What is the management of a ruptured hepatic adenoma in pregnancy?

Management of Ruptured Hepatic Adenoma in Pregnancy

Immediate surgical intervention with multidisciplinary team involvement is required for management of a ruptured hepatic adenoma in pregnancy to control hemorrhage and stabilize both mother and fetus.

Initial Assessment and Stabilization

• Hemodynamic assessment: Evaluate for signs of shock (tachycardia, hypotension, decreased urine output)
• Laboratory studies: Complete blood count, liver function tests, coagulation profile
• Imaging: Bedside ultrasound if patient is stable; avoid CT when possible due to radiation exposure

Management Algorithm

For Hemodynamically Unstable Patients (Active Bleeding)

1. Immediate surgical intervention:

   • Exploratory laparotomy with control of hemorrhage 1, 2
   • Options include:
     • Packing and temporary abdominal closure
     • Hepatic resection (anatomic or non-anatomic depending on location)
     • Consider concurrent cesarean delivery if fetal distress or viable gestational age (>34 weeks) 2

2. Interventional radiology:

   • Transarterial embolization of feeding vessels if surgical control is incomplete 2
   • May be used as adjunct therapy after initial surgical control

3. Obstetric management:

   • Continuous fetal monitoring if viable gestational age
   • Emergency cesarean delivery if fetal distress or maternal instability 2

For Hemodynamically Stable Patients (Contained Rupture)

1. Gestational age assessment:

   • <24 weeks: Consider surgical resection if technically feasible 3, 4
   • 24-34 weeks: Consider antenatal corticosteroids for fetal lung maturity before intervention
   • >34 weeks: Consider delivery followed by definitive management of adenoma

2. Surgical approach:

   • Laparoscopic resection if feasible (early pregnancy, small lesion, favorable location) 3
   • Open resection for larger lesions or difficult locations 5

Important Considerations

Risk Factors for Rupture

• Tumor size >5 cm (highest risk factor) 1
• Previous hemorrhage of adenoma 1
• β-catenin mutation on exons 7/8 1
• Peripheral or exophytic location 1

Pitfalls to Avoid

• Avoid liver biopsy in suspected adenomas during pregnancy as this can precipitate rupture 3
• Do not delay intervention in unstable patients - maternal mortality and fetal loss approach 50% with spontaneous rupture 3
• Avoid estrogen-containing medications in postpartum period 6

Follow-up After Acute Management

• Ultrasound monitoring of any residual adenoma tissue every 3 months during remainder of pregnancy 1
• Consider definitive treatment (resection) postpartum if conservative management was initially chosen
• Counsel regarding risk of recurrence in future pregnancies and consider resection of adenomas >5 cm before future pregnancies 1, 7

Prevention Strategies for Future Pregnancies

• Women with known hepatocellular adenomas >5 cm should undergo treatment prior to pregnancy 1
• For smaller adenomas (<5 cm), close monitoring with ultrasound each trimester is recommended 1, 7
• Consider radiofrequency ablation in the first trimester for hormone-sensitive adenomas to prevent growth later in pregnancy 7

Ruptured hepatic adenoma in pregnancy represents a true obstetric emergency requiring prompt recognition and management to optimize both maternal and fetal outcomes.