Surgical treatment of HELLP syndrome-associated liver rupture -- an update

In some 2% of the cases of the HELLP syndrome, severe spontaneous bleeding into the liver accompanied by haemorrhagic liver cell necrosis and rupture of the organ occurs and represents one of the main cause of death. On the basis of our own experience with four cases, a review of the literature is presented with particular focus on a therapeutic concept based on appropriate surgery. Within a MEDLINE search covering the period 1990-1999, the case reports of this kind of liver complication in the literature were analysed in terms of clinical course and outcome.In addition to our own four patients, a total of 49 cases with rupture of the liver were found in the literature. Despite surgical interventions, HELLP syndrome-associated liver rupture carried a mortality of 39%. Most patients died of haemorrhagic shock and organ failure. In order to improve survival, patients with ruptured liver or hepatic failure should be transferred to a centre with the necessary experience in liver surgery including liver transplantation. An interdisciplinary approach is required, including the use of temporary packing of the liver to control the bleeding, and during the further course of the condition, possibly even liver transplantation, as in one of our own cases.     

Natural history of twin-twin transfusion syndrome

OBJECTIVE: To determine the natural history of pregnancies with twin-twin transfusion syndrome (TTTS). STUDY DESIGN: All cases of TTTS at our institution since 1991 and in a MED-LINE search since 1966 were retrospectively reviewed. The prenatal diagnosis of TTTS required the presence of monochorionic/diamniotic placentation (absence of twin-peak sign, thin membrane, single placenta, same sex) and of polyhydramnios (largest pocket > 8 cm) in one sac and oligohydramnios (largest pocket < 2 cm or stuck twin) in the other. Only cases diagnosed at < or = 28 weeks were included. Upon diagnosis, all patients were counseled as to the availability, risks and benefits of serial amniocentesis, laser therapy, septostomy, umbilical cord ligation, and other medical and surgical interventions. RESULTS: Of 29 pregnancies identified at our institution with the above strict criteria for TTTS, 5 (17%) declined in utero therapy and were managed expectantly. The mean gestational age at presentation was 19.2 weeks (range, 16-28) and at delivery, 33.8 weeks (range, 22-41). Four (40%) of the twins survived past the neonatal period, and of the three with follow-up, all are free of neurologic sequelae despite the death in utero of their cotwin. From the literature, 136 fetuses with TTTS as defined above and managed expectantly were identified; 37 (27%) survived; 75% (9/12) of survivors with follow-up are neurologically normal. The most recent four studies have reported survival of untreated cases of 50% (17/34) when diagnosed at < or = 26 weeks and of 63% (20/32) when diagnosed at < or = 28 weeks. CONCLUSION: The perinatal survival of TTTS pregnancies managed without in utero procedures is approximately 30% overall and 63% in the four most recent series when diagnosed at < or = 28 weeks. The success of in utero therapeutic intervention should be assessed by randomized studies or at least compared to that in similar cases managed without such intervention.     

Adnexal torsion

We performed a retrospective audit of 24 cases of adnexal torsion managed at National Women's Hospital from 1996 to 1997 inclusive. There have been several reports in the recent literature of ovarian conservation in cases of ovarian infarction secondary to torsion in women desiring further fertility (1-3). In our review 50% (12 of 24) of patients were treated by oophorectomy or salpingo-oophorectomy and most of these women desired further fertility. In spite of torsion being suspected in 73% (17 of 24), the time interval between admission and operation varied from 0.5 to 52 hours with a mean of 8 hours; 46% (11 of 24) were treated laparoscopically without recourse to laparotomy. As expertise increases, we consider that adnexal torsion will be increasingly managed laparoscopically. These results suggest that more urgent surgery should be scheduled if ovarian torsion is suspected, and in view of recent reports in the literature greater consideration should be given to conservation of infarcted ovaries if further fertility is required.     

