Hemoperitonium: Atypical Presentation Caused by Spontaneous Rupture of Hepatocellular Carcinoma in an Undiagnosed Patient

Introduction: Acute hemoperitoneum due to the spontaneous rupture of hepatocellular carcinoma (HCC) is a rare case of non-traumatic intra-abdomen bleeding that requires a high index of suspicion to approach, especially if no known history of HCC. It can mislead the physicians when the patient presents in an atypical way. Case Presentation: In this case report, we describe a fortuitous rupture of hepatocellular carcinoma in a 58-year-old male who was not previously diagnosed as having HCC and who came with atypical symptoms and signs of hemoperitoneum. He was then treated by trans-arterial embolectomy. Discussion: Diagnosis of hemoperitoneum in a case with bradycardia and hypotension is uncommon, as it goes more towards cardiogenic shock than hypovolemic shock, especially in a patient who is previously not symptomatic and has no risk factor for hepatocellular carcinoma. Conclusion: physicians should be alert to the possibility of encountering a hemorrhagic shock, although no trauma injury in any hypotensive patient with no clear reason for his condition.

Predictors of liver failure after transarterial chemoembolization in patients with spontaneously ruptured hepatocellular carcinoma:A retrospective study

Background: Spontaneously ruptured hepatocellular carcinoma(rHCC) is a life-threatening condition. Transarterial chemoembolization(TACE) is a widely accepted treatment;however, it can lead to serious complications,especially liver failure. We sought to identify preoperative predictors of liver failure in patients with rHCC undergoing TACE.Methods: Patients with rHCC who received TACE as the initial therapy were retrospectively studied at our institution between January 2016 and December 2021. Based on the occurrence of liver failure after TACE, the patients were divided into liver failure and no-liver failure groups. Predictors of liver failure after TACE were analyzed using univariate and multivariate regression analyses. The predictive performance was assessed using the area under the curve(AUC). Delong’s test was used to compare predictive efficiency.Results: Sixty patients(19 and 41 in the liver failure and non-liver failure groups, respectively) were included.Multivariate analysis showed that preoperative prothrombin activity(PTA) level(odds ratio [OR], 0.956;95%confidence interval [CI], 0.920–0.994;P = 0.024) and Child-Pugh grade B(OR, 6.419;95% CI, 1.123–36.677;P= 0.037) were independent predictors of liver failure after TACE in patients with rHCC. The AUCs of the preoperative PTA levels and Child-Pugh grade B for predicting liver failure after TACE in patients with rHCC were0.783 and 0.764, respectively.Conclusion: Preoperative PTA level and Child-Pugh grade B were significant independent risk factors for liver failure after TACE in patients with rHCC. These can be used to predict liver failure after TACE in patients with rHCC for individual decision-making regarding treatment planning.

Acute abdomen caused by spontaneous rupture of degenerative hysteromyoma during pregnancy:A case report

BACKGROUND Hysteromyoma is not a rare tumor among pregnant women.During pregnancy,the symptoms caused by hysteromyoma can be improved through conservative treatment in most cases.However,in order to ensure the safety of mothers and children,surgeries are necessary in some special cases.CASE SUMMARY We report a case of pregnancy complicated with hysteromyoma red degeneration.The patient had peritonitis after sudden abdominal pain during the 20th week of pregnancy.Laparoscopic exploration suggested rupture and bleeding of hysteromyoma,which were improved after drainage and an anti-inflammatory treatment.A cesarean section was performed after full term.This case shows the complications of rupture after red degeneration of hysteromyoma during pregnancy.CONCLUSION We should be alert to rupture of hysteromyoma during pregnancy,and active laparoscopic exploration is essential to improve the prognosis of such patients.

