Subcapsular hepatic hematoma as a complication of severe preeclampsia: a case report.

BACKGROUND: Subcapsular hepatic hematoma is a rare and life-threatening complication of pregnancy. It is most commonly associated with severe preeclampsia and hemolytic anemia, elevated liver enzymes, and low platelets syndrome. Patients with subcapsular hepatic hematoma typically present with epigastric, right upper quadrant or shoulder pain, nausea and vomiting, and/or shortness of breath. Here we describe a patient with a classic pain presentation, a large unruptured hematoma, and an unusual postpartum course. CASE: A 40-year-old gravida 1 para 0 Caucasian woman presented at 39 + 6 weeks gestational age with a 3-day history of new onset pain in an otherwise uncomplicated pregnancy. She described the pain along her right torso as severe, shooting, and sharp, but at times pleuritic in nature. She was found to have new onset preeclampsia and hemolytic anemia, elevated liver enzymes, and low platelets syndrome. Induction of labor was initiated and eventually she delivered by cesarean section. Her pain persisted in the postpartum period and abdominal computed tomography scan revealed a 16 cm subcapsular hepatic hematoma. Despite the hematoma being thin walled, conservative management was recommended by the general surgeon. She then re-presented on postpartum day 15 with tachypnea, dyspnea, and pleuritic chest pain. Secondary to the subcapsular hepatic hematoma, she then developed an infected and loculated, large pleural effusion. This required video-assisted thoracoscopic surgery before her eventual discharge home on postpartum day 21. CONCLUSIONS: There should be high clinical suspicion of subcapsular hepatic hematoma in patients with persistent pain in the right upper quadrant of the abdomen. Urgent imaging to investigate for subcapsular hepatic hematoma is then indicated. Cesarean delivery without labor and treatment for severe preeclampsia should be undertaken if subcapsular hepatic hematoma is found. Conservative management and serial imaging are reasonable for the follow-up of a large, unruptured hematoma. Hepatic artery embolization should also be considered. Subcapsular hepatic hematoma may be complicated by infected pleural effusions and require video-assisted thoracoscopic surgery.

Epidural Volume Extension During Combined Spinal-Epidural Labor Analgesia Does Not Increase Sensory Block.

BACKGROUND: Combined spinal-epidural (CSE) analgesia is widely used for delivering labor analgesia. Epidural volume extension (EVE) involves the injection of fluid into the epidural space compressing the dural sac, causing cephalad shift of the cerebral spinal fluid. Our hypothesis was that EVE with 10 mL normal saline during CSE would increase the sensory block height at 15 minutes after intrathecal injection. We expected EVE to decrease pain scores, decrease analgesia onset time, and decrease motor block compared with performing CSE without EVE (NEVE). METHODS: We randomly assigned 60 healthy term laboring nulliparous parturients with cervical dilation <5 cm to receive CSE either with EVE of 10 mL normal saline through the Tuohy needle before catheter insertion or CSE NEVE. Intrathecal analgesia consisted of 2 mg plain bupivacaine and 10 µg fentanyl (1 mL total). A blinded researcher assessed sensory dermatome level, analgesia, and motor blockade at regular intervals for 30 minutes. The primary outcome measure was the median peak sensory dermatome level at 15 minutes. RESULTS: Fifty-four parturients were analyzed. There was no significant difference in peak sensory dermatome levels at 15 minutes (median difference, 1 dermatome level; 95% confidence interval of median difference, 0 to 2; P = 0.22) and 30 minutes (median difference, 0 dermatome level; 95% confidence interval, -2 to 2; P = 0.76). There was no difference in the time to peak dermatome, minimum pain score, or the time to minimum pain score between groups. CONCLUSIONS: We found no significant difference between groups with regard to sensory dermatome level or pain scores when using EVE compared with NEVE. Our study demonstrates that addition of EVE does not offer superior analgesia when using a CSE technique for parturients requesting labor analgesia.

Persistent paralysis after spinal anesthesia for cesarean delivery.

Anterior spinal artery syndrome has rarely been reported as a cause of permanent neurologic complications after neuraxial anesthesia in obstetric patients. A parturient developed anterior spinal artery syndrome after spinal anesthesia for cesarean delivery. A healthy 32-year-old parturient presented at 41(2/7) weeks for primary elective caesarean delivery for breech presentation. Spinal anesthesia was easily performed with clear cerebrospinal fluid, and block height was T4 at 5 minutes. Intraoperative course was uneventful except for symptomatic bradycardia (37-40 beats per minute) and hypotension (88/44 mm Hg) 4 minutes postspinal anesthesia, treated with ephedrine and atropine. Dense motor block persisted 9 hours after spinal anesthesia, and magnetic resonance imaging of the lumbosacral region was normal, finding no spinal cord compression or lesion. Physical examination revealed deficits consistent with a spinal cord lesion at T6, impacting the anterior spinal cord while sparing the posterior tracts.