Laparoscopic management of an 11-week rudimentary uterine horn pregnancy using extracorporeal Roeder knot to secure the dilated vascular pedicle

Pregnancy in a uterine rudimentary horn carries a high risk of uterine rupture with severe and potentially lethal intra-abdominal haemorrhage. There is now growing evidence that this condition can be safely managed by minimally invasive surgery. We report a case of an unruptured 11-week rudimentary horn pregnancy that was diagnosed and treated laparoscopically. We have performed a literature review using PubMed, Embase and Cochrane Database of Systematic Reviews to identify relevant cases and draw conclusions with regards to their management. We have collated 20 published cases of rudimentary horn pregnancies that were managed by laparoscopy. The surgical technique appears consistent among these cases with few variations. In advanced gestations, feticide may need to be performed. Morcellation has been shown to be possible without compromising patient safety from trophoblast spill. The possibility of uncommon presentations such as duplicated or absent ureter should be taken into account. Extracorporeal Roeder knot can be used safely to secure unusually dilated vascular pedicles. Overall, laparoscopy appears to be as safe as and potentially superior to laparotomy for the management of rudimentary horn pregnancies.     

Liver capsule rupture in eclampsia: treatment with hepatic artery embolisation

Introduction: Spontaneous hepatic rupture associated with pregnancy is a rare and very serious complication associated with eclampsia or pre-eclampsia. Case report: We report a case of hepatic rupture following eclampsia at 27 weeks gestation which was managed successfully by selective hepatic artery embolisation as an adjunct to liver packing. Conclusion: Selective embolisation of the hepatic artery is an effective means of therapy for hepatic artery bleeding and is an adjunct to liver packing in spontaneous hepatic rupture in eclamptic patients.     

从胎儿期延续至新生儿期的心房扑动三例报告(附文献复习)

目的 探讨新生儿心房扑动(简称房扑)的起病、病因、治疗及预后. 方法回顾分析2005年至2007年我院新生儿病房收治的3例房扑患儿的起病、治疗和预后,并对相关文献进行复习和总结. 结果 3例患儿药物治疗有效,随访结果预后较好,分别随访至8个月和2岁,房扑未复发. 结论宫内胎儿房扑应积极给孕母治疗,新生儿房扑可选择药物治疗、食道心房超速起搏及直流电复律等,预后较好.     

Laparoscopic management of tubal pregnancy.

Early detection of an unruptured tubal pregnancy has been made possible by the recent use of vaginal sonograms, thus more conservative management can be undertaken. From February 1989 to June 1989, we attempted to treat tubal pregnancies by surgical laparoscopy at the Keelung Chang Gung Memorial Hospital. Fourteen consecutive cases of tubal pregnancy were treated by surgical laparoscopy with a success rate of 70% (10 out of 14). Six of the 10 successfully treated cases were managed conservatively. Use of the laparoscope may be considered as a major trend towards conservative tubal pregnancy treatment, such as salpingotomy for women with an unruptured ectopic pregnancy who want to conserve fertility. These 10 cases of tubal pregnancy benefited enormously from the surgical laparoscopic technique which led to a shorter hospital stay, early ambulation and resume point of normal activities within days. No complications related to surgical laparoscopy were noted in this series. Our conclusion is that surgical laparoscopy should be considered an alternative to laparotomy for the treatment of tubal pregnancy.     

Spontaneous hepatic rupture of pregnancy. A report of four cases and medical literature review

The spontaneous liver rupture associated with preeclampsia is a potential life threatening condition that requires a multidisciplinary team approach. There are near 200 cases reported in the world literature. This paper presents four cases of liver rupture associated with preeclampsia, three of which were consecutive with only two days apart, describing the clinical features and the therapeutic approaches. We also discussed about the mortality, which occurred in one of our cases, and perinatal mortality that affected one newborn and another one had neonatal encephalopathy secuelae. Three of the cases were managed in a surgical manner, one of them also with selective hepatic artery embolization meanwhile another one received conservative management. It is important to suspect this pathology in the preeclamptic patient, especially if she develops HELLP syndrome, in order to establish opportune diagnosis and treatment with a team including the intensive care, surgery and obstetrical staff.     