Relationship between Vascular Elasticity and Spontaneous Rupture of Hepatocellular Carcinoma

Objective Spontaneous rupture of hepatocellular carcinoma (HCC) is common in Asia and Africa with unclear mechanism. In our previous study, we found that the deposition of immune complex on vascular wall and vascular injury were related to the HCC rupture. In this study, the structure of elastin around the small artery was deeply investigated to confirm our previous study. Methods Immunohistochemical technique and transmission electron microscopy were used to study 23 specimens from ruptured HCC and 30 cases of nonruptured HCC. Results The layer of elastin around the vascular wall was significant thicker in patients with ruptured HCC than that in nonruptured HCC. The proliferation of elastin, abnormal distribution of neutrophil elastase and degradation of collagen fibril were predominantly present in the specimens from ruptured HCC. The phenomenon of electron—dense deposit in the elastic lamina that represented the deposition of immune complex, and the signs of infiltrated neutrophils from bloodstream into the vascular wall that caused the vascular injury, also can be found in ruptured HCC. Since the damaged vessels could become stiff and weak, which would more prone to be splitting and results in hemorrhage and the rupture of HCC, we postulated that the preexisting of immune complex deposition and vascular injury may be relate to the ruptured HCC. Conclusion The vascular injury caused by immune complex deposition might relate to ruptured HCC. Key words hepatocellular carcinoma - rupture - elastin - elastase

Predictors and clinical outcomes for spontaneous rupture of hepatocellular carcinoma

AIM:To determine the risk factors for hepatocellular carcinoma(HCC) rupture,and report the management and long-term survival results of patients with spontaneous rupture of HCC.METHODS:Among 4209 patients with HCC who were diagnosed at Eastern Hepatobiliary Surgery Hospital from April 2002 to November 2006,200(4.8%) patients with ruptured HCC(case group) were studied retrospectively in term of their clinical characteristics and prognostic factors.The one-stage therapeutic approach to manage ruptured HCC consisted of initial management by conservative treatment,transarterial embolization(TACE) or hepatic resection.Results of various treatments in the case group were evaluated and compared with the control group(202 patients) without ruptured HCC during the same study period.Continuous data were expressed as mean ± SD or me-dian(range) where appropriate and compared using the unpaired t test.Categorical variables were compared using the Chi-square test with Yates correction or the Fisher exact test where appropriate.The overall survival rate in each group was determined using the Kaplan-Meier method and a log-rank test.RESULTS:Compared with the control group,more patients in the case group had underlying diseases of hypertension(7.5% vs 3.0%,P =0.041) and liver cirrhosis(87.5% vs 56.4%,P < 0.001),tumor size >5 cm(83.0% vs 57.4%,P < 0.001),tumor protrusion from the liver surface(66.0% vs 44.6%,P < 0.001),vascular thrombus(30.5% vs 8.9%,P < 0.001) and extrahepatic invasion(36.5% vs 12.4%,P < 0.001).On multivariate logistic regression analysis,underlying diseases of hypertension(P = 0.002) and liver cirrhosis(P < 0.001),tumor size > 5 cm(P < 0.001),vascular thrombus(P = 0.002) and extrahepatic invasion(P < 0.001) were predictive for spontaneous rupture of HCC.Among the 200 patients with spontaneous rupture of HCC,105 patients underwent hepatic resection,33 received TACE,and 62 were managed with conservative treatment.The median survival time(MST) of all patients with spontaneous rupture of HCC was 6 mo(range,1-72 mo),and the overall survival at 1,3 and 5 years were 32.5%,10% and 4%,respectively.The MST was 12 mo(range,1-72 mo) in the surgical group,4 mo(range,1-30 mo) in the TACE group and 1 mo(range,1-19 mo) in the conservative group.Ninety-eight patients in the control group underwent hepatic resection,and the MST and median diseasefree survival time were 46 mo(range,6-93 mo) and 23 mo(range,3-39 mo) respectively,which were much longer than that of patients with spontaneous rupture of HCC undergoing hepatic resection(P < 0.001).The 1-,3-,and 5-year overall survival rates and the 1-,3-and 5-year disease-free survival rates in patients with ruptured HCC undergoing hepatectomy were 57.1%,19.0% and 7.6%,27.6%,14.3% and 3.8%,respectively,compared with those of 77.1%,59.8% and 41.2%,57.1%,40.6% and 32.9% in 98 patients with-CONCLUSION:Prolonged survival can be achieved in selected patients undergoing one-stage hepatectomy,although the survival results were inferior to those of the patients without ruptured HCC.

