Managing Life-Threatening Spontaneous Liver Rupture in Pregnancy: A Case Study

Introduction

Spontaneous liver rupture during pregnancy is a rare but life-threatening condition with high maternal and perinatal mortality rates [1,2]. While often associated with hepatic hemangiomas, metastases from choriocarcinoma, or other unknown causes, it is frequently linked to preeclampsia and HELLP syndrome [3] These conditions are thought to compromise hepatic microvasculature, leading to subcapsular hematoma formation and subsequent rupture. Pre-existing liver lesions or vascular abnormalities may also predispose patients to this catastrophic event [4].

From a diagnostic perspective, the condition is challenging due to its non-specific symptoms, such as epigastric pain or hypovolemic shock, which overlap with other pregnancy-related complications [5]. Prompt diagnosis is critical, often requiring imaging techniques such as ultrasound or CT to confirm the presence of subcapsular hematomas or active bleeding [6].

In this case report, we present the successful management of spontaneous liver rupture in a 35+5-week pregnant woman. This case highlights the interplay of early diagnosis, surgical management, and intensive postoperative care in achieving favorable outcomes, even in the absence of typical predisposing factors like preeclampsia or HELLP syndrome.

Case Report

A 34-year-old pregnant woman, gravida 2 para 1, at 35+5 weeks gestation, presented with severe epigastric pain, nausea, and vomiting. She had a history of a cesarean section 2 years prior due to cephalopelvic disproportion (CPD) and underwent a laparoscopic appendectomy 1 year ago. Her ante-natal care (ANC) began at 6 weeks with 9 regular visits, and her pregnancy was otherwise uneventful. Her blood tests at 31 weeks showed Hb of 12 g/dL and platelets of 269 000 cells per microliter (cells/µL). She was diagnosed with alpha-thalassemia, with normal blood sugar, blood group B Rh positive, and 10-kg weight gain during pregnancy. Blood pressure ranged from 126/81 to 108/70 mmHg, and urine tests were consistently negative.

At 35+5 weeks, the patient was admitted to a private hospital with severe epigastric pain and vomiting, without diarrhea or fever. Initial vital signs showed BP 122/75 mmHg, HR 96 bpm, and RR 20 breaths/min. She was diagnosed with GERD, but her symptoms persisted despite treatment. For the suspected GERD or gastritis, she was initially treated with proton pump inhibitors (PPIs) and antacids. However, her symptoms did not improve with this treatment, and her clinical condition deteriorated, prompting further evaluation. Laboratory test results revealed WBC count 11 120 cells/µL, platelets 253 000 cells/µL, and normal liver enzymes and electrolytes. Due to worsening symptoms, she was referred to Siriraj Hospital.

At Siriraj Hospital, the fetal heart rate was 148 bpm, with contractions every 3–4 minutes. The epigastric pain was severe, scoring 10/10. Despite treatment for suspected GERD or gastritis, her condition deteriorated, with vomiting and early signs of shock (PR 150 bpm, BP 130/90 mmHg). Suspecting a ruptured abdominal aortic aneurysm (AAA), an emergency cesarean section was performed. Given the patient’s clinical deterioration and the urgent need for intervention, the decision was made to proceed directly to surgery for diagnostic and therapeutic purposes, as imaging might not have provided immediate actionable information.

A Pfannenstiel incision revealed 1300 mL of blood in the abdomen. The male newborn weighed 2810 g with Apgar scores of 5 and 7. No uterine rupture was noted. Intraoperatively, a vascular surgeon was consulted, and a normal aortic ultrasound ruled out AAA causes. The hepatobiliary surgeons were consulted due to the high clinical suspicion of a liver rupture or other significant liver pathology. Their involvement was critical for the surgical management of the liver mass and the large amount of blood. A second upper midline incision was made, which revealed 1500 mL of intra-abdominal blood clots beneath the liver capsule. A large liver mass, measuring 10×10 cm, was found with a posterior capsular tear at the left lateral segment (Figure 1). Packing was done to control the bleeding, and the patient was transferred to the ICU for further investigation and management.

A CT scan postoperatively confirmed a large subcapsular hematoma (9.9x4.6x9.1 cm) at hepatic segments 2/3, with suspected bleeding from hepatic segment 2, corresponding to the liver capsular tear (Figures 2, 3). No active extravasation or pseudoaneurysm was found, and no definite liver mass was visible on the CT scan (Figure 4).

The patient was monitored in the ICU, and a second surgery was performed the following day. Intraoperatively, a subcapsular hematoma was observed at the left lateral segment (Figure 5), along with moderate blood clots in the subdiaphragmatic space (Figure 6). The liver surface appeared smooth on the right lobe. A left lateral sectionectomy was performed, and a Jackson-Pratt drain (JPD) was placed in the surgical bed. The patient recovered well postoperatively and remained stable throughout her ICU stay.

