lynch, 2015; Swank, 2012). In our experiences from Parkland Hospital, amylase levels were seldom elevated in preeclamptic women (Nelson, 2014a).