Spontaneous coronary artery rupture after lung cancer surgery:A case report and review of literature

BACKGROUND Spontaneous coronary artery rupture(SCAR)is a rare and life-threatening complication after lung cancer surgery.We present a case of SCAR following left upper lobectomy,successfully managed through emergency thoracotomy and coronary artery ligation.CASE SUMMARY A 61-year-old male patient underwent left upper lobectomy and mediastinal lymph node dissection for lung cancer.The surgery was performed using singleport video-assisted thoracoscopic surgery,and there were no observed complications during the procedure.However,19 h after surgery,the patient experienced chest discomfort and subsequently developed severe symptoms,including nausea,vomiting,and a drop in blood pressure.Urgent measures were taken,leading to the diagnosis of SCAR.The patient underwent emergency thoracotomy and coronary artery ligation,successfully stopping the bleeding and stabilizing the condition.Despite postoperative complications,the patient made a successful recovery and was discharged from the hospital.CONCLUSION SCAR is a rare but life-threatening complication following lung cancer surgery.Immediate thoracotomy has been shown to be a life-saving measure,while stenting is not the preferred initial approach.

Treatment of A Case of Spontaneous Rupture of Achille's Tendon

Mr. Guo, 51 years old, paid his first visit on November 7, 2001. The patient felt sudden pain in the right Achille's tendon in June 1999 with no apparent predisposing factors. Several months later he palpated a small pitting in the middle of the right Achille's tendon, which expanded gradually in size. In June 2000, two thirds of the tendon was diagnosed to be ruptured in a local hospital. Ten days later the tendon was ruptured completely when he felt sudden severe pain, numbness and distention, and he was unable to raise the heel. The lesion was healed three months later after being treated with a plaster model, but it was partially ruptured again 6 months later. Though the ruptured tendon was healed again with the help of a plaster model, he still suffered from local swelling and pain, which was aggravated during movement and made him difficult in walking, squatting down and standing up. During the examination, the right heel was found hyperemic and swollen with ecchymosis and tenderness. The tongue proper was dark red and the pulse thready and rapid. The condition was due to depletion and deficiency of liver-qi, stagnant blood with dampheat obstructing the collaterals. The principle of nourishing the liver and soothing the tendon was adopted, assisted by invigorating blood circulation and removing blood stasis, clearing heat and transforming dampness.

Feasibility and safety of sorafenib treatment in hepatocellular carcinoma patients with spontaneous rupture

AIM: To report the outcome of patients with ruptured hepatocellular carcinoma (HCC) treated at a single center during a 5-year period.

Survival outcome of patients with spontaneously ruptured hepatocellular carcinoma treated surgically or by transarterial embolization

AIM: To evaluate clinical outcomes of patients that underwent surgery, transarterial embolization (TAE), or supportive care for spontaneously ruptured hepatocellular carcinoma (HCC). METHODS: A consecutive 54 patients who diagnosed as spontaneously ruptured HCC at our institution between 2003 and 2012 were retrospectively enrolled. HCC was diagnosed based on the diagnostic guidelines issued by the 2005 American Association for the Study of Liver Diseases. HCC rupture was defined as disruption of the peritumoral liver capsule with enhanced fluid collection in the perihepatic area adjacent to the HCC by dynamic liver computed tomography, and when abdominal paracentesis showed an ascitic red blood cell count of > 50000 mm 3 /mL in bloody fluid. RESULTS: Of the 54 patients, 6 (11.1%) underwent surgery, 25 (46.3%) TAE, and 23 (42.6%) supportive care. The 2-, 4and 6-mo cumulative survival rates at 2, 4 and 6 mo were significantly higher in the surgery (60%, 60% and 60%) or TAE (36%, 20% and 20%) groups than in the supportive care group (8.7%, 0% and 0%), respectively (each, P < 0.01), and tended to be higher in the surgical group than in the TAE group. Multivariate analysis showed that serum bilirubin (HR = 1.09, P < 0.01), creatinine (HR = 1.46, P = 0.04), and vasopressor requirement (HR = 2.37, P = 0.02) were significantly associated with post-treatment mortality, whereas surgery (HR = 0.41, P < 0.01), and TAE (HR = 0.13, P = 0.01) were inversely associated with posttreatment mortality. CONCLUSION: Post-treatment survival after surgery or TAE was found to be better than after supportive care, and surgery tended to provide better survival benefit than TAE.