The patient recovered well postoperatively, and her JPD was removed on day 3. Both the mother and baby were stable and discharged home together on day 7. The mother was able to successfully breastfeed her newborn.

Discussion

DIAGNOSTIC CHALLENGES AND IMPORTANCE OF ABDOMINAL EXAMINATION:

In pregnant patients presenting with epigastric pain, a thorough abdominal examination is essential to distinguish between benign conditions such as gastroesophageal reflux disease (GERD) or gastritis and potentially life-threatening pathologies, including liver rupture. Although epigastric symptoms are non-specific and can overlap with common pregnancy-related discomforts, careful attention to clinical signs, such as tenderness, rigidity, or rebound tenderness, can provide critical diagnostic clues.

In this case, the patient exhibited significant abdominal tenderness without rebound or rigidity, findings that initially suggested a less severe etiology. However, given the persistence of symptoms and lack of resolution with empirical treatment, the importance of revisiting the abdominal examination cannot be overstated. Such reassessment may raise suspicion for more serious intra-abdominal pathology, prompting timely imaging studies to identify conditions such as subcapsular hematoma or hemoperitoneum, as seen in this case.

PATHOGENESIS AND DIAGNOSTIC CHALLENGES:

The pathogenesis of liver rupture typically involves subcapsular hematoma formation, often driven by microvascular injury and altered hepatic perfusion. HELLP syndrome and preeclampsia are frequently implicated due to endothelial dysfunction and platelet aggregation, which compromise hepatic micro-vasculature [12]. Non-alcoholic fatty liver disease (NAFLD), associated with obesity and metabolic changes during pregnancy, has also been suggested as a contributing factor [13]. In this case, the patient had a high BMI of 31 kg/m2, indicating class I obesity, raising the possibility of underlying NAFLD as a contributing factor to hepatic fragility. While she exhibited no overt signs of HELLP syndrome or preeclampsia, obesity-related metabolic stress might have increased her vulnerability to hepatic complications.

Unique to this case is the absence of HELLP syndrome, preeclampsia, or other common predisposing factors. On examination, the patient exhibited significant abdominal tenderness without rebound, guarding, or rigidity. Symptoms such as severe abdominal pain, nausea, and vomiting are non-specific and can mimic other pregnancy-related conditions, complicating diagnosis [14]. Prompt imaging, particularly ultrasound and CT, is crucial for identifying subcapsular hematomas or active bleeding. A high index of suspicion is essential to ensure timely intervention [12].

MANAGEMENT AND OUTCOMES:

The primary objective in managing liver rupture is immediate hemorrhage control. In this case, perihepatic packing was performed to stabilize the patient and manage active bleeding. Subsequent imaging confirmed the diagnosis and guided the decision for partial liver resection to remove compromised hepatic tissue [15]. Multidisciplinary coordination, including hepatobiliary surgeons, was critical for effective management and optimizing surgical outcomes.

UNIQUE CASE FEATURES:

A distinguishing feature of this case is the absence of any underlying conditions commonly associated with spontaneous liver rupture, such as HELLP syndrome, preeclampsia, or a history of cancer. Unlike many reported cases that link liver rupture to malignancies or pharmacological hepatotoxicity, this patient was otherwise healthy, with no history of adrenal carcinoma or mitotane therapy. This highlights the rarity of liver rupture occurring in the context of an otherwise un-complicated pregnancy, posing significant diagnostic and management challenges.

IMPLICATIONS FOR PRACTICE:

The patient’s elevated BMI suggests a possible link between non-alcoholic fatty liver disease (NAFLD) and spontaneous liver rupture in pregnancy, even in the absence of systemic conditions such as HELLP syndrome. This underscores the importance of early recognition, timely intervention, and a multidisciplinary approach when managing acute abdomen symptoms in obese pregnant patients.

INTEGRATION WITH LITERATURE:

Previous studies have reported that NAFLD can contribute to hepatic complications in pregnancy, particularly in patients with metabolic risk factors such as obesity. This case aligns with existing literature suggesting that obesity-related liver disease can increase susceptibility to severe complications, including spontaneous rupture. Early diagnosis and intervention are critical for improving maternal and fetal outcomes [14].

FUTURE DIRECTIONS:

Research should focus on elucidating the mechanisms underlying liver rupture in atypical cases, particularly the potential contributions of obesity-related liver disease and metabolic stress. Expanding our understanding of these pathways could refine diagnostic approaches, broaden differential diagnoses for acute abdomen during pregnancy, and improve therapeutic outcomes.

Conclusions

In conclusion, spontaneous liver rupture in pregnancy is a rare but life-threatening condition. Prompt imaging and intervention, alongside a multidisciplinary approach, are key to improving outcomes. Early packing, followed by imaging to confirm the diagnosis and prepare for surgery, is a critical management strategy.