Preeclampsia and HELLP syndrome complicated by subcapsular liver hematoma and rupture | Canada News Media
Connect with us

Health

Preeclampsia and HELLP syndrome complicated by subcapsular liver hematoma and rupture

Published

 on

A previously healthy 30-year-old primiparous woman at 39 weeks’ gestation presented to her family physician with decreased fetal movement and was referred to triage at the labour and delivery unit. She had a 4-day history of right upper quadrant pain, cramping, nausea, vomiting and anorexia. She had no headache, visual changes, chest pain, dyspnea or edema to suggest preeclampsia. She was normotensive and tachycardic (heart rate 115 beats/min), and her cardiorespiratory examinations were unremarkable. Her abdomen was tender to palpation. Investigations revealed anemia with a hemoglobin level of 83 (normal range 120–160) g/L, thrombocytopenia, a normal creatinine level and an elevated protein-to-creatinine ratio (Table 1). Her hemoglobin level had been normal 8 weeks previously. Fetal heart rate abnormalities were seen with a sudden, severe and prolonged deceleration, and the patient was moved to the operating room for an emergency cesarian delivery.

Table 1:

Laboratory results of a 39-year-old woman (39 wk gestation) from initial presentation to 7 days postpartum

In the operating room, the patient had a hemoperitoneum of about 700 mL with unclear origin. We consulted the general surgery team emergently for intraoperative exploration, but the source of the hemoperitoneum was not identified. The team delivered a live female infant with Apgar scores of 9 at 1 and 5 minutes. The patient’s estimated blood loss was 1795 mL and she was resuscitated with packed red blood cells, platelets, tranexamic acid and activated fibrinogen. She also received a total of 9 g of intravenous magnesium sulfate (bolus and subsequent infusion), given the concern for evolving preeclampsia. Postoperative computed tomography (CT) of her abdomen and pelvis using a multiphasic abdomen protocol (unenhanced, arterial and portal venous phase) showed a large subcapsular liver hematoma (5.8 × 16.4 × 19.3 cm) with rupture through the hepatic capsule and extension along the right paracolic gutter into the pelvis (Figure 1) and a partially occlusive left gonadal (ovarian) vein thrombosis with extension into the left proximal renal vein. Three sites of active extravasation were identified and confirmed with digital subtraction angiography to originate from branches of the right hepatic artery. These sites were embolized successfully with a slurry of hemostatic absorbable gelatin powder.

<a href=”https://www.cmaj.ca/content/cmaj/195/45/E1543/F1.large.jpg?width=800&height=600&carousel=1″ title=”Coronal portal venous phase computed tomography scan of a 39-year-old woman after emergent cesarean delivery at 39 weeks’ gestation, showing subcapsular liver hematoma breaking through the liver capsule (arrows) and extension along the right paracolic gutter.” class=”highwire-fragment fragment-images colorbox-load” rel=”gallery-fragment-images-1873405200″ data-figure-caption=”

Coronal portal venous phase computed tomography scan of a 39-year-old woman after emergent cesarean delivery at 39 weeks’ gestation, showing subcapsular liver hematoma breaking through the liver capsule (arrows) and extension along the right paracolic gutter.

” data-icon-position data-hide-link-title=”0″>

Figure 1:

Coronal portal venous phase computed tomography scan of a 39-year-old woman after emergent cesarean delivery at 39 weeks’ gestation, showing subcapsular liver hematoma breaking through the liver capsule (arrows) and extension along the right paracolic gutter.

Postoperatively, the patient reported gradually resolving abdominal pain and distension. On postpartum day 2, she developed hypertension (peak blood pressure 151/100 mm Hg) and we started her on oral nifedipine XL (30 mg every 12 h). Based on clinical and laboratory abnormalities, we diagnosed preeclampsia complicated by hemolysis, elevated liver enzymes and low platelets (HELLP) syndrome (Table 1). We also diagnosed acute kidney injury after comparing her presenting creatinine level to her improved creatinine level postpartum in the absence of a pre-pregnancy baseline.

A CT scan on postpartum day 2 showed hypoattenuation consistent with hepatic infarction, likely as a complication of hepatic artery embolization, and stable appearance of both the hematoma and ovarian vein thrombosis (Figure 2). Her blood pressure was well controlled on oral nifedipine XL, and she was discharged on postpartum day 5 in stable condition.