Post-cesarean vesicouterine fistula (Youssef syndrome): report of two cases

Vesicouterine fistula (VUF) is a rare complication of cesarean section. We present two cases of VUF that were successfully managed by transperitoneal surgical repair. The first case presented with the Youssef classical triad: cyclical hematuria (menouria), amenorrhea and urinary continence, while the second case presented with total urinary incontinence with normal menstruation. In both cases, diagnosis was confirmed by hysterogram and both were managed by transperitoneal surgical repair. The clinical features, etiologic factors, diagnostic procedures and treatment modalities are discussed in relation to the case and others as reported in the literature.     

Two-stage surgical management of Budd-Chiari syndrome with obstruction of the inferior vena cava

A two-stage approach to the surgical management of acute Budd-Chiari syndrome complicated by inferior vena caval obstruction was advocated by our group in 1984. This entailed initial hepatic decompression by suprahepatic, mesoatrial shunt, with subsequent takedown of the mesoatrial shunt combined with conversion to a short infrahepatic, portacaval shunt. We report herein the late follow-up results for two patients managed in this manner. While both patients are alive and doing well, both of the courses have been complicated by stenosis of the inferior vena cava. The cause is unclear but probably relates to fibrosis at the hepatic venous orifices. Management was by percutaneous balloon dilation, which relieved the recurrent hepatic congestion. This cautions others considering this approach to provide careful longitudinal follow-up study for such patients.     

Whole abdomen radiation therapy after a short chemotherapy course and second-look laparotomy in advanced ovarian cancer

From April 1983 through December 1989, 42 consecutive patients with diagnosis of epithelial ovarian carcinoma were initially managed by aggressive surgery and three courses of endoperitoneal cis-platinum-based chemotherapy followed by an alternating combination chemotherapy and second-look laparotomy. Patients with residual tumor less than or equal to 2 cm subsequently received whole abdominal radiation therapy (WAR). Twenty-eight patients (42% with no residual disease, 21% with microscopic disease, and 36% with residual disease less than 2 cm) were eligible for WAR. WAR was delivered using an open-field technique up to 22 Gy in 20 fractions followed by a pelvic boost of 18 Gy in 10 fractions. The kidneys were shielded posteriorly at 1100 cGy; hepatic shields were not added. One patient did not complete WAR for lung metastases after 5 radiotherapy fractions. The complete treatment program lasted 8 months (range, 6.8-11). The median follow-up of the 28 patients entered into the study was 50 months. Eight patients are alive and disease-free at 5 years. The overall and disease-free survival rates at 5 years are 45 and 30%, respectively. All but 2 patients relapsed within the abdominopelvic cavity and 3 developed brain metastases. Toxic effects, during WAR, required treatment interruption in all but 4 patients: 3 developed a small bowel obstruction requiring surgery and 1 died of surgical complications in complete remission. The poor disease-free survival and the severe toxicity encountered have been valid indications that WAR should be discontinued as a treatment modality in advanced ovarian cancer at our department.     

Laparoscopic management of hepatic endometriosis: report of two cases and review of the literature

Hepatic endometriosis is rare. Only 15 cases have been reported in the literature. All 15 were treated by laparotomy. We report two additional cases of hepatic endometriosis managed for the first time laparoscopically. Endometriosis is a progressive disease especially in women of reproductive age. One of the differential diagnoses of liver endometriosis is malignancy. Currently, there are no reports in the literature regarding complications arising from the progression of hepatic endometriosis. However, this lack of evidence does not deny its existence.     

Uterine rupture on unscarred uterus following labor induction for 2(nd) trimester termination of pregnancy with oral misoprostol: conservative management

Uterine rupture occurred at 25 weeks amenorrhea during pregnancy termination by misoprostol for fetal polykystosis. Rupture occurred on an unscared uterus after administration of significant accumulated doses of oral misoprostol (1400 g). The patient was managed conservatively and carried a subsequent pregnancy six months after the intervention. This accident occurs in 0.1% to 1% of the cases (0.59% in our experience) and only rare cases have been attributed to the use of misprostol. Clinicians should be particularly careful in patients with prior cesarean section or a weakened uterus.     

Abdomino-pelvic packing to control severe haemorrhage following caesarean hysterectomy.