A new tumor-associated antigen prognostic scoring system for spontaneous ruptured hepatocellular carcinoma after partial hepatectomy

Objective:Spontaneous hepatocellular carcinoma(HCC)rupture can be fatal,and hepatic resection could achieve a favorable long-term survival among all strategies of tumor rupture.However,there is no available prognostic scoring system for patients with ruptured HCC who underwent partial hepatectomy.Methods:From January 2005 to May 2015,129 patients with spontaneous HCC rupture underwent partial hepatectomy.Preoperative clinical data were collected and analyzed.Independent risk factors affecting overall survival(OS)were used to develop the new scoring system.Harrell’s C statistics,Akaike information criterion(AIC),the relative likelihood,and the log likelihood ratio were calculated to measure the homogeneity and discriminatory ability of a prognostic system.Results:In the multivariable Cox regression analysis,three factors,including tumor size,preoperativeα-fetoprotein level,and alkaline phosphatase level,were chosen for the new tumor-associated antigen(TAA)prognostic scoring system.The 1-year OS rates were 88.1%,43.2%,and 30.2%for TAA scores of 0–5 points(low-risk group),6–9 points(moderate-risk group),and 10–13points(high-risk group),respectively.The TAA scoring system had superior homogeneity and discriminatory ability(Harrell’s C statistics,0.693 vs.0.627 and 0.634;AIC,794.79 vs.817.23 and 820.16;relative likelihood,both<0.001;and log likelihood ratio,45.21 vs.22.77 and 21.84)than the Barcelona Clinic Liver Cancer staging system and the Cancer of the Liver Italian Program in predicting OS.Similar results were found while predicting disease-free survival(DFS).Conclusions:The new prognostic scoring system is simple and effective in predicting both OS and DFS of patients with spontaneous ruptured HCC.

Risk factors and surgical outcomes for spontaneous rupture of BCLC stages A and B hepatocellular carcinoma: A case-control study

AIM: To investigate the risk factors and surgical outcomes for spontaneous rupture of Barcelona Clinic Liver Cancer (BCLC) stages A and B hepatocellular carcinoma (HCC).

Prognostic factors of spontaneously ruptured hepatocellular carcinoma

AIM: To evaluate the prognostic factors in patients with spontaneously ruptured hepatocellular carcinoma(HCC). METHODS: Seventy-nine patients experiencing spontaneous rupture of HCC between April 2004 and August 2014 were enrolled in this study. The clinical features, treatment modalities and outcomes were reviewed. The statistical methods used in this work included univariate analysis, Kaplan-Meier survival analysis with log-rank tests, and multivariate analysis using a Cox regression hazard model. RESULTS: Of the 79 patients with HCC rupture, 17(21.5%) underwent surgery, 32(40.5%) underwent transarterial embolization(TAE), and 30(38%) received conservative treatment. The median survival time was 125 d, and the mortality rate at 30 d was 27.8%. Multivariate analysis revealed that lesion length(HR = 1.46, P < 0.001), lesion number(HR = 1.37, P = 0.042), treatment before tumor rupture(HR = 4.36, P = 0.019), alanine transaminase levels(HR = 1.0, P = 0.011), bicarbonate levels(HR = 1.18, P < 0.001), age(HR = 0.96, P = 0.026), anti-tumor therapy during the followup period(HR = 0.21, P = 0.008), and albumin levels(HR = 0.89, P = 0.010) were independent prognostic factors of survival after HCC rupture. The BarcelonaClinic Liver Cancer(BCLC) stage was also an important prognostic factor; the median survival times for BCLC stages A, B and C were 251, 175 and 40 d, respectively(P < 0.001).CONCLUSION: Anti-tumor therapy during the followup period, without a history of anti-tumor therapy prior to HCC rupture, small tumor length and number, and early BCLC stage are the most crucial predictors associated with satisfactory overall survival. Other factors play only a small role in overall survival.

Granulomatous reaction in hepatic inflammatory angiomyolipoma after chemoembolization and spontaneous rupture