<a href=”https://www.cmaj.ca/content/cmaj/195/45/E1543/F2.large.jpg?width=800&height=600&carousel=1″ title=”Coronal portal venous phase computed tomography scan of a 39-year-old woman on postpartum day 2 showing gonadal vein thrombus (arrows) and stable appearance of hepatic hematoma.” class=”highwire-fragment fragment-images colorbox-load” rel=”gallery-fragment-images-1873405200″ data-figure-caption=”

Coronal portal venous phase computed tomography scan of a 39-year-old woman on postpartum day 2 showing gonadal vein thrombus (arrows) and stable appearance of hepatic hematoma.

” data-icon-position data-hide-link-title=”0″>

Figure 2:

Coronal portal venous phase computed tomography scan of a 39-year-old woman on postpartum day 2 showing gonadal vein thrombus (arrows) and stable appearance of hepatic hematoma.

Three weeks postpartum, the patient was seen in the obstetric internal medicine clinic. Her blood pressure ranged from 110 to 120/60 to 80 mm Hg and nifedipine was stopped. Eight weeks postpartum, she remained normotensive.

Discussion

Hypertensive disorders of pregnancy, including severe manifestations such as preeclampsia, are increasingly common, with a reported doubling in prevalence between 2000 and 2018 in the United States.1 These disorders exist on a spectrum, including chronic or pre-existing hypertension, gestational hypertension and preeclampsia, with further characterization based on associated complications such as HELLP syndrome. According to the most recent guideline from the Society of Obstetricians and Gynecologists of Canada (SOGC), preeclampsia is diagnosed based on when hypertension is present with any one or more of new proteinuria; an adverse condition affecting the central nervous system, cardiorespiratory, hematologic, renal, hepatic or fetoplacental systems; or severe end-organ complications (SOGC Guideline No. 426 includes full diagnostic criteria).2 The syndrome of HELLP is an uncommon complication in pregnancy, affecting 1% of pregnancies but occurring in 10%–20% of patients who develop preeclampsia.3 It is typically associated with hypertension; however, 10%–20% of patients are normotensive. 4 Our patient met criteria for both preeclampsia (based on her elevated blood pressure and multiple adverse conditions and complications) and HELLP (based on evidence of hemolysis, elevated liver enzymes and low platelets), complicated by subcapsular liver hematoma. The initial biochemical abnormalities may have been explained by hemorrhage and prerenal acute kidney injury with intravascular depletion. However, the evolution of worsened anemia, thrombocytopenia, elevated liver enzymes and evidence of hemolysis, in parallel with development of hypertension, was most consistent with a unifying diagnosis of severe preeclampsia and HELLP syndrome, with associated complications of each including acute kidney injury, subcapsular liver hematoma and thrombosis.

Subcapsular liver hematoma is an uncommon complication of HELLP syndrome, reported in less than 2% of pregnancies with HELLP syndrome.5 It can progress to liver rupture or infarct, which can have devastating consequences for both the patient and baby if not promptly recognized and managed.5 Patients can present with dyspnea; shoulder, back or epigastric pain; anorexia; or nausea and vomiting, as was the case for our patient.5 Our patient was managed collaboratively by specialists in obstetrics and gynecology, general surgery, interventional radiology and obstetric internal medicine from an operative and medical perspective, given the atypical presentation, severe manifestations requiring emergent intervention and incidental finding of partially occlusive gonadal vein thrombosis.

The management options for subcapsular liver hematoma range from a conservative approach (i.e., hemodynamic support, transfusion and reversal of coagulopathy), to minimally invasive transcatheter hepatic artery embolization, to surgical intervention with packing, parenchymal suturing, resection or hepatic artery interruption.6 Some patients require liver transplantation.6 A recent systematic review reported maternal and fetal survival rates of 85% and 59% respectively, suggesting that these rates have remained largely unchanged over the last decade.7 However, this is an improvement when compared with data collected before 2003, which estimated a maternal survival rate of 61%.7 In a 2021 review of 73 patients with subcapsular liver hematoma, the best maternal and fetal survival rates were observed among those treated with hepatic artery embolization. 7 A minimally invasive approach with embolization should therefore be strongly considered as the first intervention if clinical stability allows, highlighting the importance of performing CT angiography in patients with HELLP syndrome with abdominal pain or elevated liver enzymes to facilitate timely diagnosis and management. 7 Computed tomography angiography provides both diagnostic information (particularly among patients who present with abdominal pain and abnormal liver enzymes, but who do not have indication for urgent cesarian delivery) and opportunity for minimally invasive therapy, and can be used to identify other pathology that may explain or be associated with the patient’s presentation. Open surgical intervention has been suggested as a rescue option for patients who are clinically unstable or when CT angiography is unavailable.7

