Spontaneous liver haematoma rupture associated with pre-eclampsia in a low- to middle-income country: Lessons to be learnt from maternal death assessments

Abstract

Spontaneous rupture of liver haematoma is a complication of pre-eclampsia (PE) that results in maternal mortality, particularly in the absence of an early diagnosis and appropriate interventions. The aim was to describe cases of maternal deaths due to spontaneous rupture of liver haematoma associated with PE to raise awareness of clinical features suggestive of the diagnosis and to make recommendations regarding a team approach in managing this complication. Maternal deaths due to PE that occurred in health facilities in South Africa between 2014 and 2016 were reviewed and cases due to spontaneous rupture of liver haematoma were analysed. Eight maternal deaths occurred owing to spontaneous rupture of liver haematoma, and in 62.5% (5/8) the diagnosis was established at caesarean delivery. The common presenting features were upper abdominal pain, haemodynamic instability including collapse and haemoperitoneum associated with PE, and haemolysis, elevated liver enzymes and low platelet count (HELLP) syndrome. Substandard care was associated with all, except 1 patient, and the principal area of concern was inability to make the diagnosis and failure to seek advice from a referral centre. Preventable factors in these maternal deaths included adherence to clinical guidelines, appropriate clinical and laboratory assessment with regard to the diagnosis of spontaneous rupture of liver haematoma, and management by a multidisciplinary team.