Pregnancy and liver adenoma management: PALM-study

Abstract

BackgroundHepatocellular adenoma (HCA) in pregnant women requires special considerations because of the risk of hormone induced growth and spontaneous rupture, which may threaten the life of both mother and child. Due to scarcity of cases there is no evidence-based algorithm for the evaluation and management of HCA during pregnancy. Most experts advocate that women with HCA should not get pregnant or advise surgical resection before pregnancy. Whether it is justified to deny a young woman a pregnancy, as the biological behavior may be less threatening than presumed depends on the incidence of HCA growth and the subsequent clinical events during pregnancy.We aim to investigate the management and outcome of HCA during pregnancy and labor based on a prospectively acquired online database in the Netherlands.Methods/designThe Pregnancy And Liver adenoma Management (PALM) - study is a multicentre prospective study in three cohorts of pregnant patients. In total 50 pregnant patients, ≥ 18 years of age with a radiologically and/or histologically proven diagnosis of HCA will be included in the study. Radiological diagnosis of HCA will be based on contrast enhanced MRI. Lesions at inclusion must not exceed 5 cm. The study group will be compared to a healthy control group of 63 pregnant patients and a group of 63 pregnant patients with diabetes mellitus without HCA. During their pregnancy HCA patients will be closely monitored by means of repetitive ultrasound (US) at 14, 20, 26, 32 and 38 weeks of gestation and 6 and 12 weeks postpartum. Both control groups will undergo US of the liver at 14 weeks of gestation to exclude HCA lesions in the liver. All groups will be asked to fill out quality of life related questionnaires.DiscussionThe study will obtain information about the behaviour of HCA during pregnancy, the clinical consequences for mother and child and the impact of having a HCA during pregnancy on the health related quality of life of these young women. As a result of this study we will propose a decision-making model for the management of HCA during pregnancy.Trial registrationDutch trial register: NTR3034

Outcomes of liver resection in hepatocellular adenoma and focal nodular hyperplasia

“…All patients with HCA should discontinue oral contraceptives. Until risk analyses during pregnancy have been properly studied, all patients should undergo close follow‐up during pregnancy . Hepatocellular adenoma in male patients and of >5 cm in female patients should be resected .…”

Genotype-phenotype correlations in hepatocellular adenoma: an update of MRI findings

“…We advocate that patients with a HCA larger than 5 cm be treated before becoming pregnant. In cases where a HCA larger than 5 cm is found during pregnancy, the data are currently too sparse to draw firm conclusions, and we believe that the management in these patients should be individualized (36,37).…”

“…Larger studies will need to be performed to evaluate whether there is a correlation between the subtype and bleeding and rupture. Pregnant patients with HCA deserve special attention, as maternal and fetal mortality rates are not negligible (34)(35)(36). We advocate that patients with a HCA larger than 5 cm be treated before becoming pregnant.…”

The Management of Pregnancy in Women with Hepatocellular Adenoma: A Plea for an Individualized Approach

“…We concluded not to discourage all women with HCA from pregnancy. In our tertiary referral center, we closely observe pregnant women with a HCA smaller than 5 cm in a clinical trial [10]. In this study, the size of the lesion is an exclusion criterion when exceeding 5 cm, but the number of HCAs present in the liver is not.…”

“…In our center we do not discourage pregnancy in women with a HCA <5 cm (Figure 2) if they accept the risk of interventions in case of growth of the adenoma. Close guidance of these women and monitoring of the hepatic adenoma by liver ultrasound every 6 weeks during pregnancy are strongly advocated [10, 26]. …”