Surgically uncontrollable peri-operative obstetric haemorrhage associated with coagulopathy, developed in five women who were managed by emergency caesarean hysterectomy. All women had a morbidly adherent anterior placenta praevia and a previous lower segment caesarean section scar. Conventional medical and surgical therapy to control bleeding from pelvic and abdominal raw surfaces were unsuccessful. Abdomino-pelvic packing was performed with 10-12 dry laparotomy pads applied firmly over bleeding sites. The abdomen was closed after observation of the cessation of bleeding for 5-10 minutes. Following correction of coagulation and haemodynamic disorders relaparotomy for pack removal was performed 34-48 hours later. One patient developed small bowel obstruction on the 5th post-operative day, however, there was no long term gynaecological morbidity in any of the cases. Abdomino-pelvic packing achieved complete haemostasis in all of the five women which we believe may have been impossible using alternative measures.     

Actinomycose pelvienne : est-ce prévisible ?

ObjectivesPelvic actinomycosis is a rare disease that can be diagnosed before, during or after surgical treatment of a suspected ovarian tumor, a suspected bowel obstruction, or acute peritonitis. The possibility of early detection of pelvic or abdominal abscess related to was evaluated through a personal series and literature review.Patients and methodsOur series of 11 cases of severe abdominal or pelvic actinomycosis is related and compared to 58 cases reported in the literature.ResultsSeven patients in this series were diagnosed with pelvic inflammatory disease and acute peritonitis with or without bowel obstruction, and four women were diagnosed after surgical treatment for suspected ovarian cancer. Fifty-two of the 58 cases of reproductive tract actinomycosis reported in the literature review and all our cases were associated with prolonged use of an intrauterine contraceptive device with a mean of eight years. The contribution of pelvic ultrasound and angioscanner in evaluating these patients should not be underestimated and MRI may be useful in some cases as well. Early diagnosis based on Actinomyces-positive cervical smears or abscess aspiration was accomplished only once in our series and was rare in literature. A histopathologic diagnosis during laparoscopy or laparotomy could avoid more difficult and extensive surgery. In our series of 11 patients, five women required abdominal surgery, five required salpingo-oophorectomy and three required hysterectomy. All women required surgical intervention. Effective treatment combined long antibiotic therapy with surgery. Correct preoperative diagnosis is rare but if achieved, long-term treatment with penicillin for at least two months and sometimes up to a year may completely eradicate the infection. Surgery may still be necessary to improve medical treatment or to resolve pelvic abscesses.Discussion and conclusionAny pelvic abscess occurring in a woman with a history of long-term use of an intrauterine device should be considered as possible pelvic actinomycosis. If there is no fever in association with an atypical adnexal tumor, frozen section should be obtained during surgery to rule out the diagnosis of actinomycosis.     

“Hepatic rupture in preeclampsia and HELLP syndrome: A catastrophic presentation”

The objective of index study is to review the available literature on hepatic rupture or hematoma in hypertensive disorders of pregnancy to find the incidence, associated risk factors, clinical presentation, mode of management and feto-maternal outcome. Electronic database was searched using hepatic rupture or hematoma in pregnancy, preeclampsia, eclampsia, and HELLP syndrome (Hemolysis, EL: elevated liver enzymes, LP: low platelet count) as key words and literature published since January, 2000 to December, 2018 which met the inclusion criteria was reviewed. A total of 56 articles were reviewed describing 93 cases of hepatic hemorrhage in hypertensive disorders of pregnancy. Treatment varied from conservative management to abdominal packing, hepatic artery embolization, and partial hepatectomy to liver transplantation. Seven out of 93 patients with liver rupture met mortality and in one of them diagnosis was established on autopsy. Unawareness of the hepatic rupture in pregnancy by an obstetrician demands high index of suspicion for diagnosis and requires specialized, focused and exhaustive management for optimal feto-maternal outcome. Laparotomy and perihepatic packing is a viable option in patients with unstable vitals and is feasible even in limited resource settings.Short interval between diagnosis and management may enhance the feto-maternal survival rate and prevent further morbidity or mortality.     

