Spontaneous liver rupture in pregnancy

Spontana rupture jetre u trudnoći rijedak je klinički entitet. Predstavlja po život opasno stanje koje se najčešće javlja kao komplikacija preeklampsije, eklampsije odnosno HELLP sindroma. Većinom se ruptura jetre javlja kod više rodilja starijih od 30 godina, u trećem trimestru trudnoće ili unutar prvih 24 sata postpartalno. U 75% slučajeva riječ je o izoliranoj ozljedi desnog jetrenog režnja. Lijevi jetreni režanj zahvaćen je u 11% slučajeva dok je bilateralna ozljeda prisutna u 14% slučajeva rupture jetre. Postoji široki spektar simptoma i znakova kojima se rupture jetre u trudnoći može prezentirati. Kod određenih bolesnica prisutni su blaži simptomi poput bolova u epigastriju, mučnine, povraćanja, u usporedbi sa naglo nastalom hipotenzijom i hemoraškim šokom kod bolesnica u akutnoj fazi bolesti. Jedan od prvih opstetričkih postupaka kod rupture jetre je hitno dovršenje trudnoće carskim rezom. Klasični Pfanenstiel rez nije prikladan jer ne omogućuje dobru vizualizaciju gornjeg abdomena. Za pristup u trbušnu šupljinu stoga se preporuča medijana laparotomija. Većina bolesnica s rupturom jetre u trudnoći zahtijeva kirurško liječenje. Najčešće primjenjivani postupci u liječenju trudnica s rupturom jetre su: 'packing' jetre, hemostaza šavovima, embolizacija jetrene arterije i transplantacija jetre. Zbog niske incidencije te visoke stope mortaliteta ovakvo stanje izazov je za svakog kliničara te zahtijeva preciznu i brzu dijagnostiku u kombinaciji s odgovarajućim modalitetima liječenja kako bi se osigurao najpovoljniji ishod za majku i fetus.Spontaneous hepatic rupture is a rare but life threatening condition of pregnancy that is mostly associated with preeclampsia, eclampsia, or a HELLP syndrome. In most cases, a liver rupture occurs in the third trimester of pregnancy or within the first 24 h postpartum. It occurs more often in the multiparous women above the age of 30. In 75 % of the cases, it develops as a solitary injury of the right liver lobe, in 11 % of the left liver lobe, and a bilateral injury in 14 %. There is a wide variation in the clinical presentation and severity of the symptoms and signs of hepatic hemorrhage/rupture. Some patients present with very mild symptoms such as epigastirc pain,nausea and vomiting prior to sudden and massive circulatory collapse. If a rupture occurs during pregnancy, delivery of the fetus by caesarean section is one of the first steps. A classical Pfannenstiel incision is, however, not suitable because the entire abdominal cavity cannot be explored unless a second upper abdominal incision is made. A median laparotomy is therefore the recommended approach because it has the advantage of visualizing the entire abdominal cavity, speed of execution, and less blood loss. Surgical treatment includes liver packing, hepatorraphy, hepatic artery embolisation and liver transplantation. Due to the low incidence and high mortality rates worldwide, this condition requires clinical suspicion, diagnostic accuracy, precise timing and efficacy in therapeutic resource utilization to reduce its high mortality and to offer satisfactory results to both mother and newborn