Gonadal vein thrombosis is rare, with an incidence of 0.05%–0.16% in all pregnancies, most commonly in the postpartum period. Of these thromboses, 90% occur in the right gonadal vein because of its length and dextrorotation of the gravid uterus, resulting in compression. 8 Risk factors include infection and cesarian delivery, particularly with the birth of multiples.9 No consensus exists in the literature to guide treatment, and a recent review found no statistically significant correlation between use of anticoagulation and resolution of thrombosis.8 The authors of the review suggested treatment only in the presence of symptoms, such as septic thrombophlebitis and concurrent deep vein thrombosis or pulmonary embolism. Current SOGC recommendations presume an infectious trigger for gonadal vein thrombosis and support the use of broad-spectrum antibiotics, as well as consideration of therapeutic anticoagulation.9 The decision to treat with anticoagulation must be made on an individual basis, depending on the provoking factor, location and extent of thrombosis. For our patient, the left-sided location could suggest that the inflammatory and hypercoagulable states of preeclampsia and HELLP syndrome were more influential predisposing factors than anatomic changes associated with pregnancy. Based on the risk of recurrent bleeding in the setting of subcapsular liver hematoma and rupture, multifactorial anemia with evidence of hemolysis, the partially occlusive clot burden, the lack of extension into the inferior vena cava and the lack of evidence for an infectious trigger, we decided not to treat with anticoagulation or antibiotics.

We present a severe case of a patient with preeclampsia and HELLP — complicated by acute kidney injury, subcapsular hematoma and thrombosis — who initially presented with normal blood pressure, tachycardia and nausea and vomiting, and was found to have a hemoperitoneum intraoperatively. This case highlights the importance of having a high index of suspicion for preeclampsia or HELLP syndrome for patients with red-flag symptoms such as upper abdominal pain, headache, visual changes, altered mental status or dyspnea, and early biochemical signals, even in the absence of hypertension at presentation. Clinicians should consider prompt imaging and minimally invasive intervention if patient stability, resources and time permit.

Footnotes

  • Competing interests: None declared.

  • This article has been peer reviewed.

  • The authors have obtained patient consent.

  • Contributors: All of the authors contributed to the conception and design of the work, drafted the manuscript, revised it critically for important intellectual content, gave final approval of the version to be published and agreed to be accountable for all aspects of the work.

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY-NC-ND 4.0) licence, which permits use, distribution and reproduction in any medium, provided that the original publication is properly cited, the use is noncommercial (i.e., research or educational use), and no modifications or adaptations are made. See: https://creativecommons.org/licenses/by-nc-nd/4.0/

 

 

Source link

Continue Reading

Health

What’s the greatest holiday gift: lips, hair, skin? Give the gift of great skin this holiday season

Published

 on

Give the gift of great skin this holiday season

Skinstitut Holiday Gift Kits take the stress out of gifting

Toronto, October 31, 2024 – Beauty gifts are at the top of holiday wish lists this year, and Laser Clinics Canada, a leader in advanced beauty treatments and skincare, is taking the pressure out of seasonal shopping. Today, Laser Clincs Canada announces the arrival of its 2024 Holiday Gift Kits, courtesy of Skinstitut, the exclusive skincare line of Laser Clinics Group.

In time for the busy shopping season, the limited-edition Holiday Gifts Kits are available in Laser Clinics locations in the GTA and Ottawa. Clinics are conveniently located in popular shopping centers, including Hillcrest Mall, Square One, CF Sherway Gardens, Scarborough Town Centre, Rideau Centre, Union Station and CF Markville. These limited-edition Kits are available on a first come, first served basis.

“These kits combine our best-selling products, bundled to address the most relevant skin concerns we’re seeing among our clients,” says Christina Ho, Senior Brand & LAM Manager at Laser Clinics Canada. “With several price points available, the kits offer excellent value and suit a variety of gift-giving needs, from those new to cosmeceuticals to those looking to level up their skincare routine. What’s more, these kits are priced with a savings of up to 33 per cent so gift givers can save during the holiday season.