Choriocarcinoma following term gestation

The current study reviews post-term choriocarcinoma at the New England Trophoblastic Disease Center (NETDC) in order to expand knowledge of its clinical features. Between June 1965 and June 1981, 366 patients with persistent gestational trophoblastic disease were managed at the NETDC and 15 (4.1%) of these patients had choriocarcinoma following term pregnancy. Post-term choriocarcinoma has a propensity for early metastasis with frequent involvement of the liver and brain. Metastases were detected in 13 (86.7%) patients with post-term choriocarcinoma at the time of diagnosis. Seven patients (53.8%) with metastatic post-term choriocarcinoma had hepatic and/or cerebral involvement. Complete remission was achieved in both patients with nonmetastatic disease and in 8 (61.5%) patients with metastatic disease. When the time interval from the antecedent term delivery to diagnosis was less than 4 months, 7 (87.5%) of 8 patients achieved complete remission. The 5 patients who died from post-term choriocarcinoma all had hepatic and/or cerebral involvement. Patients with post-term choriocarcinoma should undergo a meticulous metastatic evaluation and if metastases are detected these patients should be treated with primary combination chemotherapy and with the selective use of irradiation and surgical therapy.     

Management and outcome of pregnancies complicated with adnexal masses

Our purpose was to evaluate the pathologic features and outcome of pregnancies that were complicated with adnexal masses and were managed surgically. A review of patients who had persistent adnexal masses during pregnancy and needed surgical removal of tumours was performed from January 1998 to April 2001. There were 14 cases of persistent adnexal masses identified among 2000 deliveries. There were 13 patients who had surgical interventions: nine (69.2%) had surgery during ongoing pregnancy (at mean gestational age 17±3.7 weeks), two (15.3%) with caesarean section, one (7.6%) after evacuation of missed abortion and one (7.5%) after delivery. Out of 13, ten (76.9%) were benign [mature cystic teratoma, six (46.9%); serous cyst adenoma, two (15.3%); mucinous cyst adenoma, one (7.6%); paratubal cyst, one (7.6%)] and three (23%) were malignant (one immature teratoma, one papillary cyst adenocarcinoma and one krukenberg tumour]. Both patients operated on after 24 weeks had preterm delivery. The worst outcome in the form of PPROM and preterm delivery at 28 weeks occurred in a patient who underwent emergency surgery. The incidence of malignancy was four- to fivefold greater in our series than reported in the literature. Ultrasound was unable to distinguish malignant cases. Pregnancy outcome was poorer if surgical intervention was done after >24 weeks and that, too, was done as emergency surgery. Received: 13 August 2001 / Accepted: 12 December 2001 Correspondence to N. Agarwal     

Control of nonhepatic intra-abdominal hemorrhage with temporary packing.

The use of temporary packing to obtain hemostasis has long been an adjunct for surgical procedures in the pelvic area and has recently become an acceptable approach to control hemorrhage resulting from hepatic injuries. In an unstable patient with coagulopathy and diffuse capillary bleeding, packing may be the easiest way to control intra-abdominal bleeding through the simple effect of tamponade. The patient can be re-explored after a period of stabilization, when a more definitive control of hemostasis can be undertaken. Herein, we report six patients with severe underlying disease states that contributed to massive intra-abdominal bleeding refractory to control by conventional means when temporary packing was used to control hemorrhage.     

The successful management of portal vein thrombosis after hepatic transplantation with a splenorenal shunt

Portal vein thrombosis is an infrequent complication after hepatic transplantation, but is quite dramatic when it occurs. It is usually managed by retransplantation with a significant mortality rate. We present a patient in whom portal vein thrombosis after hepatic transplantation was ultimately managed by a splenorenal shunt. The portal vein thrombosis was manifested by bleeding esophageal varices and, yet, normal hepatic function obviated the need for a new graft (one was not readily available). To the best of our knowledge, this is the first presentation of a patient with a transplant of the liver with acute portal vein occlusion and maintained hepatic function who has been successfully managed by a portosystemic shunt.