What is the management of asymptomatic or symptomatic hepatic adenoma greater than 5cm in a pregnant patient?

From the Guidelines

For a pregnant patient with a hepatic adenoma greater than 5cm, surgical resection is recommended, preferably during the second trimester, to minimize the risk of adenoma-related complications and ensure the best outcomes for both mother and fetus. This approach is supported by the most recent guidelines and evidence, which highlight the increased risk of bleeding and hemorrhage associated with larger adenomas, particularly those greater than 5cm in diameter 1. The risk of adenoma rupture during pregnancy is significant, with estimates ranging from 20-40%, and is associated with high mortality rates for both mother and fetus.

Key Considerations

• Hepatic adenomas are hormone-sensitive, and the increase in estrogen levels during pregnancy can cause adenoma growth, increasing the risk of rupture and hemorrhage 1.
• The second trimester is considered the optimal time for surgical intervention, as organogenesis is complete, reducing teratogenic risks, and the uterus is not yet large enough to significantly complicate abdominal surgery.
• Close monitoring with ultrasound is essential for very large adenomas discovered early in pregnancy, until the second trimester when surgery becomes safer.
• For adenomas discovered late in pregnancy and are stable, management may involve close monitoring until delivery, followed by postpartum resection.

Evidence-Based Recommendations

• The European Association for the Study of the Liver (EASL) clinical practice guidelines recommend surgical resection for hepatocellular adenomas with a diameter greater than 5cm, particularly in pregnant women, to prevent complications such as bleeding and hemorrhage 1.
• A prospective study of 48 women with hepatocellular adenomas less than 5cm in diameter reported growth of the adenoma in 25.5% of cases, highlighting the importance of close monitoring during pregnancy 1.
• The guidelines also recommend that women planning pregnancy with a hepatocellular adenoma greater than 5cm should, where possible, have treatment prior to pregnancy to minimize the risk of complications 1.

From the Research

Management of Hepatic Adenoma in Pregnancy

The management of asymptomatic or symptomatic hepatic adenoma greater than 5cm in a pregnant patient is a complex issue.

• The risk of rupture is high, with maternal mortality and fetal loss approaching 50% in cases of spontaneous rupture 2.
• An aggressive approach to management is recommended, with laparoscopic resection considered for lesions greater than 5cm 2.
• Biopsy of liver cell adenomas in pregnancy is considered unsafe and can be complicated by rupture 2.
• In some cases, scheduled preterm cesarean delivery under combined spinal-epidural anesthesia, followed by transarterial embolization and definitive resection of the adenoma postpartum, may be considered 3.
• The management of hepatocellular adenoma during pregnancy may involve close monitoring, with surgical resection recommended for large tumors or those that have complicated previous pregnancies 4.
• Trans-arterial embolization and laparoscopic liver resection may be used to manage ruptured hepatocellular adenomas 5.
• A decision-making model for the management of hepatocellular adenoma during pregnancy is being developed, based on a prospective study of pregnant patients with hepatocellular adenoma 6.
• The study aims to investigate the management and outcome of hepatocellular adenoma during pregnancy and labor, and to propose a decision-making model for the management of hepatocellular adenoma during pregnancy 6.