There are two kits to select from, each designed to address key skin concerns and each with a unique theme — Brightening Basics and Hydration Heroes.

Brightening Basics is a mix of everyday essentials for glowing skin for all skin types. The bundle comes in a sleek pink, reusable case and includes three full-sized products: 200ml gentle cleanser, 50ml Moisture Defence (normal skin) and 30ml1% Hyaluronic Complex Serum. The Brightening Basics kit is available at $129, a saving of 33 per cent.

Hydration Heroes is a mix of hydration essentials and active heroes that cater to a wide variety of clients. A perfect stocking stuffer, this bundle includes four deluxe products: Moisture 15 15 ml Defence for normal skin, 10 ml 1% Hyaluronic Complex Serum, 10 ml Retinol Serum and 50 ml Expert Squalane Cleansing Oil. The kit retails at $59.

In addition to the 2024 Holiday Gifts Kits, gift givers can easily add a Laser Clinic Canada gift card to the mix. Offering flexibility, recipients can choose from a wide range of treatments offered by Laser Clinics Canada, or they can expand their collection of exclusive Skinstitut products.

 

Brightening Basics 2024 Holiday Gift Kit by Skinstitut, available exclusively at Laser Clincs Canada clinics and online at skinstitut.ca.

Hydration Heroes 2024 Holiday Gift Kit by Skinstitut – available exclusively at Laser Clincs Canada clinics and online at skinstitut.ca.

Continue Reading

Health

Here is how to prepare your online accounts for when you die

Published

 on

 

LONDON (AP) — Most people have accumulated a pile of data — selfies, emails, videos and more — on their social media and digital accounts over their lifetimes. What happens to it when we die?

It’s wise to draft a will spelling out who inherits your physical assets after you’re gone, but don’t forget to take care of your digital estate too. Friends and family might treasure files and posts you’ve left behind, but they could get lost in digital purgatory after you pass away unless you take some simple steps.

Here’s how you can prepare your digital life for your survivors:

Apple

The iPhone maker lets you nominate a “ legacy contact ” who can access your Apple account’s data after you die. The company says it’s a secure way to give trusted people access to photos, files and messages. To set it up you’ll need an Apple device with a fairly recent operating system — iPhones and iPads need iOS or iPadOS 15.2 and MacBooks needs macOS Monterey 12.1.

For iPhones, go to settings, tap Sign-in & Security and then Legacy Contact. You can name one or more people, and they don’t need an Apple ID or device.

You’ll have to share an access key with your contact. It can be a digital version sent electronically, or you can print a copy or save it as a screenshot or PDF.

Take note that there are some types of files you won’t be able to pass on — including digital rights-protected music, movies and passwords stored in Apple’s password manager. Legacy contacts can only access a deceased user’s account for three years before Apple deletes the account.

Google

Google takes a different approach with its Inactive Account Manager, which allows you to share your data with someone if it notices that you’ve stopped using your account.

When setting it up, you need to decide how long Google should wait — from three to 18 months — before considering your account inactive. Once that time is up, Google can notify up to 10 people.

You can write a message informing them you’ve stopped using the account, and, optionally, include a link to download your data. You can choose what types of data they can access — including emails, photos, calendar entries and YouTube videos.

There’s also an option to automatically delete your account after three months of inactivity, so your contacts will have to download any data before that deadline.

Facebook and Instagram

Some social media platforms can preserve accounts for people who have died so that friends and family can honor their memories.

When users of Facebook or Instagram die, parent company Meta says it can memorialize the account if it gets a “valid request” from a friend or family member. Requests can be submitted through an online form.

The social media company strongly recommends Facebook users add a legacy contact to look after their memorial accounts. Legacy contacts can do things like respond to new friend requests and update pinned posts, but they can’t read private messages or remove or alter previous posts. You can only choose one person, who also has to have a Facebook account.

You can also ask Facebook or Instagram to delete a deceased user’s account if you’re a close family member or an executor. You’ll need to send in documents like a death certificate.

TikTok

The video-sharing platform says that if a user has died, people can submit a request to memorialize the account through the settings menu. Go to the Report a Problem section, then Account and profile, then Manage account, where you can report a deceased user.

Once an account has been memorialized, it will be labeled “Remembering.” No one will be able to log into the account, which prevents anyone from editing the profile or using the account to post new content or send messages.

X

It’s not possible to nominate a legacy contact on Elon Musk’s social media site. But family members or an authorized person can submit a request to deactivate a deceased user’s account.

