Life-Threatening Hemorrhage from Adenomas in the Liver during Pregnancy

A primi gravida at term was admitted to a peripheral hospital with sudden right upper abdominal pain and diagnosed as having pre-eclampsia. Labor was induced and she was referred to our hospital because of increasing pain and decreasing hemoglobin levels. At admission, ultrasound examination showed a possible liver hematoma and free abdominal fl uid. After delivery of a healthy girl, she remained hemodynamically instable. A contrast-enhanced CT scan revealed four lesions in the liver resembling adenomas and free peritoneal fl uid ( fi g.1 ). The patient could not be stabilized with conservative treatment. Selective embolization of the right hepatic artery was performed successfully ( fi g. 2 ). She was discharged home 2 weeks later. Hemorrhage in pregnancy from ruptured liver adenomas is rare and therefore easily misdiagnosed. Presentation may be with severe pain localized to the epigastrium or right upper quadrant of the abdomen with radiation to the back or right shoulder. These symptoms might be misinterpreted as dyspepsia or cholecystitis. Delay in diagnosing rupture of the liver will contribute to high mortality rates. It is essential to get the diagnosis at once, preferably using contrast-enhanced CT scanning. We suggest that selective arterial embolization is a valuable tool in the acute phase of hepatocellular adenoma bleeding.