A 77-year-old Japanese woman was transported to a nearby hospital due to sudden abdominal pain and transient loss of consciousness. Abdominal computed tomography(CT) suggested hemoperitoneum and hepatic nodule. She was conservatively treated. Contrast-enhanced CT two months later revealed an increased mass size, and the enhancement pattern suggested the possibility of hepatocellular carcinoma(HCC). Under a clinical diagnosis of HCC, transcatheter arterial chemoembolization(TACE) was performed. A subsequent imaging study revealed that most of the lipiodol used for the embolization was washed out. Therefore, surgical resection was performed. Histologically, the nodule contained numerous inflammatory cells including small lymphocytes, plasma cells and macrophages. Notably, epithelioid granulomatous features with multinucleated giant cells were observed in both the nodule and background liver. Some of the multinucleated giant cells contained oil lipid. Among the infiltrating inflammatory cells,spindle-shaped, histiocytoid or myoid tumor cells with eosinophilic cytoplasm were found. The tumor cells were positive for Melan A and HMB45. The nodule contained many Ig G4-positive plasma cells; these were counted and found to number 72.6 cells/HPF(range: 61-80). The calculated Ig G4:Ig G ratio was 33.2%. The nodule was finally diagnosed as previously ruptured inflammatory angiomyolipoma modified by granulomatous reaction after TACE.

Klebsiella pneumoniae infection secondary to spontaneous renal rupture that presents only as fever:A case report

BACKGROUND Spontaneous renal rupture is a rare disease in the clinic.The causes of spontaneous renal rupture include extrarenal factors,intrarenal factors,and idiopathic factors.Reports on infection secondary to spontaneous renal rupture and the complications of spontaneous renal rupture are scarce.Furthermore,there are few patients with spontaneous renal rupture who present only with fever.CASE SUMMARY We present the case of a 52-year-old female patient who was admitted to our hospital.She presented only with fever,and the cause of the disease was unclear.She underwent a contrast-enhanced computed tomography(CT)scan,which showed that the left renal capsule had a crescent-shaped,low-density shadow;the perirenal fat was blurred,and exudation was visible with no sign of calculi,malignancies,instrumentation,or trauma.Under ultrasound guidance,a pigtail catheter was inserted into the hematoma,and fluid was drained and used for the bacterial test,which proved the presence of Klebsiella pneumoniae.Two months later,abdominal CT showed that the hematoma was absorbed,so the drainage tube was removed.The abdominal CT was normal after 4 mo.CONCLUSION Spontaneous renal rupture due to intrarenal factors causes a higher proportion of shock and is more likely to cause anemia.

A case of spontaneous hepatic hemangioma rupture:Successful management with transarterial chemoembolization alone

Hemangioma is the most common benign hepatic tumor.Although spontaneous rupture is rare,the mortality rate ranges from 60 to 75%.Only 34 cases have been reported in the literature,with only one report using transcatheter arterial embolization(TAE) alone as treatment.We report a case of spontaneous rupture with "flowering sign" of a giant hepatic hemangioma,presenting with acute abdominal pain and shock,while the volume of the hemangioma and blood loss were similar.The patient was successfully managed by transarterial chemoembolization(TACE) alone,which has an operative mortality rate of up to 36.4%.

Successful laparoscopic management of hemoperitoneum due to spontaneous venous rupture overlying a uterine fibroid

Spontaneous venous rupture overlying a uterine fibroid is a rare cause of hemoperitoneum. A 38-year-old woman presented to the emergency department with acute onset of abdominal pain. The ultrasound revealed multiple fibroids and free fluid in the peritoneum. There was a significant drop of the hemoglobin and hematocrit. The patient underwent emergent exploratory laparoscopy. A subserosal uterine leiomyoma was found, with a bleeding vein on its basis and massive hemoperitoneum. Laparoscopic myomectomy was successfully performed with local injection of vasopressin and intraoperative autologous blood transfusion. This case suggests that spontaneous intraperitoneal haemorrhage associated with uterine fibroids, although rare, should be considered in women with hypovolemic shock and a pelvic mass.

Recurrent ascites due to spontaneous intraperitoneal bladder rupture after pelvic radiation therapy for cervical cancer

Radiation cystitis is one of the major complications following radiotherapy for cervical cancer. However, spontaneous intraperitoneal bladder rupture as a result of radiation cystitis following radiotherapy for cervical cancer is extremely rare. Case presentation: We report a 52-year-old patient who received radiation therapy for cervical cancer 15 years prior to presentation. Eight years prior to presentation, she developed recurrent abdominal distension, oliguria, and ascites. Following ascites drainage and supportive treatment, all symptoms were relieved. However, all symptoms subsequently recurred every few months. The patient underwent exploratory laparotomy twice. The first exploratory laparotomy in July 2015 found no specific abnormalities. The second exploratory laparotomy in November 2016 found an intraperitoneal bladder rupture, and the patient underwent surgical repair. The ascites subsequently resolved. Conclusion: The occurrence of spontaneous intraperitoneal bladder rupture after radiation therapy for cervical cancer is rare. The prognosis is good when diagnosis and treatment are prompt.