Passwords

Besides the major online services, you’ll probably have dozens if not hundreds of other digital accounts that your survivors might need to access. You could just write all your login credentials down in a notebook and put it somewhere safe. But making a physical copy presents its own vulnerabilities. What if you lose track of it? What if someone finds it?

Instead, consider a password manager that has an emergency access feature. Password managers are digital vaults that you can use to store all your credentials. Some, like Keeper,Bitwarden and NordPass, allow users to nominate one or more trusted contacts who can access their keys in case of an emergency such as a death.

But there are a few catches: Those contacts also need to use the same password manager and you might have to pay for the service.

___

Is there a tech challenge you need help figuring out? Write to us at onetechtip@ap.org with your questions.

Source link

Continue Reading

Health

Pediatric group says doctors should regularly screen kids for reading difficulties

Published

 on

 

The Canadian Paediatric Society says doctors should regularly screen children for reading difficulties and dyslexia, calling low literacy a “serious public health concern” that can increase the risk of other problems including anxiety, low self-esteem and behavioural issues, with lifelong consequences.

New guidance issued Wednesday says family doctors, nurses, pediatricians and other medical professionals who care for school-aged kids are in a unique position to help struggling readers access educational and specialty supports, noting that identifying problems early couldhelp kids sooner — when it’s more effective — as well as reveal other possible learning or developmental issues.

The 10 recommendations include regular screening for kids aged four to seven, especially if they belong to groups at higher risk of low literacy, including newcomers to Canada, racialized Canadians and Indigenous Peoples. The society says this can be done in a two-to-three-minute office-based assessment.

Other tips encourage doctors to look for conditions often seen among poor readers such as attention-deficit hyperactivity disorder; to advocate for early literacy training for pediatric and family medicine residents; to liaise with schools on behalf of families seeking help; and to push provincial and territorial education ministries to integrate evidence-based phonics instruction into curriculums, starting in kindergarten.

Dr. Scott McLeod, one of the authors and chair of the society’s mental health and developmental disabilities committee, said a key goal is to catch kids who may be falling through the cracks and to better connect families to resources, including quicker targeted help from schools.

“Collaboration in this area is so key because we need to move away from the silos of: everything educational must exist within the educational portfolio,” McLeod said in an interview from Calgary, where he is a developmental pediatrician at Alberta Children’s Hospital.

“Reading, yes, it’s education, but it’s also health because we know that literacy impacts health. So I think that a statement like this opens the window to say: Yes, parents can come to their health-care provider to get advice, get recommendations, hopefully start a collaboration with school teachers.”

McLeod noted that pediatricians already look for signs of low literacy in young children by way of a commonly used tool known as the Rourke Baby Record, which offers a checklist of key topics, such as nutrition and developmental benchmarks, to cover in a well-child appointment.

But he said questions about reading could be “a standing item” in checkups and he hoped the society’s statement to medical professionals who care for children “enhances their confidence in being a strong advocate for the child” while spurring partnerships with others involved in a child’s life such as teachers and psychologists.

The guidance said pediatricians also play a key role in detecting and monitoring conditions that often coexist with difficulty reading such as attention-deficit hyperactivity disorder, but McLeod noted that getting such specific diagnoses typically involves a referral to a specialist, during which time a child continues to struggle.

He also acknowledged that some schools can be slow to act without a specific diagnosis from a specialist, and even then a child may end up on a wait list for school interventions.

“Evidence-based reading instruction shouldn’t have to wait for some of that access to specialized assessments to occur,” he said.

“My hope is that (by) having an existing statement or document written by the Canadian Paediatric Society … we’re able to skip a few steps or have some of the early interventions present,” he said.

McLeod added that obtaining specific assessments from medical specialists is “definitely beneficial and advantageous” to know where a child is at, “but having that sort of clear, thorough assessment shouldn’t be a barrier to intervention starting.”

McLeod said the society was partly spurred to act by 2022’s “Right to Read Inquiry Report” from the Ontario Human Rights Commission, which made 157 recommendations to address inequities related to reading instruction in that province.

He called the new guidelines “a big reminder” to pediatric providers, family doctors, school teachers and psychologists of the importance of literacy.

“Early identification of reading difficulty can truly change the trajectory of a child’s life.”

This report by The Canadian Press was first published Oct. 23, 2024.

Source link

Continue Reading

Trending

Exit mobile version