Long-term survival for spontaneous rupture of hepatocellular carcinoma treated with hepatectomy

Objective- To determine the prognostic factors of ruptured hepatocellular carcinoma （HCC） and report the management of patients with spontaneous rupture of HCC in a single center during a 5-year period and to evaluate one-stage hepatectomy Methods- A series of 4,209 patients with HCC were collected at Eastern Hepatobiliary Surgery Hospital from April 2002 to November 2006, of whom 200 patients （4.8%） with ruptured HCC were studied retrospectively regarding their clinical characteristics and prognostic factors. The one-stage therapeutic approach to manage ruptured HCC consisted of initial management by conservative method, transarterial embolization （TAE） or surgical hepatectomy. Results of various treatments were evaluated and compared in the randomly selected 202 patients with no history of rupture during the same study period. Results： A total of 200 patients with spontaneous rupture of HCC were studied who underwent surgical treatment （n=105）, TAE 33 and conservative treatment （ConT 62）. A multivariate analysis using the Cox hazard regression model （including all the patients n=200） identified surgical hepatectomy as the only independent factor determining a relatively long survival period （P〈0.0001） On the other hand, in a further analysis of the patients in whom surgical hepatectomy was successfully performed （n=105）, which identified a maximum tumor size exceeding 6 cm as significant determinants of a poor 12-month （P=0.036）, and a multivariate analysis did not identify as any inverse independent factor determining relatively long-term survival, only a maximum tumor size exceeding 6 cm exhibited a tendency toward being a determinant factor （P=0.083）. Conelusionz Considering the high propensity to spontaneous rupture, as long as preoperatively clinical evaluation meet surgery requirements, elective one-stage hepatectomy for patients with ruptured HCC is the first treatment option. Prolonged survival could be achieved in selected patients with hepatic resection, although the survival results were inferior to those of the patients who did not have the complication of rupture

Huge urinoma caused by spontaneous ureteral rupture secondary to ureteral obstruction due to prostate cancer

Dear editor,Spontaneous ureteral rupture(SUR)due to prostate cancer is very rare.The most common cause is calculus.To the best of our knowledge,SUR secondary to ureteral obstruction caused by prostate cancer was first reported by Deng et al.[1],so this case may be the second report.We report a case of a huge urinoma caused by SUR secondary to prostate cancer that was difficult to treat.This case is significant because the long-term presence of urinomas has never been reported.

Diagnostic value of ultrasound in the spontaneous rupture of renal angiomyolipoma during pregnancy:A case report

BACKGROUND Spontaneous rupture and hemorrhage of renal angiomyolipoma(RAML)is a lifethreatening clinical emergency.When it occurs during pregnancy,it is compared to a"bomb explosion,"which makes the diagnosis and treatment more challenging.An ultrasound examination is a quick and safe examination with the benefit of no radiation exposure,which is always preferred for pregnant women.Currently,cases of spontaneous rupture and hemorrhage of RAML during pregnancy are rare,as is the diagnostic value and characteristics of ultrasound.The lack of understanding of the condition among ultrasound doctors makes it prone to misdiagnosis.In this study,we present the case of a pregnant woman who was preliminarily diagnosed with spontaneous rupture and hemorrhage of the left RAML using ultrasound and discuss the ultrasound characteristics.CASE SUMMARY A 38-year-old woman in her 19 th wk of pregnancy(G2 P1)was referred to our clinic for a sudden,persistent pain on the left side of the waist.She had not undergone any previous related abdominal examination.Ultrasound of the urinary system revealed a giant nonhomogenous lump in the left kidney area.The diagnosis was considered spontaneous rupture and hemorrhage of the left RAML in pregnancy via ultrasound.Her left-side waist pain continued to be intense.Subsequently,she underwent computed tomography,which led to the same diagnosis.Based on many factors,the patient underwent left nephrectomy after the induction of labor.The pathological result was the rupture and hemorrhage of a vascular leiomyoma lipoma.CONCLUSION Ultrasound examination plays an important role in the diagnosis of the spontaneous rupture and hemorrhage of RAML during pregnancy.